Review: parent-child relationships and child development in donor insemination families

The present article reviews the empirical research regarding the parent-child relationships and the development of children in donor insemination (DI) families. Over the years, follow-up studies have appeared sporadically and, despite the varying quality of the research methods, preliminary findings have emerged. Heterosexual DI parents were psychologically well adjusted and had stable marital relationships. DI parents showed a similar or higher quality of parent-child interaction and a greater emotional involvement with their children compared with naturally conceived families. The majority of studies which investigated several aspects of child development found that, overall, DI children were doing well. Findings with regard to emotional/behavioural development, however, were divergent in that some studies identified an increase of such problems while others did not. A steadily growing group within the DI population is lesbian mother families. More recently, follow-up studies have been carried out among DI children who were raised from birth by two mothers. Despite many concerns about the well-being of these children, no adverse effects of this alternative family structure on child development could be identified. As the DI children in all investigations were still young, our knowledge about the long-term effects of DI remains incomplete.     

Planned lesbian families: their desire and motivation to have children

BACKGROUND: There is no information about the desire and motivation for children among planned lesbian families. The overall aim of this research was to examine whether planned lesbian families differ from heterosexual families in desire and motivation to have a child. The reason for studying this is that desire and motivation to have children are characteristics that are supposed to effect parenting and the parent-child relationship. METHODS: A total of 100 lesbian two-mother families were compared with 100 heterosexual families. All data were collected by means of questionnaires. RESULTS: Lesbian parents and heterosexual parents rank their parenthood quite similarly; however, happiness is significantly more important for lesbian mothers than it is for heterosexual parents and identity development is less important for lesbian mothers than it is for heterosexual parents. Furthermore, compared with heterosexual parents, lesbian parents had spent more time thinking about their motives for having children, and their desire to have a child was stronger. CONCLUSIONS: Lesbian parents especially differ from heterosexual parents in that their desire to have a child is much stronger. The study's findings may be helpful for counsellors in their work to inform and assist lesbian couples in their decision to have a child.     

Choosing identity-release sperm donors: the parents' perspective 13-18 years later

BACKGROUND: A growing number of donor insemination (DI) programmes offer 'open-identity' sperm donors, who are willing to have their identity released to adult offspring. We report findings from parents who chose such donors and whose children are now adolescents. METHODS: Using mail-back questionnaires, parents from 45 households (40% headed by lesbian couples, 38% by single women, 22% by heterosexual couples) reported their experience with using an open-identity donor and disclosure about it, as well as their child's plans for donor identity-release(sm). RESULTS: Almost no parents regretted using an open-identity donor. Almost all parents had told their child about his or her DI conception early on and reported a neutral to moderately positive impact. Finally, of those who had told, almost all expected their child to obtain the donor's identity. We also discuss differences found between birth mothers and co-parents and among single women, lesbian couples, and heterosexual couples. CONCLUSIONS: Families were relatively open and positive about their use of DI and that their child could obtain the donor's identity. Disclosure did not appear to have a negative impact on the families, regardless of parental sexual orientation and relationship status.     

Child development and quality of parenting in lesbian families: no psychosocial indications for a-priori withholding of infertility treatment. A systematic review

Among fertility centres, much discussion focuses on whether to withhold infertility treatment from special patient groups (lesbians, prospective single parent(s), prospective parent(s) of relatively advanced age, or with severe diseases) because it is assumed that this is in the best interest of the child. The present study aimed to establish whether there is any empirical evidence for this assumption. A literature search was made in PubMed/Medline and PsycINFO to identify studies that had assessed psychological outcomes of children and quality of parenting after infertility treatment. Eight studies met the following inclusion criteria: published in an English-language peer-reviewed journal between 1978 and 2002, and focused on psychosocial child development and quality of parenting after infertility treatment in the above-mentioned special patient groups. All reviewed studies focused on lesbian or single-parent families. Overall, the methodological quality of studies as assessed by a standardized set of criteria was high. The evidence of the studies (assessed by the best evidence synthesis method) was strong for the conclusion that in lesbian families the psychosocial development of children (median age 6.1 years) and the quality of parenting are not different from those in healthy heterosexual two-parent families after infertility treatment or natural conception. Therefore, withholding infertility treatment from lesbian families on the assumption that such intervention may not be in the interest of the prospective child seems unjustified. For the other special patient groups, no conclusions could be drawn, because of a lack of relevant studies.     

