Disclosure of donor insemination to the child: the impact of Swedish legislation on couples' attitudes

The question whether or not parents of children conceived after donor insemination (DI) tell their offspring about its biological background was addressed. Swedish legislation from 1985 gives the child born after DI the right, when grown up, to receive identifying information about the sperm donor. Until now no information about compliance with the law has been available. All parents who gave birth to a child by DI after the new legislation in two major Swedish fertility centres (Stockholm and Umea) received a questionnaire containing questions about the issue of informing the child. The response rate was 80%. The majority of parents (89%) had not informed their children, whereas 59% had told someone else. As a response to an open question, 105/132 parents chose to comment on their answer about not having informed their child. Of these families, 61 intended to tell their child later, 16 were not sure and 28 were not going to inform the child. Compliance with the law must be regarded as low since only 52% of the parents had told or intended to tell their child. In addition, concern is raised about the children who run the risk of being informed by someone other than their parents.     

Infertility: Spontaneous ovulatory cycle donor insemination programme: prognostic indicators of a successful pregnancy

The effects of female and male infertility factors as well asthe insemination regime on the outcome of donor insemination(DI) during 1001 spontaneous ovulatory cycles were assessed.Overall, the average monthly fecundability was 4.4% and thecumulative conception rate after nine cycles was 45%. FemaleDI recipients’ age, nulligravidity or the presence ofother infertility factors were associated with a significantlylower pregnancy rate. DI recipients of azoospermic partnershad a significantly higher pregnancy rate. The likelihood ofa successful pregnancy was higher when more frequent (1) inseminationswere used or in association with higher cervical score and largerfollicle diameter at the time of insemination. We suggest thatfemale recipients of DI should be fully investigated beforecommencing DI treatment. Early resort to other methods of assistedreproduction should be considered in DI recipients aged 35 years,or in younger women if they fail to conceive after nine cyclesof DI. More frequent and better timing of inseminations is expectedto improve the fecundability rate during spontaneous ovulatoryDI cycles.     

Andrology: The predictive value of computer-assisted semen analysis in the context of a donor insemination programme

In this paper we examine the value of both conventional andcomputer-assisted semen analysis (CASA) using the Hamilton-ThornHTM-S 2030 in predicting the in-vivo fertility of cryopreserveddonor semen. Semen samples were examined prospectively and dataon the conventional criteria of semen quality, sperm morphometryand movement were collected. Of 61 ejaculates identified, 33achieved pregnancies (‘successful’) and 28 failedto do so (‘unsuccessful’), despite inseminationinto at least four different normal female recipients. Whenthe post-thaw semen profiles were compared, no differences wereobserved between the two groups in respect of the conventionalcriteria of semen quality determined by conventional laboratorytechniques; however, there were differences in respect of bothmorphometry and movement characteristics determined by the HTM-S.When multiple logistic regression was used to examine the abilityof the variables measured to predict the achievement of pregnancy,the conventional criteria of semen quality were of no value(X² = 6.67, P = 0.353). However, the CASA assessment successfullypredicted outcome in 86.9% of cases (X² = 44.3, P = 0.0021).It was concluded that CASA assessment is of significant valuein predicting the ability of an ejaculate to achieve pregnancy.     

Methods to increase the success rate of artificial insemination with donor semen

Donor insemination was performed in two fertility clinics usingcryopreserved semen from the same sperm bank. Donors were selectedin agreement with American Fertility Society recommendations.In the first clinic, cup insemination was combined with intra-uterineinsemination in 321 cycles. Follicular development was closelymonitored with vaginal echography and serum hormonal measurements.In the second clinic, 1287 insemination cycles were performedusing intra-cervical insemination, timed only on basal bodytemperature. In the first clinic, a total of 53 pregnancieswere obtained, of which seven were in 55 unstimulated cycles(12.5%), 21 in 159 cycles with clomiphene citrate stimulation(13.1%, P> 0.1), and 25 in 107 cycles stimulated with clomipheneplus human menopausal gonadotrophin (HMG) (23.9%, P< 0.03).No multiple pregnancies were observed in the latter group. Inthe second clinic, 159 pregnancies occurred during 1287 inseminationcycles (12.4%). It is concluded that neither intra-uterine insemination,nor hormonal and echographic cycle monitoring, nor clomiphenecitrate enhances the success rate of artificial inseminationwith donor semen, but HMG treatment probably exerts a favourableeffect     

A randomized trial between GIFT and ovarian stimulation for the treatment of unexplained infertility and failed artificial insemination by donor.

