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Meet our donor applicants…
Hallie, age 23, has been accepted as an egg donor at a donor egg (DE) program which practices anonymity. During a blood draw, she mentions to the nurse that she is hoping that she can someday meet her genetic offspring. The nurse shares the conversation with the program’s mental health professional.
Eva, age 28, meets with a psychologist for an egg donor evaluation. She describes a relatively problem-free life as a well-functioning graduate student with a close circle of friends. She denies psychological problems, psychotherapy and psychiatric medication usage, past and present. But the MMPI-2 psychological testing, taken later that day, reveals a likelihood of clinical depression.
Jeff, age 28, applies for the sperm donor program after a report in the news about the shortage of sperm donors. He tells the mental health professional that he’s currently not in a relationship or in a phase of life where he cares much about children. He has not thought much about potential offspring and seems not to care either way. However, he’s enthusiastic about getting thoroughly screened and learning more about his own fertile status. The laboratory technician who goes over the paperwork with him notices that Jeff seems extremely interested in his sperm count and his genetic screening.
Kaitlyn, age 25, is enthusiastic about anonymously donating her eggs and feels comfortable with the prospect that her donation will result in the creation of one or more children who are genetically related to her but not her children. During the course of her psychological evaluation, she reveals that she does not plan to tell her boyfriend about the prospective donation. She explains that she was brought up in a highly progressive family but that he was raised in a very traditional culture and “wouldn’t understand” her desire to help another woman in this way.
James, age 35, meets the psychologist who does the counseling for the sperm donor program. He is motivated to donate sperm as he’s experienced his best friend Sam struggling with not being able to conceive naturally. After discussing his idea of becoming a donor with his wife, the couple decides that they would prefer an anonymous system so as not to interfere too much with their own family life with their two sons. James is a well-functioning lawyer without a history of psychological problems. His family history, however, reveals several cases of bipolar disorder.
Barbara, age 24, tells the reproductive medicine program’s social worker that she is highly motivated to donate her eggs because she wants to help childless couples. However, she is strongly against abortion and wants to be assured that a pregnancy she could help to create could not potentially end up being terminated.
Introduction
“It’s a very important decision in my life to donate sperm. It fits into my life and into my way of thinking. I’m a bone marrow donor, I’m registered as an organ donor in case I have an accident or something. I’m just saying, donating sperm is a very personal issue. It defines me.”
The egg donor or sperm donor plays a very important role in the reproductive medicine practice. The donor is both a patient and not a patient. He or she is a patient in that s/he must be taken care of both physically and psychologically. He or she is not a patient, in that the donor is not presenting for his/her own treatment. In fact, especially for the egg donor, who is undergoing medical risk in order to provide her oocytes to another woman who wishes to have a child, treatment goals for the patient (i.e., the donor egg recipient) may be in conflict with the interests of the donor [1]. One could argue that, when it comes to psychological aspects of gamete donation, the interests of either the sperm or the egg donor could conflict with the interests of those receiving donated gametes. For example, a parent’s wish for his/her child to someday know the identity of the egg or sperm donor, whose gametes helped to create this child, may conflict with a donor’s desire to not be known and/or contacted by any genetic offspring.
Anonymous gamete donation: history and current practice
Though isolated cases of donor insemination were reported at various points in the early and mid twentieth century, it was in the 1970s and 1980s that improved methods of sperm collection led to the creation of sperm banks [2]. Contrary to popular belief, sperm donation is not the result of a casual impulse that leads a young man to pay a quick visit or two to a sperm bank, make a few dollars, and rapidly move on. Rather, most sperm banks in the United States require the donor to make a relatively time-intensive and long-term commitment of at least one donation weekly for a period of one year [3].
Oocyte donation requires the technology of in vitro fertilization, which was pioneered in 1978. In 1983, oocyte donation was introduced when Australian physicians provided an egg from one patient to another fertility patient with ovarian failure [2].
Though sperm cryopreservation has been practiced for over 60 years, oocyte cryopreservation has been a more challenging endeavor for scientists. Oocyte cryopreservation is only recently a promising technology due to medical and laboratory advances, in particular the use of a freezing technique known as vitrification. As of 2012, the American Society for Reproductive Medicine (ASRM) no longer considers oocyte cryopreservation to be an experimental procedure [4]. Though egg donation with fresh oocytes (i.e., synchronization of donor egg recipient and donor in their cycles, retrieval of eggs from the donor, fertilization by recipient’s partner or sperm source, and consequent creation of an embryo or embryos which are then transferred into the uterus of the recipient) remains prevalent, egg “banks” of cryopreserved donor oocytes clearly represent a growing trend in the world of egg donation.