Donor insemination: child development and family functioning in lesbian mother families

Findings are presented of a comparative study investigating the family relationships and the emotional and gender development of children raised in lesbian mother families. A total of 30 lesbian mother families with 4-8 year old children created as a result of donor insemination (DI) were compared with 38 heterosexual families with a DI child and with 30 heterosexual families who had a naturally conceived child. A variety of assessment measures, including a standardized interview and questionnaires from the parents and psychological testing of the child were used to collect the data. The quality of the couples' relationships and the quality of the mother-child interaction did not differ between lesbian mother families and either of the heterosexual family groups. The quality of the interaction between the social mother and the child in lesbian families was superior to that between the father and the child in both groups of heterosexual families. Childrens' own perception of their parents was similar in all family types; the social mother in lesbian families was regarded by the child to be as much a 'parent' as the father in both types of heterosexual families. With regard to their emotional/behavioural development, boys and girls raised in lesbian mother families were well adjusted and their gender role development did not differ from that of children raised in heterosexual families. These results indicate that child and family development in lesbian mother families is similar to that of heterosexual families.      

Lesbian mothers who conceived after donor insemination: a follow-up study

This study investigated the development of family relationshipsin lesbian families who conceived after donor insemination (DI).The main characteristics of this unknown family structure wereanalysed. An anonymous donor was used to conceive, the familyunit consisted of two mothers and a father was non-existent,and both women had a homosexual orientation. A total of 50 lesbiancouples who conceived after DI with children aged between 1and 2 years participated in this study, using a standardizedinterview created for this study. After the birth of their child,56% of the lesbian mothers (n = 100) would have wanted the identityof the donor to be registered, while 10% would have done soat the time of the insemination. Opinions differed in 12 ofthe 50 couples: the biological mother was in favour of identityregistration while the social mother was not. Both women consideredthemselves a parent of the child with equally shared responsibilities.Mothers were open about the special features of their familystructure with children and within their immediate social network.Only 30% disclosed their lesbian identity in a broader socialenvironment. The features of these newly created families mayinfluence the psychological development of the children andtherefore make long-term follow-up studies indispensable.     

PGD in 47,XXY Klinefelter's syndrome patients

The use of ICSI has been a major breakthrough in the treatment of male infertility. Even azoospermic patients with focal spermatogenesis in the testis, may benefit from the ICSI technique in order to father a child. As ICSI use has become more common, centres have introduced infertility treatment for Klinefelter patients. To date, 34 healthy children have been born using ICSI without PGD, and the conception of one 47,XXY fetus has been reported. In view of the possible risk of an increased gonosome number in the spermatozoa of Klinefelter patients, a safer approach--offering these couples ICSI combined with PGD--has been used, and has resulted in the birth of three healthy children. Couples in which the male suffered from Klinefelter's syndrome were first treated in 1995; these patients were offered ICSI + PGD using FISH technology, notably to enumerate the X and Y chromosomes. ICSI + PGD was performed in 32 cycles of 20 couples with spermatozoa originating from a fresh ejaculate (n = 1), testicular biopsy (n = 21) or frozen-thawed testicular biopsy (n = 10). Normal fertilization occurred in 56.0 +/- 22.4% of the successfully injected oocytes. On day 3 of development, 119 embryos from 29 cycles were of sufficient quality to undergo biopsy and subsequent PGD; a positive result was obtained in 113 embryos. Embryos were available for transfer in 26 cycles, with a mean of 1.6 +/- 0.6 embryos per transfer. Eight pregnancies were obtained, and five resulted in a delivery. A total of 113 embryos from couples with Klinefelter's syndrome was compared with 578 embryos from control couples with X-linked disease where PGD was used to determine gender. A significant fall occurred in the rate of normal embryos for couples with Klinefelter's syndrome (54.0%) compared with controls (77.2%). Moreover, a significantly increased risk of abnormalities was observed for sex chromosomes and autosomes; for each autosome separately, this reached significance level for chromosomes 18 and 21 only. Hence, a cautious approach is warranted in advising couples with non-mosaic Klinefelter's syndrome. Moreover, the use of ICSI + PGD or prenatal diagnosis should be carefully considered.     

