Susan Caruso Klock, Ph.D.,* Jan Elman Stout, Psy.D., and Marie Davidson, Ph.D.

Transcription

1 FERTILITY AND STERILITY VOL. 72, NO. 6, DECEMBER 1999 Copyright 1999 American Society for Reproductive Medicine Published by Elsevier Science Inc. Printed on acid-free paper in U.S.A. Analysis of Minnesota Multiphasic Personality Inventory-2 profiles of prospective anonymous oocyte donors in relation to the outcome of the donor selection process Susan Caruso Klock, Ph.D.,* Jan Elman Stout, Psy.D., and Marie Davidson, Ph.D. Section of Reproductive Endocrinology, Northwestern Medical Faculty Foundation, Northwestern University School of Medicine; and IVF Illinois, Chicago, Illinois Objective: To examine the scores of prospective anonymous oocyte donors on the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) in four outcome groups. Design: Chart review. Setting: Academic medical center. Patient(s): One hundred fifty prospective anonymous oocyte donors who underwent a preliminary screening and a 1-hour structured psychological interview and who completed the MMPI-2. Intervention(s): Psychological evaluation prior to donation. Main Outcome Measure(s): Scores on the MMPI-2 and outcomes of the donor selection process. Result(s): Seventy (47%) women were accepted as donors and completed one donation cycle; 30 (20%) were accepted as donors but did not donate because of medical reasons or relocation; 18 (12%) were accepted as donors but were noncompliant; and 32 (21%) were rejected as donors because of psychological concerns. Statistically significant differences were found between outcome groups on scales F, K, 1, 2, 7, 8, and 0. Although these differences were statistically significant, all group subscale mean scores were in the average to low-average range and differences between group means were small. Conclusion(s): The MMPI-2 differentiates between prospective donor outcome groups, but psychologists need to interpret the results of the MMPI-2 carefully in the context of clinical interview information. (Fertil Steril 1999;72: by American Society for Reproductive Medicine.) Key Words: Oocyte donation, psychological, MMPI-2 Received March 23, 1999; revised and accepted June 30, Reprint requests: Susan Caruso Klock, Ph.D., Department of Obstetrics and Gynecology, 333 East Superior Street, Suite 1576, Chicago, Illinois (FAX: ; sck318@nwu.edu). * Department of Obstetrics and Gynecology, Northwestern University School of Medicine. Department of Psychiatry, Northwestern University School of Medicine. IVF Illinois /99/$20.00 PII S (99) The use of donated oocytes has made pregnancy possible for women with impaired or absent ovarian function (1). According to the 1995 data of the Society of Assisted Reproductive Technology, 8% of IVF cases, or approximately 4,783 cycles, involved the use of donated oocytes that year. The rate of live birth per transfer in 1995 was 35.5%; 3,352 fresh transfers resulted in the births of approximately 1,190 infants (2). Expanded clinical application and consumer demand likely will yield a substantial increase in the number of live births derived from donated oocytes in the future. A 1993 survey conducted by the Mental Health Professional Group of the American Society for Reproductive Medicine of providers of donated oocytes indicated that although there is increasing clinical demand for donated oocytes, there is little uniformity in the medical and psychological screening of prospective donors (3). Psychological screening of prospective donors was required by 77% of programs, but the content of the screening examination was inconsistent. This led the Mental Health Professional Group to draft guidelines for the psychological screening of oocyte donors. These guidelines recommend a structured clinical interview and psychological testing for prospective gamete donors (4). A psychological test that has been used with prospective oocyte donors is the Minnesota Multiphasic Personality Inventory (MMPI) 1066

2 (5, 6). The second edition of this test (the MMPI-2) contains 567 true/false empirically derived items that are used to differentiate between individuals with various types of maladaptive personality styles and psychological problems (7). The MMPI-2 is useful in generating hypotheses about the test-taker s psychological functioning but should not be used solely to diagnose psychiatric illness (7). The items are divided into three validity scales that indicate the test-taker s propensity to answer in socially desirable, defensive, and/or untruthful ways. There also are 10 clinical scales that assess hypochondriasis, depression, hysteria, psychopathic deviance, masculinity/femininity, paranoia, psychasthenia, mania, schizophrenia, and social introversion. Raw scores on all subscales are converted to standardized T-scores and interpreted in the context of the