ARTIFICIAL INSEMINATION DONOR: CLINICAL AND PSYCHOLOGIC ASPECTS

Transcription

1 FERTILITY AND STERILITY Copyright 1976 The American Fertility Society Vol. 27, No.5, May 1976 Printed in U.S.A. ARTIFICIAL INSEMINATION DONOR: CLINICAL AND PSYCHOLOGIC ASPECTS AMNON DAVID, M.D., AND DALIA AVIDAN, M.A. Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer Hospital, University of Tel Aviv Medical School, Tel Aviv, and Community Mental Health Center, Ministry of Health, Malben, Jaffa, Israel Forty-four sterile couples in whom the main cause of infertility was the male factor were investigated. Artificial insemination donor (AID) was performed, timed according to the basal body temperature chart. It was found that it is important to match not only the physical appearance of the couple to that of the donor but also the blood group of at least one of the future parents. Patients were interviewed by a psychologist in order to define their marital relationship, their attitude toward the infertility, their feelings about AID in comparison to adoption, their attitude toward the donor and pregnancy, and their attitude toward their physician. The role of the psychologist in AID treatment was found to be important for careful selection of cases. He can also guide and prepare these couples to face family life in the future. Artificial insemination donor (AID) in humans is a medical procedure that has been used for roughly 55 to 60 years in the treatment of infertility involving a male factor. Its legal status has not yet been established; its moral implications are still hotly contested, and its psychologic implications are only now coming under scientific scrutiny. The main problem raised by AID does not seem to be of a clinical nature but mainly legal and psychologic. ' MATERIALS AND METHODS Forty-four infertile couples in whom the main cause of the infertility was the male factor (Table 1) were studied. Thirty-two husbands had azoospermia, two had necrospermia, and nine had severe oligospermia, with a count of 1 to 4 million/ml, with poor motility. One husband had a normal count but was the carrier of a serious hereditary autosomal Accepted December 24, recessive disease (muscular atrophy, or Hoffmann's disease), and his first child had the disease. Artificial insemination with the husband's sperm, using split ejaculates and controlled by Huhner tests, was attempted in the nine cases with severe oligospermia. When two Huhner tests were classified as very poor or bad, AID was suggested to the couples. None of the husbands knew about his infertility before his marriage. TABLE 1. Male Factor Spermatogram patients Etiology Azoospermia 32 Varicocele-treated, 2; untreated, 2 Necrospermia 2 Orchitis after mumps," 1 Oligospermia b 3-4 x IO"/ml 3 Cryptorchidism, x IO"/ml 3 Klinefelter's syndrome, 1 1 x IO"/ml 3 Unknown, 37 (84%) Normal" 1 "One child before orchitis. b Seven men had no motile sperm; two had a motility grade of 2 to 3. cpatient had familial muscular atrophy and had fathered one child with the disease.

2 Vol. 27, No.5 ARTIFICIAL INSEMINATION DONOR 529 The ages of the wives ranged from 21 to 43 years; 8 patients were 20 to 25 years old, 20 patients were 25 to 30, 9 patients were 30 to 35, 4 patients were 35 to 40, and 3 patients were over 40 years of age. The number of patients in each age group is in accordance with the Gauss curve expected in the common reproductive age. Twenty-seven women had normal ovulation; seventeen"had abnormal ovulation responding to regular hormonal treatment including clomiphene citrate or exogenous gonadotropins. The emotional factor played only a very small role in inhibiting ovulation, and only 3 of the 44 women had poor basal body temperature curves during the treatment, compared with the curves before AID. Three patients were Rh-negative. All of the donors were students. They were physically and mentally sound and had uneventful medical histories and good sperm analyses. They were selected in sufficient number to match most of the gross physical characteristics of both spouses: height, complexion, and color of eyes and hair. Blood groups were matched to those of at least one of the future parents. This was considered important because of early training in first aid given in our schools and knowledge of blood groups. The importance of matching to a negative rhesus factor of the future mother is obvious. The rare possibility that AID children conceived from the donor and the donor's own children might unwittingly marry and have children was explained to the donor. This possibility seems to be very small, once in 50 or 100 years according to Glass,! provided that the number of babies fathered by a single donor remains small. Fresh semen was obtained by masturbation and was deposited by means of a syringe in the external os of the patient's cervix. Since the life-span of spermatozoa is short, timing of insemination is critical. The basal body temperature chart was used for accurate timing. In patients with normal, biphasic cycles and in patients treated with clomiphene or exogenous gonadotropins, insemination was carried out beginning on day 12 of the cycle. An elevation of temperature, even of 0.10 C above that of the previous day, induced us to inseminate. If the temperature rose on consecutive days, insemination was performed on alternate days. The rise in temperature is more reliable than the classic midcycle fall (noted in only 40% of our cases) as an indicator of the day of ovulation. Following insemination, patients were allowed to remain supine for 30 minutes. A privileged and secret record of the donor was kept, and in cases where another pregnancy was wanted we tried to use the same donor. A psychologic evaluation was made of all patients. The patients were divided into three groups. The first group was interviewed before AID was performed. The second group was interviewed during pregnancy, and the third group after delivery. Both husband and wife were interviewed separately by a psychologist, and were told that anonymity would be fully respected. The interview consisted of an oral questionnaire, and the full answers were written down by the interviewer. This type of interviewing was preferred to yes or no answers, since the aim was to gather as much information as possible on each question, not limiting the answers of the patients as often occurs in routine questionnaires. The questionnaire did not focus on the personality structure of each spouse but on some interpersonal factors that might represent the frame of the future family in which the AID child would have to develop. The interview did not concentrate on attitude toward the child, since nearly all were newborns and parental overenthusiasm over newborn first babies could not be excluded. The questionnaire was composed of 60 questions. The questions were focused on the following problems: (1) marital rela-

