The Use of Donors for Artificial Insemination A Survey of Current Practices* Alan F. Guttmacher, M.D., John 0. Haman, M.D., and John Macleod, Ph.D.

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1 The Use of Donors for Artificial Insemination A Survey of Current Practices* Alan F. Guttmacher, M.D., John 0. Haman, M.D., and John Macleod, Ph.D. THE MEDICAL SCIENCES concerned with human procreation are more intimately intertwined with social problems than any other disciplines of medicine. At present there is no absolute agreement on any one of the medical social problems involved, problems probing the very essence of life. Yet about several there is a well-defined and well-documented majority opinion. This opinion is shared by laymen and doctors alike when legal adoption, sexual behavior, abortion, contraception, or sexual sterilization is under consideration. Certain religious minorities, to be sure, have opinions on some of these which are antithetic to the majority view. There are two reproductive problems, infanticide of the hopelessly handicapped newborn, and artificial insemination, about which there is less well-formulated opinion and agreement. The present discussion will be limited to a consideration of one of these, artificial insemination. It will be confined to those cases in which a donor other than the husband is the source of semen. No social problem exists when the husband is both the biologic and supposed father, no matter how conception occurs. However, a problem does arise in the presence of splitpaternity, one biologic father and a different assumed father. Despite the century-old history of human artificial insemination, its place in morals, religion, and the law has not been clarified. Recently the Public A report of a committee of the American Society for the Study of Sterility, Dr. Guttmacher, Chairman. 264

2 Vol. 1, No. 3, 1950] DONORS IN ARTIFICIAL INSEMINATION 265 Morality Council of England published a series of lectures on the subject. In this symposium as well as that held in Chicago,"' artificial insemination on the one hand was branded as adultery and on the other extolled as the ideal way to populate certain childless homes. The legal status of a child conceived through donor insemination is also undetermined. In 1939 the Journal of The American Medical Association, f basing its conclusion in large part on a Canadian Court opinion, was very dubious of such a child's legitimacy. However a favorable opinion by a New York State Supreme Court Justice in January, 1948, has made the child's position more secure.t Justice Greenberg said, "assuming again that plaintiff was artificially inseminated with the consent of the defendant this child is not an illegitimate child." It is not within the scope of this discussion to detail the steps of legal reasoning upon which his opinion was founded. A bill to assure the legitimacy of such children was introduced into the New York State legislature several months ago. In the face of so much ambiguity it appeared important to canvass the attitude and practices of physicians regarding artificial insemination. After all, the opinion of physicians in medical social matters is just as important as the opinion of jurists and clergymen. All too often doctors are prone to follow public opinion in fields where they should mold it. Previous to this study no attempt had been made to determine any cross section of medical opinion regarding donor insemination. The American Society for the Study of Sterility in 1947 appointed the authors as a committee to consider artificial insemination. The committee in turn determined to interrogate the full membership by questionnaire regarding their views of donor insemination. Ninety-six members were questioned and 71 replies were received, this constituting answers from 7 4 per cent of the membership. This excellent response is particularly remarkable when one considers that 7 of the 25 who did not answer are engaged in fundamental research and have no contact with human patients. The 71 answered questionnaires were coded by Mr. Orner Huesman, a professional statistical technician, who then compiled tables of results. The attitude of these sterility specialists toward donor insemination was tersely expressed by their answers to the first question: "Do you favor arti- American Practitioner l: , t "Artificial insemination and illegitimacy." J.A.M.A. 112:1832, t "Legitimacy of a child from artificial insemination." Human Fertil. 13:28, 1948.