validity scales and as a unified profile. T-scores of 65 are considered clinically elevated. The test has been validated on a randomized, stratified sample of healthy subjects as well as on psychiatric patients with various emotional disorders. Validation studies indicate that the test can differentiate healthy individuals from those with diagnosable psychiatric disorders. The MMPI-2 is used in a wide variety of personnel selection tasks, particularly when public safety is at risk, such as in the selection of pilots, law enforcement officers, and military personnel (8 10). The MMPI-2 has been demonstrated to discriminate between those who respond truthfully and those who underreport psychopathologic behavior. Therefore, it is an appropriate test to use when a clinician believes that an individual may be motivated to deny psychopathologic behavior, such as is the case with prospective oocyte donors. The MMPI has been used in a few small studies with prospective oocyte donors. Schover et al. (5) reported the results of interviews and MMPI testing of 45 prospective anonymous oocyte donors. They found that 35% of the sample had at least one elevated T-score on the clinical scales. Fifty-nine percent had a validity subscale configuration that indicated attempts to conceal or underreport psychopathologic behavior. Scores on the MMPI were not related to the outcome of the selection process or to donor satisfaction after donation. Lessor et al. (6) reported the results of a study of 95 prospective anonymous oocyte donors. On the MMPI, the profile generated from mean scores from the entire sample indicated a tendency toward psychological defensiveness and underreporting of psychopathologic behavior. The clinical scales indicated that donors were socially conventional, outgoing and free from psychopathology. Donors did not endorse traditional female roles or submit to male authority. Unfortunately, the investigators did not conduct group comparisons to determine whether there were any differences in MMPI scores between the women who ultimately donated and those who did not. The purpose of the present study was to compare the MMPI-2 scores among prospective oocyte donors in different outcome groups: those who were accepted as donors and completed a donation cycle, those who were accepted as donors but did not complete a donation cycle, and those who were rejected as donors because of psychological concerns. These data could help determine whether the MMPI-2 has predictive validity in the selection of oocyte donors. MATERIALS AND METHODS One hundred fifty anonymous donor applicants from a university-based IVF program and two private donor recruiters were identified by chart review after their clinical evaluation was completed. The donor applicants had been recruited through advertisements in local newspapers and by word of mouth. They were screened over the telephone for basic demographic information and general health status. Women who smoked, took psychoactive medications, or had a major medical illness were excluded during this step. The donation process was described and women who were still interested were sent a 25-page donor history questionnaire to assess their personal and family health histories. Completed personal and family history forms were reviewed by the program staff or recruiter. Women who had no major genetic, medical, or psychiatric illnesses either themselves or in first-degree relatives were invited for a psychological screening. Prospective donors were seen by the program s psychologist or a consulting psychologist for a structured interview to discuss their psychosocial history, motivation for donation, and sexual and reproductive history. All prospective donors then completed the MMPI-2 as a clinical requirement of the donor application process. Donor applicants who were deemed acceptable by the psychologist were referred for a medical consultation and physical examination. The outcome of the selection process was monitored by the recruiter or program staff and noted in the chart. Donors who completed a donation cycle were compensated $2,400. The study was approved by the institutional Human Subjects Review Board. RESULTS The demographic characteristics and reproductive histories of the entire sample are summarized in Table 1. In summary, most prospective donors were single white women without children who had completed high school and some college. Seventeen percent had a history of sexual assault, 43% had had at least one elective abortion, and 50% had experienced some type of early parental loss (divorce, death of a parent, or abandonment by a parent). Ten percent had a history of psychiatric medication use and 34% had received outpatient psychological counseling. In terms of outcome, 70 prospective donors (47%) were FERTILITY & STERILITY 1067