3 530 DAVID AND AVIDAN May 1976 tions, (2) attitude of the husbands toward their infertility, (3) feelings about AID versus adoption, (4) feelings toward the donor, (5) feelings concerning the pregnancy, and (6) attitude of the patients toward their physician. Fifteen questions dealt with the marital relationship of the couple. For example, Question 16: "Are there any traits which you and your husband have in common-sociability, optimism, openness?" Question 17: "Are your attitudes similar to your spouse's (education, rearing children)?" Question 18: "What happens when your opinions about a specific subject differ?" Ten questions dealt with their attitude toward infertility. For example, Question 9: "Once you learned about your sterility/your husband's, how long did it take you to seek AID treatment?" If it was a long period: "Why did it take so long?" Question 14: "What did you experience when you discovered your/his sterility?" Question 24: "Have you thought about a divorce because of your/your husband's sterility?" Twenty questions were related to the attitude of the patients to the treatment, specifically AID versus adoption. For example, Question 30: "Why did you choose AID?" Question 31: "Do you plan to have other children with the same treatment? Why?" Question 32: "Did you have any religious doubts while deciding about AID?" Question 35: "Do you believe a woman could become more inclined to adultery because of the AID?" Question 41: "Do you think the husband should be present, near his spouse, during the treatment? Or immediately following insemination?" Question 42: "Should the process of insemination be carried out by the husband himself (after being instructed by the doctor)?" Five questions concerned the couple's attitude toward the donor. For example, Question 52: "Do you think you should know who the donor is?" Question 53: "Is there any difference between a blood donor and a sperm donor?" Five questions were related to the pregnancy. For example, Question 44: "What did you experience during the last 3 months of your/her pregnancy? (growing abdomen, active movements ofthe fetus)?" Question 45: "Did the pregnancy have any influence on your relationship?" Five questions were related to the couple's attitude toward the physician. For example, Question 39: "Do you resent any particular feelings about the physician treating you/your wife?" Question 40: "Did you, or do you have, any sexual feelings towards your gynecologist performing the insemination?" The origins of our patients are listed in Table 2. Patients of Eastern origin were considered to be more religious, keen about tradition, and strict about morality. Religion and tradition were not obstacles to treatment. Twenty-five per cent of our patients were observantly religious. Only Orthodox patients refused AID. RESULTS Of the 44 patients undergoing AID, 37 conceived, resulting in 30 living children, 6 abortions, and 1 stillbirth. The sex ratio was 61.5% boys to 38.5% girls. The newborns were examined at birth and all but one were found to be in good health and without apparent defects. The eldest of these children is now 6 years old and is mentally and physically welldeveloped. One child died of a severe congenital anomaly of the heart, but TABLE 2. Origin of Patients Born in Israel Born abroad Origi.-:t patients Origin patients European 12 European 12 Eastern 3 Eastern 14 (N orth Africa, Iraq, Iran) Yemenite 1 Yemenite 2