This study was designed to investigate the surplus effect of gamete intra-Fallopian transfer (GIFT) over ovarian stimulation alone, in patients with unexplained infertility. A total of 50 patients with unexplained infertility of at least 3 years duration, or unexplained failure of artificial insemination by donor (AID) for at least 12 cycles, meeting strict inclusion criteria, were randomly selected for either two GIFT cycles or two ovarian stimulation cycles. Ovarian stimulation was combined with timed intercourse, or timed cervical donor insemination. In 38 completed GIFT cycles, five clinical pregnancies (13.2% per cycle) occurred and in 44 ovarian stimulation cycles four clinical pregnancies occurred (9.1% per cycle). Five remaining GIFT cycles were converted into in-vitro fertilization leading to two pregnancies. Of the 50 patients suffering from unexplained infertility, the 23 who did not have AID gave rise to four pregnancies out of 39 cycles (10.3%); from the remaining 27 patients who underwent AID, seven pregnancies were achieved out of 48 cycles (14.6%). No statistical differences between GIFT and ovarian stimulation treatment were found. Therefore, the GIFT success rates can be explained at least in part, if not fully, by the effect of ovarian stimulation alone. Consequently, ovarian stimulation should be considered in unexplained infertility before more elaborate forms of assisted reproduction are used.     

Prognostic factors in assessment and management of male infertility.

Evaluation of 304 infertile couples with at least one abnormal semen analysis (sperm density < 20 x 10(6)/ml and/or motility < 50%) and no apparent female factors was performed in a multicentre prospective cohort study. In 73 cases therapeutic donor insemination was performed (TDI group) with a resulting pregnancy rate of 48%. The remaining 231 couples (non-TDI group) had an overall pregnancy rate of 25%. The TDI group had a shorter duration of infertility. The ages of both partners were comparable in TDI and non-TDI groups. In the non-TDI group, univariate analysis resulted in identification of six clinical variables associated with a change in pregnancy rates. The strongest association was noted for length of infertility. There was a weaker association for semen volume, concentration of leukocytes in semen, history of pregnancy in the female partner and laparoscopy. Multiple variable analysis of data from the non-TDI group revealed that independent predictors of pregnancy were 'duration of infertility' and 'history of pregnancy in the female partner'. The multiple variable modelling suggested that (i) an increase in the length of infertility by 1 month prolongs the time to pregnancy by an additional 1.6% (95% confidence interval: 1.5-1.7%); and (ii) a history of past pregnancy in the female partner reduces the time of pregnancy by 51% (95% confidence interval: 47-56%).     

Parental coping with sudden infant death after donor insemination: case report

We report the case of an artificial donor insemination couple experiencing sudden infant death of their 8-month-old child. Six months after the incident, the couple were investigated by means of an extensive interview, a repertory grid investigation and the Family Assessment Measure, as well as at 6 years after the incident by an extensive interview. The results show the importance of the diagnosis of male infertility and the preceding fertility treatment for coping with the death of their child. Six months after the incident, acute feelings associated with bereavement are mixed with feelings of anger and shame, apparently due to the experience of infertility. However, secrecy and shame associated with male infertility and donor insemination make it impossible for the couple to communicate their feelings to each other or to friends and relatives; furthermore, they decline psychological counselling. Repertory grid investigation and the Family Assessment Measure point to significant problems within the partnership. Six years after the incident, the couple's relationship is destabilized and both partners plan to divorce. We suggest a possible link between donor insemination secrecy and difficulties with coping. We discuss implications for couple counselling and emphasize the necessity for an improved legal framework for donor insemination in Germany.     