3 266 GUTTMACHER et al. [Fertility & Sterility Rcial insemination from a foreign donor-do you oppose it?" Of the 71 who answered, 52 Riled "Yes" in the space to register approval, and 12 "Yes" in the space to register condemnation, a proportion of more than four to one in favor. Seven made an equivocal response. Three of these wrote "Do not oppose''; the others answered "Yes" after both "Do you favor?" and "Do you oppose...?" Even adding the 7 equivocal responses to' the 12 who clearly opposed, the sterility specialists expressed unqualired approval in the order of almost three to one. Two of the 12 who condemned donor insemination based their disapproval on a purely legal basis, 2 solely on religious grounds, 4 on combined legal and religious reasons, 1 on aesthetic repugnance to the procedure, and 3 gave no cause for their opposition. One wrote, "It is illegal, I think. It contravenes the purpose of civil marriage laws. Psychologically and sociologically dangerous. Few individual doctors are competent to discharge tremendous responsibilities involved and certainly are not licensed to do so." Another wrote, "Religious practice forbids use of donor." Yet another said, "I am of the opinion that the legal and moral ramircations are such that at this time adoption offers a more satisfactory answer to the problems of childlessness." Of the 71 members who replied 44 practice donor insemination, while 27 do not. Five who practice arti cial insemination seem to do it with little favorable conviction, for 3 actually oppose it and the other 2 were catalogued as ambivalent in attitude. Of the 27 who do not perform it, 11 are opposed, 3 are neutral and 13 favor it. In an attempt to discover what pathologic conditions of reproduction in the husband serve as indications for donor insemination, six abnormalities were named and the respondents were asked to designate the one, or ones they recognize as indications. We shall list the results, giving the total number of respondents who view the particular condition as indication for donor insemination. Azoospermia, 42; oligospermia, 24; sensitized Rh-negative wife, 18; cacogenic factors in husband's line, 11; increased number of abnormal forms in husband's semen, 10; poor motility, 9. One physician added that he considered four sequential abortions and two or more abnormal children as indications for donor insemination. Some experts in this Held have advocated the routine addition of the sterile husband's specimen to the donor's, as a psychotherapeutic aid to the

4 Vol. 1, No. 3, 1950] DONORS IN ARTIFICIAL INSEMINATION 267 couple. This appears to be an infrequent procedure, since only 5 do it consistently, and 7 occasionally, while 25 never combine the two. The great majority of physicians who employ donor insemination precede the initial treatment by a complete sterility study of the recipient. To choose the optimum time for insemination, 33 rely on temperature graphs, 8 on menstrual-interval data alone, 3 on the quality of the cervical mucus, and 1 on vaginal smears. Opinion is evenly divided between two and three inseminations per month as routine practice. When donor insemination fails to achieve pregnancy 3 respondents would discontinue attempts after the second month, 4 after the third, 4 after the fourth, 1 after the fifth, and 4 after the sixth, while 12 would continue even after ten months of failure. Forty-eight answered the question concerned with the technic employed. After exposure of the external os by a bivalve speculum, 17 ordinarily place the insemination cannula only in the region of the external os, 10 actually within the os, 10 in the cervical canal itself, and 7 routinely into the uterine cavity. Two usually introduce the cannula into the vagina without the aid of a speculum and with no attempts to expose the cervix. Sixteen of the 48 had no experience with intra-uterine insemination, while 32 had tried it either once or many times. Twenty-five of these had no infections following intra-uterine insemination while 7 did. Two of the latter reported that the infections were severe enough to require surgery. Fourteen respondents prescribe a douche previous to treatment, and 12 preliminary coitus with the husband. Forty require neither the douche nor coitus. More than half have the patient remain lying on her back for thirty minutes or longer after treatment; on the other extreme 5 think five to ten minutes sufficient. The questionnaire then considered the selection of the donor. Various authors who have published on this topic have established different criteria. Our study listed four of the commoner requisites and asked the respondents if their selection of donors was governed by them. Thirty-eight sought physical resemblance to the husband, 36 racial identity, 25 mental similarity, and 16 religious equality. Eleven included a matching of the husband's blood group, while 28 did not. Thirty-two were careful that the Rh group of the recipient and donor were compatible, while 7 paid no attention to this detail. Forty determined the fertility of the donor by semen analysis, while 17 put chief reliance on the fact that he had fathered children.