Solo mothers and their donor insemination infants: follow-up at age 2 years

BACKGROUND: Findings are presented of the second phase of a longitudinal study of solo-mother families created through donor insemination (DI). METHODS: At the time of the child's second birthday, 21 solo DI mother families were compared with 46 married DI families on standardized interview and questionnaire measures of the psychological well being of the mothers, mother-child relationships and the psychological development of the child. RESULTS: The solo DI mothers showed greater pleasure in their child and lower levels of anger accompanied by a perception of their child as less 'clingy'. Fewer emotional and behavioural difficulties were shown by children of solo than married DI mothers. CONCLUSIONS: The findings from this first cohort of solo DI families to be studied lend further weight to the view that these women represent a distinct subgroup of single parents, who, out of a strong desire for a child, have made the active choice to go it alone. Moreover, this route to parenthood does not necessarily seem to have an adverse effect on mothers' parenting ability or the psychological adjustment of the child.     

Anonymous or identity-registered sperm donors? A study of Dutch recipients' choices

BACKGROUND: The aim of the present study was to gain insight into parents' own donor preferences within a system offering the choice between an anonymous and identity-registered donor. A comparison was made between recipients choosing for an anonymous donor (AD choosers) and those choosing for an identifiable donor (ID choosers) with regard to their sexual orientation, demographic characteristics, disclosure issues and infertility distress. METHODS: Data from 105 couples (61% heterosexual, 39% lesbian) were registered on a standardized form during implication counselling sessions previous to treatment. RESULTS: Sixty-three per cent of the heterosexual couples and 98% of the lesbian couples had chosen an ID donor. Major differences between ID and AD choosers were identified. Among the ID choosers secrecy towards the child was no option, whereas 83% of the AD choosers did not intend to inform their child. Compared with heterosexual ID choosers, AD choosers were more distressed about their infertility and had a lower educational level. CONCLUSION: Legislation imposing ID donors appears to be acceptable for the majority of this study population. For a vulnerable group of heterosexual couples, who remained secretive about the use of a donor, adaptation to the new system is not self-evident.     

Counselling and selection of homosexual couples in fertility treatment

Artificial insemination with anonymous donor sperm (AID) is a widespread practice for heterosexual couples in which the male partner appears to be infertile. The Centre for Reproductive Medicine of the Brussels University teaching hospital has been one of the first to extend this form of therapy to lesbian couples. In the course of the past 7 years, 27 lesbian couples have come to the centre with a request for AID. The question of whether children can be brought up within such a frame of reference cannot be dissociated from the question of attitudes towards homosexuality as such. Such attitudes still solicit a whole range of controversial reactions. This paper will deal with the most important findings from investigations thus far carried out on the issue of homosexual parenthood. It also sets out the selection criteria used in the evaluation of applicants. A profile of the homosexual couples selected will be presented, with particular attention to their social status, their psychosexual development and their motivation towards parenthood.     

Lesbian families and family functioning: an overview

OBJECTIVES: In the last 30 years a growing body of studies on lesbian parents and the development of children has been published. METHODS: Four computerized databases were identified studies for inclusion in this review of research on lesbian families, namely PsychInfo, Educational Resources Information Centre (ERIC), Medline, and the Social Sciences Citation Index. RESULTS: Forty-four empirical studies on lesbian families published between 1978 and 2003 were reviewed. In the research on lesbian families two phases were identified. To begin with, systematic studies on lesbian families focused on lesbian families with children who were born in a previous heterosexual relationship. More recently, studies included lesbian families whose children were born to the lesbian couple (planned lesbian families). In both phases, articles reporting results on children's development (such as sexual identity, emotional/behavioral development, social relationships and cognitive functioning), and parental functioning (such as mental psychological health and parenting skills). This paper presents and discusses major finding of the reviewed articles. CONCLUSION: Studies in both phases have emphasized that lesbian and heterosexual families are very much alike. However, it is the stigma of lesbianism that makes the family situation of lesbian families different. PRACTICE IMPLICATIONS: Healthcare workers should be informed about the similarities and differences between lesbian families and heterosexual families, and about the non-traditional family situation of planned lesbian families.     

Pregnancy and child outcome after oocyte donation

During the last decade oocyte donation has been highly successful for treating women previously thought to be hopelessly infertile. The pregnancy rate after oocyte donation is among the highest reported for any fertility-enhancing procedure. Most investigators have noted an increased rate of obstetric complications in these pregnancies. In particular, pregnancy-induced hypertension appears to occur more often than expected, and the Caesarean section rate is high. However, the majority of oocyte recipients experience a favourable pregnancy and perinatal outcome. When perinatal complications occur they are usually related to multiple gestation. The high frequency of multiple pregnancy after oocyte donation, as well as in all other fields of assisted reproduction, deserves attention, and efforts to avoid multi-fetal gestation must be made. There are only a few studies on post-natal growth and development of young children born after oocyte donation. The health of these children appears to be within normal ranges. The psychological consequences of the treatment on the child require further investigation. Thus far, studies have shown normal socio-emotional development in the child and a warm relationship between the parents and the child in oocyte donation families.     