Worldwide, gamete donation is by no means a homogenous entity. In some countries, gamete donation is legally prohibited. The International Federation of Fertility Societies (IFFS) 2013 survey found that sperm donation for use in non-IVF infertility is not allowed in 22% of the countries surveyed, it is permitted in 51% of the cases, it is not specifically mentioned in roughly 20% (suggesting that it is used in about 70% of countries), and the status is unknown in 4% [5]. Respondents reported that sperm donation is not allowed in Egypt, Libya, Senegal, Tunisia, Saudi Arabia and Turkey, and in other African countries it is not addressed (Uganda, Togo, Ivory Coast, and Democratic Republic of the Congo). These prohibitions stem from religious, moral and/or cultural traditions. In most countries that follow Islamic law, gamete donation is disallowed or restricted. With respect to egg donation, a similar trend is recognized from the survey, with 73% of the countries reportedly performing the procedure, 12% reporting it is “not mentioned” in the guidelines and 14% not performing egg donation [5]. Most European countries reportedly allow egg donation, with the exceptions of Austria, Germany, Norway and Switzerland.
For countries that do allow gamete donation, policies and practices vary, most notably in terms of the issues of donor anonymity and monetary donor compensation. A donor who begins in the context of anonymity, meaning that he or she is unknown to the donor sperm or egg recipients, may remain anonymous or, alternatively, at some point his or identity may be revealed to the recipients or, more likely, to the adult (18-year-old) offspring of the gamete donation. In the United Kingdom, in 2005, the Human Fertilisation and Embryology Authority (HFEA) eliminated all donor anonymity and monetary compensation (other than minimal expenses) and established a central donor registry; all gamete donors must agree to be contacted in the future by genetic offspring [6]. In Australia, the state of Victoria has a mandatory donor registry [7]. Canada established the Assisted Human Reproduction Agency in 2004. Canada moved to prohibit donor anonymity through the Assisted Human Reproduction Act, but legal challenges to the Act have left the anonymity question under the jurisdiction of the individual provinces, and Canada allows for both anonymous and identity release donation. Donor compensation is prohibited [8].
When countries have implemented regulations to eliminate donor anonymity and/or to eliminate or drastically reduce donor compensation, these countries have often seen significant drops in individuals donating their eggs or sperm. According to a review in 2011 by HFEA of changes in gamete donation in the UK since the 2005 removal of donor anonymity and donor compensation, there are reported waiting times of up to five years for donor oocytes. The number of patients receiving donor gametes has dropped, and unlicensed donor/recipient matching websites are on the rise [9]. In Canada, del Valle and associates [10] attempted to recruit sperm donors based on altruistic rather than economic motivation, but the vast majority of prospective donors either withdrew their applications or were disqualified, and the recruitment effort had little success. Ekerhovd and colleagues [11] note that in Sweden, where legislation requires that sperm donors be identifiable to offspring, there is a “shortage of sperm donors.” Swedish healthcare providers are willing to assist in treatment abroad and more than 250 Swedish donor sperm recipients travel to Denmark each year for reproductive purposes. A study of Danish sperm donors [12] concluded, “few [donors] would continue if they did not receive financial compensation” and also that “to maintain anonymity is still important for the majority of the donors.”
At the same time, it has been posited that, although the initial response of prospective donors is a negative attitude to a legislative change of removing anonymity, the way in which donors are recruited and the current societal legislation, practices or beliefs about anonymity or openness seem to play a very important role in donors’ attitudes and perhaps in their behavior, meaning their decision to donate or to continue donating [13]. Demographics also seem to matter: sperm donors who are older and married with children tend to donate even when anonymity is not assured. Daniels [14], in reviewing the research regarding sperm donors’ views on anonymity, has hypothesized that identity release donors will need to be recruited via a different model than has been used to attract anonymous donors.
Gamete donation and the role of the fertility counselor
“I think it’s important to be able to see a professional counselor because, you know, it needs to be a conscious decision. You have to be sure you know what you’re getting into.”
The fertility counselor is a mental health professional (MHP) with specialized training who, in the context of gamete donation, often serves multiple functions. One important function is consulting with the gamete donor for evaluation and counseling. Within this function, the fertility counselor plays multiple critical roles, from “assessing the suitability of the donor, to facilitating the donor’s understanding of the implications of donating one’s genetic material to another person, and in providing long-term support and education” [2]. It is important that the fertility counselor recognize the complex nuances of his/her clinical relationship with the donor.
The fertility counselor’s primary goal is assessing the donor in order to determine his/her suitability as a provider of gametes/genetic material to others (the recipients of the genetic material). The aim of the session is not to tackle the donating individual’s general psychological concerns or difficulties, nor to enhance the donor’s psychological well-being, as would occur in counseling or psychotherapy. Specifically, the fertility counselor is addressing these broad questions:
1) Is there reasonable certainty that the donor is without significant psychological difficulties that could potentially indicate problematic genetic susceptibilities that could be passed on to prospective genetic offspring?
2) Is there reasonable certainty that the life experience of donating would be psychologically tolerable for the donor, that there are neither inherent psychological susceptibilities nor specific emotions/psychological conflicts about donating gametes that could render the experience of donation emotionally harmful or destabilizing for the donor?
It is important for the fertility counselor to recognize the nature of his/her clinical relationship with the donor; and gamete donor candidates need to be made aware that the fertility counselor is meeting with them for assessment rather than therapeutic purposes. At the same time, the fertility counselor must prioritize the psychological well-being of the egg or sperm donor in the counselor’s dealings with the donor and with the medical team.
