Abstract
Sperm donation in the United Kingdom was first described as a treatment in 1945 in Mary Barton’s article in the British Medical Journal (BMJ) [1]. Before and since that publication, innumerable children have been born as a result of either formal or informal sperm donation. Sperm freezing has been undertaken in animal work e.g. cattle for many years, and advances in the reliability of freezing and thawing techniques paved the way for the formation of sperm ‘banks’. In the United Kingdom in 1990, the storage of human gametes became a licensable activity through the Human Fertilisation and Embryology Act regulated by the Authority (HFEA) [2].
1 Introduction
Sperm donation in the United Kingdom was first described as a treatment in 1945 in Mary Barton’s article in the British Medical Journal (BMJ) [1]. Before and since that publication, innumerable children have been born as a result of either formal or informal sperm donation. Sperm freezing has been undertaken in animal work e.g. cattle for many years, and advances in the reliability of freezing and thawing techniques paved the way for the formation of sperm ‘banks’. In the United Kingdom in 1990, the storage of human gametes became a licensable activity through the Human Fertilisation and Embryology Act regulated by the Authority (HFEA) [2].
Registration of all donors and recording of all treatment cycles using those donors has given a unique record of the generation of donor-conceived families in the United Kingdom, and around 40,000 children have now been born as a result of licensed treatment using donated gametes or embryos.
Regulations initially restricted donor use to the conception of 10 children, later to be extended to include genetic siblings i.e. 10 families rather than individuals [3]. This is most relevant for sperm donors since a series of donations will readily supply enough sperm to meet that number. HFEA data confirms that sperm (and egg) donors have been registered at a steadily increasing rate over some years [4]. Egg donors may be used to treat more than one recipient in any one treatment cycle but are unlikely to undertake sufficient successful cycles to meet the 10-family limit. Altruistic egg donors are generally in short supply; the shortfall being made up by known donors and so-called egg sharers, if possible siblings are catered for by embryos frozen in the same cycle.
Sperm donors may limit their donation to a single known family or withdraw their consent before the quota is reached whilst others may simply not be selected by that many recipients over the duration of their donation storage. Moreover, there is a mismatch in the numbers of donors and recipients in some racial groups resulting in a scarcity of suitable sperm. It is therefore the experience of many treatment centres and patients that there is not enough sperm to meet demand or not enough choice to satisfy need. Many patients arrange the import of sperm from abroad or travel abroad for treatment. Others may resort to online resources for sperm donors which can be risky in terms of safety and health as well as legally, including for the donor. Some such websites and services have operated illegally and been closed down.
There have been a number of initiatives over recent years which have been considered to have an effect on donor recruitment either as a primary factor or as a secondary result.
Much anxiety was generated in 2004 when the move was made to ensure that all UK registered donors (gametes or embryos) could be identifiable to offspring when those children reached their age of maturity at 18 [5]. The experience of our clinic [6] was that sperm donors in fact continued to be recruited at a similar rate but their demographics changed – they were older, more likely to be in a relationship and more likely to have children of their own. The immediate effect of the removal of anonymity was that donors recruited prior to the legal changeover could no longer be used for first pregnancies, reserved only for sibling treatments to allow completion of families. Unfortunately, shelving those previous donors (a bank built up over the course of 20 years) left a significant shortfall which has taken a further 10 years to recoup [7].
It has been argued that there should now be a lesser demand for sperm donation since intracytoplasmic sperm injection (ICSI) introduced in the early 90s greatly improved in vitro fertilization (IVF) outcomes for couples where there was a significant male factor problem. More recently, sophisticated surgical techniques for sperm retrieval have made IVF with ICSI accessible to azoospermic men including some in whom spermatogenesis is extremely limited and resulting in respectable chances of pregnancy and live birth. This change in demand has been offset, at least in part, by the increasing numbers of women either single or in same-sex relationships who come forward for licensed treatment not only because of the legal and quality assurance of the regulated centre but also because for some, and in some areas only, there is a recognition that NHS funding is appropriate in these situations thus allowing better access.
It remains true, however, that since donor sperm insemination is a low tech, minimally invasive and arguably a more natural treatment than the complexity of IVF for a woman who has no fertility problem of her own, the use of donor sperm remains a first-line choice for some heterosexual couples also.