Psychosocial aspects of surrogate motherhood

This review addresses the psychosocial research carried out on surrogacy triads (surrogate mothers, commissioning mothers and offspring) and shows that research has focused on a number of specific issues: attachment and disclosure to surrogate offspring; experiences, characteristics and motivations of surrogate mothers; and changes in profiles of the commissioning/intended mothers. Virtually all studies have used highly selected samples making generalizations difficult. There have been a notable lack of theory, no interventions and only a handful of longitudinal studies or studies comparing different populations. Few studies have specifically questioned the meaning of and need for a family or the influence and impact that professionals, treatment availability and financial factors have on the choices made for surrogate and intended mothers. Societal attitudes have changed somewhat; however, according to public opinion, women giving up babies still fall outside the acceptable remit. Surrogate and intended mothers appear to reconcile their unusual choice through a process of cognitive restructuring, and the success or failure of this cognitive appraisal affects people's willingness to be open and honest about their choices. Normal population surveys, on the contrary, are less accepting of third party reproduction; they have no personal need to reconsider and hence maintain their original normative cognitively consonant state.     

The importance of folate, zinc and antioxidants in the pathogenesis and prevention of subfertility

Current treatments of subfertile couples are usually empiric, as the true cause of subfertility often remains unknown. Therefore, we outline the role of nutritional and biochemical factors in reproduction and subfertility. A literature search was performed using MEDLINE, Science Direct and bibliographies of published work with both positive and negative results. The studies showed that folate has a role in spermatogenesis. In female reproduction, folate is also important for oocyte quality and maturation, implantation, placentation, fetal growth and organ development. Zinc has also been implicated in testicular development, sperm maturation and testosterone synthesis. In females, zinc plays a role in sexual development, ovulation and the menstrual cycle. Both folate and zinc have antioxidant properties that counteract reactive oxygen species (ROS). Thiols, such as glutathione, balance the levels of ROS produced by spermatozoa and influence DNA compaction and the stability and motility of spermatozoa. Oocyte maturation, ovulation, luteolysis and follicle atresia are also affected by ROS. After fertilization, glutathione is important for sperm nucleus decondensation and pronucleus formation. Folate, zinc, ROS and thiols affect apoptosis, which is important for sperm release, regulation of follicle atresia, degeneration of the corpus luteum and endometrial shedding. Therefore, the concentrations of these nutrients may have substantial effects on reproduction. In conclusion, nutritional and biochemical factors affect biological processes in male and female reproduction. Further research should identify pathways that may lead to improvements in care and treatment of subfertility.     

Spermatozoal nuclear determinants of reproductive outcome: implications for ART

A male factor is implicated in more than 50% of couples treated with IVF. However, neither the routine testing of male fertility potential nor its treatment address the specific mechanisms by which spermatozoal factors may impact upon reproductive outcome. An important function of spermatozoa is to deliver the paternal genome to the oocyte. Recently, a number of acquired spermatozoal nuclear factors that may have implications on reproductive outcome have been described. These include non-specific DNA strand breaks, numerical abnormalities in spermatozoal chromosome content, Y chromosome microdeletions and alterations in the epigenetic regulation of paternal genome. The exact mechanisms by which these factors affect reproduction are unknown and their implications for assisted reproduction technology outcome need to be further investigated. These recent findings point to the need for novel and more personalized approaches to test and treat male factor infertility.     

Consequences on offspring of abnormal function in ageing gametes

The present review aims to analyse (i) the molecular, biochemical and cellular changes that accompany oocyte and sperm ageing in any of the internal or external environments where they can reside, and (ii) the consequences of the abnormal function in ageing gametes on pre- and post-implantation development and later life of offspring. This review also aims to propose and discuss cellular/molecular mechanisms framed within the 'free radical theory of ageing'. It appears that the ageing of gametes prior to fertilization may affect many molecular, biochemical and cellular pathways that may jeopardize not only pre- and post-implantation embryo/fetal development but also later life of offspring. Consequences of gamete ageing range from decreased vigour (with the concomitant decrease in intelligence, reproductive fitness and longevity) of apparently normal-looking offspring to severe congenital, epigenetic and/or genetic anomalies. All these effects may be easily prevented by efficient diffusion of both the potential risks of gamete ageing and the steps that should be taken by couples wishing to achieve pregnancy to guarantee a correct maturational synchronization of gametes at fertilization. Although in-vitro antioxidant therapy appears to protect from or retard the ageing process of gametes, it may not assure the total absence of negative effects on the resulting offspring.     