The ASRM recommends psychological screening of oocyte and sperm donors in their Practice Committee opinion and outlines guidelines for psychological care in gamete donation [15]. In 2002, the Psychological Special Interest Group (PSIG) of the European Society of Human Reproduction and Embryology (ESHRE) published the Guidelines for Counselling Infertility, a comprehensive document outlining fertility counseling issues with specific recommendations on sperm and oocyte donation [16]. Additionally, ESHRE has issued a wide array of Task Force reports including one on gamete donation [17]. Included in the ESHRE guidelines are recommendations that the psychological evaluation include an assessment “of the general abilities and intellectual capacity of the donor candidates,” along with “minimal information about the donor concerning appearance, education, profession, social background and motivation for donating” [17, p. 1408].
Over the years, worldwide, fresh egg donation cycles have generally taken place within a reproductive medicine practice or program. Often, per ASRM and IFFS recommendations, egg donors are evaluated by a fertility counselor, frequently one who practices within the reproductive medicine program or has an ongoing affiliation with the program. In sharp contrast, in the USA and throughout the world, sperm donors are typically not offered fertility counseling for gamete donation or meet with a MHP. Donation cycles generally take place in physicians’ offices and reproductive medicine programs with sperm banks supplying the frozen sperm and, while anonymous sperm donors are evaluated medically by the banks, they rarely meet with a MHP for counseling or assessment.
Assessment of the gamete donor
The psychological evaluation of the gamete donor and the attention to the donor’s well-being go hand in hand, and do not entail separate or distinct approaches in the fertility counselor’s interactions with the donor. Evaluation of the donor involves a psychological assessment of the donor’s childhood and life history, his/her psychological functioning both as a child and as an adult, and the assessment for any psychopathology, including possible mental health and substance abuse issues. Table 8.1 contains a detailed list of areas to be addressed in the psychological assessment of the gamete donor.
Donor interview: psychological assessment.
A) Current/Adult Life Situation 1) Job/career 2) Educational background 3) Relative stability of life situation vs. current/ongoing stresses 4) Marital/relationship status & relationship history 5) Interpersonal/social relationships 6) High and low points of donor’s adult life |
B) Childhood/Family History 1) Family constellation/family life 2) Donor’s personality/experience of self as a child 3) Donor’s experience of parents 4) Parents’ relationship with each other 5) Donor’s experience of siblings 6) Significant family problems – physical or mental illness of parent or other family member, alcoholism/substance abuse in family member, abuse within or outside family, sexual abuse within or outside the family 7) High and low points of donor’s childhood |
C) Psychological Assessment 1) Mood and affect of donor 2) Content and process of thought 3) Donor’s communication with interviewer 4) Assessment of possible mood disorder 5) Assessment of possible anxiety disorder 6) Assessment of possible eating disorder 7) Assessment of possible alcohol/substance use/abuse 8) Assessment of psychosis |
D) Psychological History 1) History of psychological difficulties 2) History of psychotherapy 3) Psychiatric medication usage past or present 4) Alcohol/substance abuse history 5) Family history of psychological and/or substance problems |
Psychological evaluation of the donor also includes a detailed effort to understand the donor’s relationship to his/her donation: motivation for and feelings about donating gametes, feelings about the prospective genetic offspring, and implications of the donation in terms of anonymity vs. identity release. Table 8.2 details important areas to cover in speaking with donors about the psychological meaning and implications of donating one’s gametes.
Donor interview: implications of donation.
A) Motivation 1) Stated motivation for donating eggs or sperm 2) Altruistic and/or economic motives, or other motives (personal/psychological motives) 3) Need for money, plan for using money earned through donating 4) Any coercion/pressure from others (e.g., for financial reasons) 5) History of reproductive/pregnancy loss or pregnancy termination 6) Donor’s relationship to his/her own children |
B) Donation of Genes/Genetic Connection with Prospective Child 1) Perceived connection to recipient(s); feelings about person(s) receiving gametes 2) Relinquishment of control/dominion over gametes 3) Feelings about genetic connection with child “out there” who is not one’s own 4) Thinking about prospective genetic connection in the shorter and longer term 5) Relationship to/feelings about own’s gametes/DNA |
C) Anonymity vs. Identity Release Issues 1) Clarity of donor regarding anonymous vs. non-anonymous nature of gamete donation 2) Comfort of donor with anonymity (or non-anonymity) plan 3) Limits of anonymity 4) Implications of anonymity or identity release over the long term 5) Willingness to be contact in the future if there is medical need of donor-conceived offspring. |
D) Physical/Medical Aspects 1) Comfort with medical setting 2) For egg donors, comfort with medical procedures and medications 3) For egg donors, appreciation of risks of donation process 4) Restrictive aspects of serving as a gamete donor |
E) Social Support 1) If donor has an intimate partner, has he/she discussed the donation with the partner?  Stay updated, free articles. Join our Telegram channel
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