4 Vol. 27, No.5 ARTIFICIAL INSEMINATION DONOR 531 following another pregnancy with AID a normal baby was born. The psychologic interviews of the husbands disclosed that 80% had guilt feelings. They felt that they could not give proof of their manhood or act as real fathers. They had the feeling that they did not fulfill the expectations of their families and society. They also showed guilt feelings and self-accusation toward their wives because "she is the victim of the treatment which is triggered by my infertility." Most of the wives felt guilty because they did not share their husband's failure in the reproductive process. Part of the guilt feeling was due to their pride in their femininity, which they could prove by the treatment. Until treatment, they would be blamed for their infertility, which aroused in them a feeling of resentment against such an image. The same feeling of resentment was directed, subconsciously, against the husband who was really responsible for the infertility. During the pregnancy itself, most of the couples reported a significant fall in the rate of intercourse. One husband was very severely upset during the second and third trimesters of his wife's pregnancy and described a few episodes of clinical depression. Fifty per cent of the pregnant women were proud of their pregnancies, deliberately exaggerating their lordosis, and 90% of the stepfathers were overwhelmed at 12 weeks of pregnancy when listening to the fetal heart beats with an ultrasonic apparatus. In two cases of marital conflict the cause was tension on the part ofthe wife, due to the pregnancy, since it seemed that the presence of any child would only be a burden for her. In the third group-those interviewed after delivery-inquiry disclosed parental happiness. The wives reported that the fact that the husbands were escorting them to the treatment and were near them after the insemination gave them the feeling that the husbands were involved in the achievement of their goal. Five patients reported feelings of an emotional tie with the gynecologist, but all were against the possibility of the husband's performing the insemination: "It is a treatment and should be done by a doctor." Husbands and wives unanimously favored AID over adoption. They wanted the child to inherit the qualities and characteristics of his mother. They wanted to experience pregnancy and the delivery of a baby. All maintained that the child "is more ours." The attitude toward the donor was on a narcissistic level. All of the patients inquired about his mental and physical qualities. They regarded the semen of the donor as a mere fertilizing agent whose product in conception imparted nothing alien to the marriage. By paying the donor, indirectly, they had no resentment or other feelings toward him. DISCUSSION The psychologic aspects of AID have received very little attention 2-5 ; the emphasis has been mainly on the psychologic aftereffects of AID following the birth of the child. Guilt feelings of husband and wife, husband's distress by lack of manhood proof, conflict of the wife between the feeling of sharing her husband's failure and her own pride-all of these began as soon as the couple learned the true and definitive etiology of their infertility and continued during the time they had to decide how to solve the problem, by AID or adoption. Following their mutual decision for AID, they expressed a solid and united approach to the various situations that they had to face. There was a definitive consolidation of the marital relationship in the group before the treatment as well as after delivery of the AID child. The choice of AID by these patients is understandable, since the future parents felt more confident and

5 532 DAVID AND AVIDAN May 1976 united when no one knew the etiology of their infertility and when the masculine pride of the husband was respected. Adoption would have created more conflicts with their environment, especially for families of Eastern origin. The fact that the rate of intercourse was lower during the time of pregnancy could be interpreted as a detachment of the husband from his spouse. But when investigating 10 couples infertile as a result of hormonal disturbances, we encountered the same fall due to the fear of causing abortion. On the other hand, the growing abdomen may be a reminder to the husband of his "incapability" and of a rival father. The cases of nervous breakdown and marital conflict stress the importance of careful selection of cases for AID, as it may render unstable personalities more unstable or intensify frigidity and guilt feelings. The interviews pointed out that both spouses are more concerned by the pregnancy and the baby itself. They do not prepare themselves for the new aspect of family life, so that the role of the psychologist would also seem to include guiding and preparing these couples to face family life. In analyzing the results of the interviews it was evident that the patients did not consider the treatment as adultery, and the gynecologist seemed to be the one entitled to perform it; the donor had only one function, which was to produce the agent offertilization. Donors were not interviewed, although it would have been interesting to learn their motives, apart from the financial aspect, if any. This positive view on the treatment is reinforced by the fact that 13 patients requested new treatment following the birth of their first child. In conclusion, AID is likely to be used more widely in the future than it is at present if only because fewer babies will be available for adoption, in view of the increased use of contraceptives and abortion. Because of its relative newness" many countries have inadequate legislation on AID, and there have been very few controlled studies, especially of psychologic implications. The expanding use of this treatment without doubt will involve couples who are psychologically unsuited for it, leading to unfortunate consequences. As soon as these couples are informed of the cause of their infertility and until they make a decision, they are in need of psychologic aid and guidance for emotional support. On the other hand, the 20 couples interviewed after their delivery were satisfied because of the consolidation of their marital relationship. Moreover, 13 patients requested another treatment. To the five known characters in the AID drama, i.e., the mother, the donor, the stepfather, the child, and the gynecologist, we should add another important one, the psychologist, to ensure a complete chance of success in this form of treatment of the infertile couple. REFERENCES L Glass DV: Quoted in report of the departmental committee on human artificial insemination, London, HM Stationery Office, , Farris EJ, Garrison M: Emotional impact of successful donor insemination. Obstet Gynecol 3:19, Jackson MH: Artificial insemination (donor). Eugen Rev 48:203, Levie LH: An inquiry into the psychological effects on parents of artificial insemination with donor semen. Eugen Rev 59:97, Watters WW, Sousa-Poza J: Psychiatric aspects of A.I.D. Can Med Assoc J 95:106, 1966