3 TABLE 1 Demographic characteristics and reproductive histories of the total sample. Variable No. Percentage Marital status Single Married Divorced 13 9 No information 2 1 Ethnic background White Black 8 5 Hispanic 14 9 Asian 1 1 Other 2 1 Education High school graduate High school some college College graduate Postgraduate work 11 7 No information 3 2 Religion Catholic Protestant Jewish 6 4 Other No information 12 8 Source Recruiter Recruiter Program Other 3 2 No. of children Elective abortion Yes No Miscarriage Yes 6 4 No Sexual assault Yes No Psychiatric counseling Yes No Psychiatric medication Yes No Psychiatric hospitalization Yes 2 1 No Note: The mean ( SD) age of the sample was years. deemed psychologically acceptable and completed at least one donation cycle (group 1). Thirty prospective donors (20%) were deemed psychologically acceptable but did not complete a donation cycle (group 2). The prospective donors in group 2 were excluded from donating because of findings on the medical examination or genetic screening, because of a poor stimulation cycle (n 19), or because they could not be matched to a recipient or relocated before they were matched (n 11). Eighteen prospective donors (12%) were deemed acceptable but did not donate because they were not compliant with the donation process (group 3). Thirty-two prospective donors (21%) were rejected because of psychological concerns and did not donate (group 4). Demographic characteristics and reproductive histories were analyzed by 2 test to determine whether there were any differences in these variables between groups. The results indicated that there were no statistically significant differences between groups in marital status, parity, ethnicity, education, religion, psychiatric hospitalization, elective abortion, parental loss, or recruiter source. Statistically significant differences between groups were found for previous use of psychiatric medications ( , P.001) and history of psychiatric counseling ( , P.001), sexual assault ( , P.001), and miscarriage ( 2 8.1, P.04). Group 4 (rejected) had more women who reported histories of psychiatric medication use, previous counseling, sexual assault, and miscarriage (Table 2). On the MMPI-2, the mean validity profile for the entire sample of prospective donors was in the normal range and indicated appropriate levels of acknowledging psychological difficulties and psychological defensiveness (Fig. 1). The overall clinical profile score for prospective donors in this study was 5 9, indicating that this group did not endorse traditional sex role beliefs or behaviors. They reported being somewhat unconventional and inclined to take risks. They were socially outgoing and gregarious. They also reported having a relatively high degree of energy. They reported lower than average levels of depression, paranoia, and obsessive-compulsive tendencies. We then compared the MMPI-2 scores between groups using analysis of variance and Tukey s test for post hoc group comparisons. The mean T-scores on the MMPI-2 validity and clinical subscales by group are given in Table 3. Statistically significant differences were found between groups on subscales F, K, 1, 2, 7, 8, and 0. For the validity scales, group 4 (rejected) had a significantly higher mean score on scale F than group 1 (accepted, donated) or group 2 (accepted, no donation-medical). Group 4 had a significantly lower mean score on scale K than group 1 or group 2. This indicates that women in group 4 had a testing-taking attitude that made them more inclined to acknowledge psychological symptoms and to be less defensive than women in the other two groups. For the clinical scales, statistically significant differences between groups were found on 5 of the 10 subscales: 1, 2, 7, 8, and 0. On scale 1, group 2 (accepted, no donationmedical) had a significantly higher mean score than group Klock et al. MMPI-2 and oocyte donors Vol. 72, No. 6, December 1999

4 TABLE 2 Frequency distributions for psychiatric medication use, psychological counseling, and sexual assault for the four outcome groups. Group 1 Group 2 Group 3 Group 4 Variable No. Percentage No. Percentage No. Percentage No. Percentage Psychiatric medication No Yes Psychiatric counseling No Yes Sexual assault No Yes (accepted, donated), indicating greater attention to physical ailments and somatic complaints. On scale 2, group 4 (rejected) had a significantly higher mean score than the other three groups. On scales 7 and 8, group 4 (rejected) had significantly higher scores than group 1 (accepted, donated). On scale 0, group 4 had a significantly higher mean score than the three other groups. There were no statistically significant differences in MMPI-2 scores between prospective donors in group 2 (accepted, no donationmedical) and group 3 (accepted, no donation-noncompliant). The pattern of