Egg donation has been available since the first IVF cycles were undertaken since the uterus can accept an embryo whatever its parental makeup. Thus, eggs donated by another woman can be fertilized with the male partner’s sperm and placed into the recipient woman’s uterus with rates of success that mirror those attributes of the donor rather than the recipient. Egg donors are relatively hard to come by and many egg donors donate specifically for someone they know (including a family member) rather than as a so-called altruistic donation to an unknown individual. Egg sharing, a well-established strategy, has facilitated egg donation for many years but is essentially limited to those women who are paying for their own treatment. It was anticipated that those women would be deterred from donating when the anonymity of donors was withdrawn since there became then the possibility of contact from genetic offspring whom they had never parented, with the distinct possibility that they may themselves remain childless. This is offset of course by the attraction of potentially affordable treatment that might otherwise be beyond their reach in a culture where state funding for fertility treatment remains rationed. Thus careful counselling of such donors is required to ensure they have fully considered the potential ramifications of their choice to donate both for their current situation and also for their long-term future.
With changes in patient pathways – blastocyst and single embryo transfer – and improvements in freezing technologies, increasing numbers of embryos are being stored for later use. With legal storage of up to at least 10 years it is unsurprising that many embryos are abandoned or destroyed. Donation to research makes use of a proportion of those embryos where couples are willing. A smaller number are donated to treat others. Given that the decision to donate is usually made some time after the embryos have been stored and often nearing the storage consent limits, the cost effectiveness of taking a couple through the counselling, screening and consents to allow for embryo donation is in doubt if there is not already an identified recipient. Few couples have an absolute need for embryo donation i.e. where there is both a female egg problem (usually age) and an insurmountable sperm problem. Embryo recipients may however, include single, older women and older women in same-sex relationships where the chances of pregnancy are age limited. Of course whilst the principle of using embryos that have already been created is hugely attractive both ethically and financially, the drawback of such treatment for them is little freedom in the selection of characteristics of the gamete providers in combination, which may mean that embryos are rejected.
2 Recruitment of Donors
It is clear then, that there will continue to be a need for donated gametes and/or embryos to fulfil couples’ or individuals’ family aspirations, including the potential for a woman to carry her own child. It is also clear that in the United Kingdom the need has yet to be fully met with shortfalls in both egg and sperm donations and the limitations relating to embryo donation. Good and effective donation programmes are required to support that need. In Europe, successful donation – particularly sperm donation – is centred in donor banks where the core business is recruitment and management of donors. In the United Kingdom there is an increasing awareness that such an approach is valuable; however, there must be an aspiration that such banks sit within the NHS as part of a fully resourced, fully funded fertility service. Sadly that is not likely and donation is already being exploited by private markets – sperm banks, recruitment agencies etc. An attempt to provide a state-run sperm donor service failed after two years in 2016 [8]. Fresh oocyte donation is currently the usual method although with improvement in vitrification techniques the idea of an oocyte bank is becoming more attractive for more efficient use of eggs and fairer distribution. Agencies managing embryo ‘adoption’ have developed in the United States and may alter the way embryo donation is managed in the United Kingdom in time. The steps to developing a functional national service is outwith the remit of this chapter; however, whatever the setting, good donor recruitment practice is key.
Donor recruitment requires consideration of what makes a good donor and also how best to look after those men and women who come forward to be donors.
2.1 What Makes a Good Donor?
Whilst not addressing all areas of donor recruitment and assessment, the joint paper [9] published on behalf of the British Fertility Society (BFS) and Royal College of Obstetricians and Gynaecologists (RCOG) in conjunction with the British Andology Society (BAS) and Association of Clinical Embryologists (ACE) and the Association of Biomedical Andrologists (ABA) remains the authoritative document for donor screening and is referred to by HFEA in its Code of Practice [10].
2.1.1 A Suitable Donor
There are some basic requirements to ensure that a gamete donor will provide the best chance of success for treated recipients (Box 31.1).
For cost effectiveness and success and to limit the risk of a child with problems, both egg and sperm donors will be selected on the basis of age (recommended under 36 years for egg donation; recommended under 41 years for sperm and the equivalent at the time of storage for each for embryo donors). Egg quality relates to age but efficient treatment requires a number of eggs to be available which can be retrieved easily; hence, egg donors need to have a good ovarian reserve and have ovaries that are readily accessible for oocyte retrieval. Sperm quality should be good (normal WHO parameters [11]) but also survive the freeze and thaw in good condition. A decision to accept a donor whose sperm could only be used through ICSI would be considered controversial. Clearly where gametes or embryos have been stored an effective and successful freeze programme is necessary.
2.1.2 A Safe Donor (Table 31.1)
2.1.2.1 Genetic Safety
Best practice dictates that all donors provide a good account of their family history in order to pick out any thread of an inheritable disorder. A specific concern should be further explored with them, including the possibility of genetic referral for further evaluation of the family. By way of screening a simple karyotype excludes sex chromosome duplications and will pick up significant translocations. Depending on the population of origin, common specific recessive disorders are sought (typically in the United Kingdom, Caucasian population cystic fibrosis as a minimum).
Table 31.1 Screening tests for donors
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