Guidelines for counselling in infertility: outline version

The Guidelines for Counselling in Infertility describe the purpose, objectives, typical issues and communication skills involved in providing psychosocial care to individuals using fertility services. The Guidelines are presented in six sections. The first section describes how infertility consultations differ from other medical consultations in obstetrics and gynaecology, whereas the second section addresses fundamental issues in counselling, such as what is counselling in infertility, who should counsel and who is likely to need counselling. Section 3 focuses on how to integrate patient-centred care and counselling into routine medical treatment and section 4 highlights some of the special situations which can provoke the need for counselling (e.g. facing the end of treatment, sexual problems). Section 5 deals exclusively with third party reproduction and the psychosocial implications of gamete donation, surrogacy and adoption for heterosexual and gay couples and single women without partners. The final section of the Guidelines is concerned with psychosocial services that can be used to supplement counselling services in fertility clinics: written psychosocial information, telephone counselling, self-help groups and professionally facilitated group work. This paper summarizes the different sections of the Guidelines and describes how to obtain the complete text of the Guidelines for Counselling in Infertility.     

The value of single versus repeated insemination in intra-uterine donor insemination cycles

Pregnancy rates per cycle of intra-uterine donor inseminationfollowing ovulation induction were compared retrospectivelyfor those patients having a single, and those having repeatedinsemination using frozen donor semen. Single insemination wasperformed in 69 cycles in which 15 women became pregnant (pregnancyrate = 22%). Of 65 cycles in which repeated insemination wasperformed, 16 women became pregnant (pregnancy rate = 25%).This difference in pregnancy rates was not statistically significant(x² = 3.6, P = 0.84). We conclude that cycle fecundity may notbe increased by repeating insemination.     

Attitudes towards donor insemination--a post-Warnock survey

In a multi-centred study, a total of 799 patients, donors andhealth-care professionals concerned with artificial inseminationwith donor semen (AID) responded to a questionnaire regardingtheir attitudes towards current provision of AID services andproposed legislation. There was little support for any fundamentalchange in the way in which AID is practised, at least in thosecentres. The anonymous status of the donor met with universalagreement. Although there was some support for the communicationof non-identifying details to the recipient couple, where theywanted them, there was no support for any legislation whichmight give the AID child a right of access to details of thedonor. The greatest divergence of opinion was over the questionof who should have access to AID treatment and whether or notscreening procedures should be applied to prospective parents.Most respondents felt that the closed and confidential relationshipbetween the clinic and the other parties involved should notautomatically be extended to general practitioners or any nationalbodies. In respect of specific recommendations of the WarnockCommittee, there was support for changes which might legitimizeor assist the present system, but not for any which might berestrictive.     

Ovary and Ovulation: Home ovulation testing In a donor insemination service

The use of home ovulation testing kits in donor insemination(DI) has been proposed to increase patient and clinic conveniencewhile not compromising fecundity rates. Such a system was introducedinto our Dl service in December 1994, and we here report anaudit of experience over 6 months. Patients were offered homeor laboratory luteinizing hormone (LH) testmg, and those requestinghome testing were asked to store an aliquot of tested urinefor subsequent assay in the laboratory allowing retrospectiveanalysis of the accuracy of cycle timing. Insemination usingcryopreserved semen was performed on the day home testing predictedovulation, or on the day an LH surge was detected in the laboratory,and on the following day. Pregnancy rates were significantlyreduced in home testers: 3.4% per cycle (174 cycles, 64 women)versus 12.7% (110 cycles, 53 women) over the same time period(P<0.005, 95% confidence interval 6.5–18.9). Urinesamples from 140 cycles from 51 women using home testing wereanalysed. There were insufficient data in nine to allocate thecycle. Of home tested cycles, 37 (28%) were inseminated on aday other than the first day of the LH surge. In 13 of theseinsemination was performed after the first day of the LH surge.Incorrect treatment was associated with high baseline LH, butthose with ‘late’ treatment had low basal LH concentrations,similar to those correctly treated. Analysis of individual urinesamples showed that the positive predictive value of home testingwas 72%. These results suggest that home ovulation testing resultsin reduced chance of pregnancy, with increased frustration forboth patients and clinic staff. This may be particularly soin women with high baseline LH concentrations.     

