Donor insemination (DI) has undergone radical changes in the last 25 years; for example, moving to exclusive use of cryopreserved semen, increasing treatment of patients who do not suffer from male factor infertility and changes in society’s attitudes to the use of donor gametes, to name but a few. The main focus of this chapter is to briefly examine the past to gain some perspective of where we have been, present a discussion of what major changes have occurred and thoughts on where the future may lie.

In the 1980s, a dramatic event changed the way DI operated, namely the transmission of human T-cell lymphotropic virus type III (HTLV-III) (since termed HIV) to four of eight recipients of donor semen from a man who was HIV sero positive. This added further evidence that HIV was transmitted via semen but, for DI, it had a profound impact on the recruitment, selection and screening of donors [1]. It was also recognised that there was a delay in men sero-converting after they became infected. Effectively, not only did it mean the mandatory use of cryopreserved spermatozoa, but also that frozen donor semen needed to be quarantined prior to treatment. Although a number of authorities (e.g. CECOS – Centre d’Étude et de COnservation du Sperme) had operated a cryopreservation service prior to 1985, many other clinics used fresh semen for convenience and the perception of higher success rates. Unfortunately, the change to exclusive use of cryopreserved cells and quarantining samples was a gradual process with many reluctant to change their beliefs that cryopreservation dramatically reduced success rates as well as adding significant inconvenient steps and associated costs to the process. Remarkably, even 10 years after the recognition of the risk of HIV transmission, some clinics still used fresh semen. We do not know if this latency in uptake had an effect on the transmission of HIV, such as were there further unnecessary cases of HIV following insemination of non-quarantined semen? Technology took some time to catch up with clinical practice so that rapid testing of samples for HIV and other viruses would be robust and reliable; however, even with these available technologies, cryopreservation and quarantine remain the standard practice.

Further changes regarding the way DI services operated were catalysed by the introduction of intra-cytoplasmic sperm injection (ICSI), which enables the use of partners’ sperm utilising in vitro fertilisation (IVF) technology, thus avoiding the need for donor sperm. Initial data in national registers showed a dramatic decrease in the use of DI as ICSI steadily replaced DI as a potential treatment. In fact, for some time it looked as though DI would become a redundant treatment and disappear altogether. On reflection, this doomsday scenario was premature. Data from the United Kingdom (UK), where ART is regulated by the Human Fertilisation and Embryology Authority (HFEA) shows that since 1992 (when data were recorded) there is a clear trend with a decline until about 2007 (3,901 cycles), but then an increase or at least stabilisation to current times (5,446 cycles, 2016) (Figure 16.1, Table 16.1). Moreover, the use of donor sperm in IVF/ICSI has increased steadily (1,288 cycles in 1992 compared to 3,041 in 2016, Table 16.1). A similar picture is seen in other countries, for example in Australia and New Zealand, where there has been a decline from 5,425 DI cycles in 1998 to 3,356 cycles in 2005, but this figure then stabilised to 3,198 in 2016. In parallel, there has been an increase in the number of ICSI cycles in the UK (137 in 1992 to 24,441 in 2016, Table 16.2, Figure 16.2), although the proportion of ICSI/IVF cycles has not changed since 2004 (~35%) (Figures 16.3 and 16.4).

Figure 16.1 Number of DI cycles per year in the UK, 1992–2016.

Figure 16.2 Number of ICSI cycles per year in the UK, 1992–2016.

Figure 16.3 Percentage of total IVF/ICSI treatment cycles which used ICSI, in the UK 1992–2016.

Figure 16.4 Proportion of IVF/ICSI cycles in the UK, 1992–2016.

Whilst it is not possible to accurately quantify the reasons for the decline in DI treatment, an overriding factor is the availability of ICSI. However, in the UK, as with a number of other countries (see below), there has been a significant number of changes in the regulatory framework, for example removal of anonymity of gamete donors which may have exacerbated the decline in the availability of donor sperm hence restricting the possibility of treatment. To counterbalance this there has been increased use of DI for non-male factor cases. As such, there appears to be a continual steady demand for DI (~100 per million population). For example, in 2016 in the UK, only 42% of the DI recipient cycles were for male partner infertility, 41% of patients had a female partner and 17% for no partner. DI is therefore a treatment which has evolved from almost exclusively treatment for male factor infertility to include almost equal numbers of social infertility (no male partner) cases.

A third key change in DI has been in the regulatory and operational landscape. Perhaps the most significant change was the removal of anonymity in a number of countries. Sweden was one of the first to effectively remove anonymity. On 18 March 1985, the Swedish Parliament enacted legislation providing the child with the right “when sufficiently mature” to receive identifying information about the semen provider. The reasons for the removal of anonymity include the principle that children have a right for information regarding their genetic parents. Following the example of Sweden, a number of countries have removed the use of anonymous sperm donors, for example, the UK. Whilst there were initial concerns among infertility service providers that the change in policy would result in a significant decline in the availability of donors, at least in UK, the number of donors has stabilised so that the demand for treatment (~4,500 DI cycles per annum) can be satisfied. Interestingly, not all countries have adopted a regulatory framework whereby the children born from DI can find out the identity of their biological father and there is wide variation, even within the European Union (EU).

The change in anonymity status has been in place in several countries for some time, hence we have more research, albeit variable, in its conclusions, to indicate the magnitude of these changes. Clearly, despite existence of regulation/legislation, at least initially, not all couples had told their children about the mode of conception let alone their ability to identify their biological father [2]. The inevitable conclusion is that considerable support needs to be in place for recipient couples. A 20-year follow-up study in Sweden provided encouraging data in that the majority of couples were relatively open about their treatment and their likelihood of disclosure to the offspring. Moreover, data from a single CECOS centre where sperm donation is anonymous showed that an overwhelming majority of parents of DI-conceived children had disclosed the use of donor gametes to their children [3]. Furthermore, a nationwide study of CECOS centres came to similar conclusions [4]. In contrast, an Australian study found that only one in three couples had told their offspring about their origins [5]. However, further research is necessary to determine exactly how this information is presented to the offspring, at what stage, in what format and what support structures both formal and informal are necessary to facilitate the information sharing process [2,6].

Whatever the intellectual arguments for/against anonymity, we must be cognisant of the real-world situation. Critically, in this age that genetic testing is widely available to individuals such as “23and me” (www.23andme.com/en-gb/), it is inconceivable that we can maintain a system where children are prevented from discovering the identity of their biological father. McGovern and Schlaff present this eloquently in their article “Sperm donor anonymity: a concept rendered obsolete by modern technology” [7]. It may be a difficult transition for some countries/states to move to a system whereby the children are able, by regulation or legislation, to identify the biological father but we can learn from other examples such as Sweden and be proactive in this important arena.

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