The psychopathogenic power of secrecy: child development and family dynamics after heterologous insemination

This study presents the outcome of a 7-year psychotherapy of a girl who was born after donor insemination (DI) and who became ill with a compulsive disorder at the age of 8 years. Our demonstration supplements the present existing statistical data about families into which children have been born with the aid of DI. Aspects of child development, communication within the family, and family dynamics related to this specific constellation will be pointed out. This case study shows important aspects of the individual and the development of the family with regard to DI-constellations. Our paper emphasizes, in contrast to constellations of foster care or adoption, the impact on the parents' conscious knowledge and the child's unconscious knowledge of an absent--as well as less-known--family member (here: the invisible father) on the child's emotional development, health and competence of tying bonds. We also examine the relationship between the parents and their relationship with their DI child. Implications for individual therapy and therapeutic management of the family will be discussed, covering development of bonding and identity of the DI child, the father's role, dynamics of the couple, and the incognito of the 'invisible father'.     

Intrauterine insemination: state-of-the-art in humans

Despite its being used for a long time, intrauterine insemination (i.u.i.) remains debated as to its precise place and efficacy among assisted reproductive technologies. Data issued from the French Health Ministry inquiries are strictly limited to the number of cycles and the pregnancies and births including the multiple ones. Concerning 2000, more than 44,000 cycles were registered with 8% deliveries per cycle and 12% multiple pregnancies. Apart from the cervical female infertility which is considered to have the best prognosis with i.u.i., literature data remain controversial with male and unexplained infertility. Prospective randomized studies are rather scarce, particularly when considering the inclusion of untreated control population. Meta-analyses have been published for ten years, which allowed to better define the place of i.u.i. in patient management. However one may notice that the sperm cut-off parameters for male infertility and the respective contribution of i.u.i. and ovulation treatment do not allow develop some evidence-based guidelines for i.u.i. good practice. Quite all meta-analyses modulated their conclusions by addressing the need for large randomized controlled studies. Such a need seems now quite reinforced since results were until now expressed as pregnancy rate per cycle or pregnancy rate per couple, whereas single live birth rate and drop out rate are claimed to be taken into account nowadays. Moreover the level of controlled hyperstimulation is highly questionable with both hyperstimulation ovary syndrome and multiple pregnancy risks. Patients facing with failed i.u.i. cycles may turn to i.v.f. or i.c.s.i.. Interestingly data coming from the French national register (FIVNAT) did not show major differences between couples turning to i.v.f. (i.c.s.i.) after previously failed i.u.i. cycles or using directly i.v.f. (i.c.s.i.). Moreover the prognostic as evaluated on pregnancy rate per cycle was unchanged between such patients, which does not support some selection of patients by i.u.i. failure. Thus, although i.u.i. seems likely a cost-effective treatment in infertile couples, the precise conditions of its management (spontaneous or stimulated cycle, mono-, pauci- or multi-follicular induction) remain to be assessed. Indeed large controlled randomized studies including untreated group are required even if such design might have a non negligible cost. However these rather common treatments do have a high cost and any effort to rationalise them will have some economical impact. Another practical approach, although less ambitious, might consist in developing a per cycle registry which should allow to precise the French practice at a large national level.     

Therapeutic insemination

Except in special circumstances, therapeutic insemination with a husband's sample has a low success rate. Couples in whom oligozoospermia has been identified as the principal cause of infertility do not benefit from therapeutic insemination by husband. Because of this low success rate, intrauterine insemination to provide sperm in closer proximity to the egg has become popular, but intrauterine insemination also has a low success rate. We suggest that intrauterine insemination should be approached aggressively in cases of male factor infertility. The recipient should be stimulated to enhance egg production and closely monitored for ovulation. A semen specimen of not less than 1 X 10(6) motile sperm with antibiotics added should be placed in the uterus the day after ovulation. If no pregnancies occur within four cycles, alternate approaches should be considered. Therapeutic insemination by donor involves careful donor selection to avoid inheritance of malformations and familial diseases. Because of the possibilities of sexually transmitted diseases, careful and repeated screening should be conducted. A complete sexual history should be obtained, and donors should be excluded if they have had any homosexual contact since 1978, if they have been an intravenous drug user, if they come from a geographic area where the sex ratio of AIDS is close to 1:1, or if they have recently had multiple sexual partners. A permanent record preserving the confidentiality but allowing the tracing of genetic anomalies, even if not present at birth, should be kept.