Psychological screening and the success of donor insemination

In a previous case series, a psychologist‘s rating ofcouples’ emotional adjustment and readiness for donorinsemination was predictive of pregnancy rates. We attemptedto replicate this finding with an extended series of 120 consecutivecouples in which each spouse filled out questionnaires whenevaluated for donor insemination. The Stress and InfertilityQuestionnaire measured specific attitudes and anxieties aboutdonor insemination. The Brief Symptom Inventory assessed psychologicaldistress. The Dyadic Adjustment Scale measured marital happiness.A psychologist used these questionnaires to rate the couple‘soverall adjustment in regard to donor insemination. Those couplesrated as distressed had a session of psychological counselling.Outcome was reviewed at a mean of 20 months after evaluation,with categories of pregnancy, continuing donor insemination,failure to begin the programme, or dropped out. For the 120couples overall, psychological factors did not predict pregnancyoutcome. Younger age of the wife did predict higher pregnancyrates     

Reproductive decisions of men with microdeletions of the Y chromosome: the role of genetic counselling.

Couples dealing with microdeletions of the Y chromosome have to make decisions about their reproductive future. Do they opt for intracytoplasmic sperm injection (ICSI), artificial insemination with donor insemination (AID) or no treatment? We analysed this decision in 28 couples and investigated the role of the counsellor and the counselling process on the final decision of the couple. Ten counsellors from six fertility clinics in The Netherlands and Belgium were interviewed about their genetic counselling of couples dealing with microdeletions. The answers to the questionnaire were converted to 11 dichotomous variables. Of the 1627 tested men in the six centres, 37 (2.3%) had a microdeletion in the AZFc region, a subregion of the AZF region on the Y chromosome important for normal spermatogenesis. The decisions of 28 of them could be analysed. Most couples chose ICSI (79%). The remaining couples chose donor insemination (7%) or refrained from treatment (14%). Several variables, including the counselling procedure, the counsellor and the available treatments in the fertility centre, influenced the decision of the couple. In conclusion, most couples dealing with microdeletions in the AZF region choose ICSI. Several aspects of the process of genetic counselling appear to be related to the final decision.     

Andrology: Preferences for intracytoplasmic sperm injection versus donor insemination in severe male factor infertility: a preliminary report

With the advent of intracytoplasmic sperm injection (ICSI),our programme noted a drop in the number of couples using donorinsemination (DI) for severe male factor infertility. Over thefirst 8 months in which our infertility programme offered bothtreatments, 27 consecutive couples scheduled for ICSI and 15consecutive couples scheduled for DI were evaluated Since allpatients in our infertility programme beginning in-vitro fertilization(TVF) with planned ICSI or starting DI undergo a semi-structuredpsychological interview, the psychologist's clinical notes aswell as the medical chart were reviewed and coded retrospectivelyto determine factors related to a couple's treatment choice.Couples who chose IVF-ICSI over DI had a higher occupationalstatus and included husbands with higher educational levels.Their most common motivation was to have the husband's biologicalchild (93% of couples in the ICSI group). The most common motivationfor choosing DI (60% of DI couples) was that IVF was not financiallyaffordable. Choice of treatment was not related to psychologicaladjustment, the husband having prior biological children, orhis risk of passing on a genetic defect to offspring. Thesepreliminary data raise the concern that, with the success ofICSI, DI may change in the USA from being an option dictatedby semen quality to a second choice treatment utilized for economicreasons.     

Artificial procreation with frozen donor semen: experience of the French Federation CECOS

The French Federation CECOS (Centre d'Etude et de Conservation du Sperme Humain) sperm banks collate the results of its 20 centres and provides annual reports on their activity. Since its creation in 1973, approximately 17,000 pregnancies have been obtained using frozen donor semen either for artificial insemination by donor (AID) or for in-vitro fertilization. The recruitment of the donors was very strict, only 62% of the 6810 donor candidates were accepted. The overall mean success rate per cycle for all women who began AID was approximately 8%, and the theoretical cumulative success rate was 48% at six cycles and 66% at 12 cycles. The population of recipient patients was very heterogeneous, including fertile, sub-fertile and infertile women. Some of these female factors have been analysed.     