Dizygotic twinning

The tendency to conceive spontaneous dizygotic (DZ) twins is a complex trait with important contributions from both environmental factors and genetic disposition. Twins are relatively common and occur on average 13 times per 1000 maternities, though the twinning frequency varies over time and geographic location. This variation is mostly attributed to the differences in DZ twinning rate, since the monozygotic twinning rate is relatively constant. DZ twinning is in part under genetic control, with mothers of DZ twins reporting significantly more female family members with DZ twins than mothers of monozygotic twins. Maternal factors such as genetic history, advanced age and increased parity are known to increase the risk of DZ twins. Recent research confirmed that taller mothers and mothers with a high body mass index (30>) are at greater risk of DZ twinning. Seasonality, smoking, oral contraceptive use and folic acid show less convincing associations with twinning. Genetic analysis is beginning to identify genes contributing to the variation in twinning. Mutations in one of these genes (growth differentiation factor 9) are significantly more frequent in mothers of DZ twins. However, the mutations are rare and only account for a small part of the genetic contribution for twinning.     

Ovulation induction in perspective

It has been suggested recently that, in some quarters, IVF be offered as first-line therapy to all infertile couples, regardless of the type of infertility. Hence, the time was thought right to scrutinise the results and complications of ovulation induction for anovulatory infertile couples. In addition to examining the outcome of conventional treatment with gonadotrophins and clomiphene citrate, special attention has been paid to the suggested improvement of results by taking into account the influence of obesity and the use of a low-dose gonadotrophin protocol. The possible contribution of more recent additions to the armamentarium such as insulin sensitizers and aromatase inhibitors, although still at an infant stage, are promising. Attention has been given to the prevention and treatment of ovarian hyperstimulation syndrome. The use of intra-uterine insemination (IUI) as an adjuvant to induction of ovulation and controlled ovarian hyperstimulation (COH) is examined. The very firm conclusion has been reached that, taking into account efficiency, complication rate and cost of treatment, at this stage, women with hypogonadotrophic hypogonadism or polycystic ovary syndrome should be offered accepted methods of ovulation induction and that couples with 'unexplained' or 'multifactorial subfertility' should still be exposed to COH with IUI and only after the failure of these therapies, be offered IVF.     

Ethics and society: Artificial insemination by donor: an alternative for single women

Artificial insemination using donor spermatozoa (AID) has beenknown as a treatment for heterosexual couples where the husbandhas been found to be infertile. The first woman without a malepartner wanting a child by AID was admitted to the fertilitycentre in 1981. In the literature, two categories of alternativerequests, i.e. those from lesbian couples and those from singlewomen, are treated as equivalent family structures since bothlack a father figure. However, single women shoulder the responsibilityfor the child's upbringing alone, whereas in lesbian couplespartners share this responsibility. Some of the objections raisedto alternative types of parenthood therefore refer more to womennot having a partner at all. Since 1981, 94 single women haveasked the Fertility Centre of the Free University of Brusselsto be considered for AID treatment. Data from this group ofalternative requests have been collected. The aim is to drawup a profile of the single women who request AID, and to makea distinction between applicants who were accepted and thosewho were refused.     

Infections in IVF: review and guidelines

Since the inception of in-vitro fertilization (IVF), questions about contamination and the transmission of infection have been raised. In this review, screening for Chlamydia trachomatis, as well as medical and ethical considerations on IVF in couples infected with hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV), are discussed. IVF is not contraindicated in case of HBV or HCV infection, but the decision is far more delicate in case of HIV infection. If donor gametes or embryos are used, prevention of infectious disease transmission resides in accurate donor selection, including screening for C. trachomatis, HIV, HBV, cytomegalovirus and Treponema pallidum. In the embryology laboratory, microbial contamination of the IVF system deserves attention, and can be prevented by using sterile technique and supplementing culture media with screened sera or serum substitutes and antibiotics. Persons whose biological material is to be cryopreserved should be screened for HBV, HCV and HIV, and separate containers should be used for infected and non-infected material. Finally, transmission of infectious diseases to laboratory personnel can be prevented by adherence to strict safety guidelines, wearing of protective clothing, HBV vaccination, prohibition of mouth pipetting, and developing a plan for the disposal of bio-hazardous material.