5 268 GUTTMACHER et a/. [Fertility & Sterility The length of time that an ejaculated specimen retains maximum fertility for purposes of artificial insemination is a moot point. The animal husbandryman has demonstrated that bull semen, if properly handled and stored, retains its fertilizing ability for a week. No such studies have been made in the human and all we have to work with are clinical impressions. On this basis 13 of the respondents believed that the semen specimen should be less than one hour old when used; 17 thought it highly fecund up to one hour and a half, 5 up to two hours, and 7 up to two and a half hours. Sixteen frequently divide the specimen between two recipients, while 25 use a whole specimen for each insemination. The next question attempted to discover how frequently specialists in sterility perform donor inseminations. The query was phrased, "How many donor cases have you attempted in 1947, including 1947 cases still current?" Thirty-eight physicians reported from 1 to 55 women on whom they had attempted donor insemination during The total number of women for the whole group was 568, giving an average annual patient load for each specialist who did donor inseminations of The over-all percentage of success for completed cases is reported in the following table: Percentage of Success No success Number of Doctors Reporting The required number of inseminations for the successful case was highly variable, but the preponderance of observers placed it at three to six inclusive, carried out over a period of two to four months. Physicians who practice artificial insemination are impressed by the number of patients who demand two or three children by meam of the technic. Twenty-one members who reported on this point had a total of 72 patients who returned during 1947 for donor re-impregnation. Of 30 obstetricians who replied to the questionnaire, 26 undertake the obstetric care of patients whom they have successfully inseminated arti-

6 Vol. 1, No.3, 1950] DONORS IN ARTIFICIAL INSEMINATION 269 ficially; 4 do not. It is a moot point in the me.dical code regulating donor inseminations whether a physician, who not only knows the facts, but actually creates them, is morally justified in signing the birth certificate of such a case with the husband named as "father" of the infant. Sixteen of the 19 obstetricians who answered a query concerning this have no compunction, while 3 do. ATTITUDE OF MAJORITY A study of the responses elicited by the questionnaire allows us to compile a statement which appears to be significantly representative of the majority attitude of American sterility specialists. 1. It is ethical and proper for physicians qualified in the diagnosis and treatment of infertility to perform donor artificial inseminations. Further, it is clearly recognized that the religious beliefs of some physicians, and the moral philosophy of others, may make it impossible for them to advocate or carry out such treatment. 2. Donor insemination is to be performed only if the husband is sterile or relatively sterile, or if there is indisputable genetic evidence that he should not father his wife's child. 3. Insemination should be preceded by an ordinary and thorough sterility study of the wife, and correctable defects should first have been treated. 4. The most practical method of selecting the fertile time for insemination is the temperature graph. 5. The average frequency of insemination is two or three times per cycle. 6. The technic of insemination consists in exposure of the cervix and injection of the semen onto the cervix, all around the external os but not actually into it. The patient should remain supine for at least thirty minutes after treatment. 7. Neither preliminary douche nor preliminary coitus is of proven value. 8. The characters to be matched in the selection of the individual donor are, in order of decreasing importance: racial, physical, mental, and religious. It is necessary to match the Rh factor but not the blood group of the recipient. Obviously the donor's Wassermann must be negative and he must be free of venereal infection. 9. The most accurate index of the donor's degree of fertility is afforded by

7 270 GUTTMACHER et al. [Fertility & Sterility analysis of his semen. A history of past fertility is considered a less important index. 10. A donor specimen received within ninety minutes after ejaculation is satisfactory. It is best not to divide one specimen between two recipients, though it is frequently done. 11. The likelihood of pregnancy resulting from donor insemination in the ordinary case is of the order of 50 to 60 per cent. The average successful case requires three to six treatments over a period of two to four months. 12. Approximately 15 per cent of the patients seeking donor insemination had previously conceived by donor insemination. 13. It is deemed proper by 84 per cent of the respondents to this questionnaire for the physician who carried out the donor insemination to deliver the child himself and to assent to the use of the husband's name as "father" on the birth certificate. Dr. Guttmacher, Chairman: The Johns Hopkins Hospital, Baltimore 5, Md. Dr. Haman: 490 Post Street, San Francisco, Calif. Dr. MacLeod: Cornell Medical School, 1300 York Avenue, New York 21, N.Y.