Filiation and secrecy in artificial insemination with donor

Artificial insemination with donor (AID) forces the gynaecologist to face the problem of filiation with his patients. Here, the authors point out the pathogenic effect, both on the parents and the child, which may result from rigidly kept secret about 'AID filiation', and they discuss some conditions which could help to avoid this pathogenic effect, possibly allowing a non-traumatic revelation of his/her filiation to the child, in the future.     

Intrafollicular insemination for the treatment of infertility

The effectiveness of intrafollicular insemination (IFI) forthe treatment of non-tubal infertility was investigated in apilot study. A total of 50 infertility patients with normaltubal function verified by laparoscopy or hysterosalpingographywere stimulated with clomiphene citrate/human menopausal gonadotrophin.Washed spermatozoa were injected into one to three pre-ovulatoryfollicles via vaginal puncture 12 or 30 h after human chorionicgonadotrophin administration. Natural progesterone was givenfor luteal support. The IFI procedure was technically very simpleand convenient for the patient and no complications were recorded.One normal intra-uterine pregnancy resulted. The results indicatethat by comparison with other assisted reproductive technologiesIFI is very inefficacious for treating non-tubal infertility.Our data suggest that the intrafollicular environment in thepre-ovulatory period is not favourable for fertilization.     

School-aged children of donor insemination: a study of parents' disclosure patterns

BACKGROUND: A major concern in relation to donor insemination (DI) is whether children should be told about their genetic origins. This study compared the thoughts, feelings and experiences of DI parents who were inclined towards openness with those who were inclined towards non-disclosure. METHODS: Forty-six families with a 4- to 8-year-old DI-conceived child were interviewed about their decision, their reasons and subsequent concerns regarding disclosure. RESULTS: Thirty-nine percent of parents were inclined towards disclosure whilst the remaining 61% were not. The two main reasons for favouring disclosure were to avoid accidental discovery and a desire for openness. Non-disclosing parents felt that there was no reason to tell and wished to protect family members. The children who had been told reacted with either curiosity or disinterest. CONCLUSIONS: In spite of donor anonymity, parents who were intending to tell their child in the future had optimistic expectations of their child's reaction. Parents who had already told their child generally described the telling experience as a positive one.     

Intrauterine insemination: evaluation of the results according to the woman's age, sperm quality, total sperm count per insemination and life table analysis

We report on 332 infertile couples who underwent 1115 cyclesof intrauterine insemination (IUI) with washed husband's semen.The indication for IUI was an abnormal post-coital test dueto either a male or cervical infertility factor. The mean numberof IUI cycles per patient was 3.4, the overall pregnancy rate18, 7%, and the pregnancy rate per cycle 5.6%. The cumulativepregnancy rate calculated by life table analysis showed that16.0% of pregnancies occurred in the first three treatment cycles,while the cumulative pregnancy rate was 26.9% by the sixth cycle.The outcome of the therapy was adversely affected if the woman'sage was >39 years and/or total motile sperm count per inseminationwas <1X106. No pregnancy occurred in women older than 44years or in cases with a total motile sperm count before semenpreparation of <1X106.     

Psychology: A comparison of single and married recipients of donor insemination

There has been some controversy surrounding the use of donorinsemination (DI) for single women. The purpose of the presentstudy was to compare psychological characteristics of marriedversus single women who were DI recipients. A total of 17 singlewomen and 17 married women completed psychological questionnairesregarding psychiatric symptomatology, self-esteem, and theirattitudes towards DI prior to treatment There were no significantdifferences between the groups in psychiatric symptomatologyor level of self-esteem. A significant difference was foundin the amount of time taken to decide to use DI with singlewomen waiting longer. There were no significant differencesbetween groups in reported concerns about the child. There weresignificant differences in attitudes towards disclosure withmore single than married women reporting that they would tellthe child about using DI to conceive.