responses of women in group 4 indicated relatively higher levels of depression, obsessive-compulsive features, idiosyncratic thinking, and social introversion than in the two other groups. FIGURE 1 Average profile on the MMPI-2 for the entire sample. The MMPI-2 clinical scales: 1 hypochondriasis; 2 depression; 3 hysteria; 4 psychopathic deviate; 5 masculinityfemininity; 6 paranoia; 7 psychasthenia; 8 schizophrenia; 9 hypomania; and 0 social introversion. Although there were statistically significant differences between groups on mean subscale scores, all group mean scores were in the normal range, with T-scores of 65. In addition, the magnitude of the differences between groups, even when statistically significant, were not large. The range of statistically significant differences between groups was between 4 and 8 T-score points. The subscales with the largest differences were F (7 points), K (8 points), and 0 (6 points); group 4 scored higher on F, lower on K, and higher on 0. This indicates a high degree of overlap on test scores across groups, which makes differentiating between outcome groups based on MMPI-2 scores alone difficult. Figure 2 TABLE 3 Analysis of variance of MMPI-2 validity and clinical subscale T-scores by outcome group. Subscale Group 1 Group 2 Group 3 Group 4 F P L NS F * K * NS NS NS NS * * NS * Note: NS not significant. * Statistically significant difference between groups 1 and 4. Statistically significant difference between groups 2 and 4. Statistically significant difference between groups 1 and 2. Statistically significant difference between groups 3 and 4. FERTILITY & STERILITY 1069

5 FIGURE 2 Profiles on the MMPI-2 by outcome group: group 1 accepted and donated; group 2 accepted but did not donate for medical reasons or inability to be matched to a recipient; group 3 accepted but did not donate because of noncompliance; and group 4 rejected. The MMPI-2 clinical scales: 1 hypochondriasis; 2 depression; 3 hysteria; 4 psychopathic deviate; 5 masculinity-femininity; 6 paranoia; 7 psychasthenia; 8 schizophrenia; 9 hypomania; and 0 social introversion. provides a graphic representation of the MMPI-2 profiles of the four groups. On the MMPI-2, a T-score of 65 indicates clinically significant psychopathologic behavior. In some personnel selection tasks, this cutoff score is used to reject an applicant. To determine the usefulness of this cutoff score in a sample of prospective donors, we converted the validity and clinical subscale scores to dichotomous scores, indicating whether they were below or above the clinical cutoff of 65. We then used the converted scores in a 2 analysis to determine whether classification by cutoff scores would be significantly associated with outcome. We found that most subjects scores were below the cutoff score of 65 on all the subscales. Statistically significant differences between groups were found on subscale F; disproportionately more women in group 4 scored 65 than women in group 1, 2 or 3 ( , P.01). Using the clinical interview as the criterion, only 12.5% of women who were rejected because of the results of their interview would also have been rejected because of their scores on subscale F. Statistically significant differences between outcome groups also were seen on subscales 4, 7, and 8; disproportionately more women in group 4 had scores over the 65-point cutoff level. On subscale 4, 15% were over the cutoff level and would have been rejected; the same was true for 6% on subscale 7 and 9% on subscale 8. These results indicate that in this sample, the use of subscale score cutoff levels alone is not an effective way of selecting donors because it may underestimate the number of prospective donors who should be rejected because of psychological concerns. This highlights the need, as recommended by the developers of the MMPI-2, for the use of this test in the context of a broader psychological evaluation. DISCUSSION The current study assessed MMPI-2 scores and demographic, reproductive, and psychological variables in a large group of women who volunteered to be anonymous oocyte donors. The women were followed up after the assessment and donation process to determine whether there were any differences between outcome groups in any of these variables. This study adds to the current body of literature on oocyte donors in several ways. First, it is among the largest studies of donors reported in the literature to date. Previous studies were limited by small sample sizes (between 21 and 95 subjects) that made generalization from the results difficult (5, 6, 11 13). In terms of the demographic and reproductive variables, our sample in general had a lower mean age (25 years) than samples in other studies (27 32 years) (5, 11 13). In the current study, 40% of prospective donors had children compared with higher percentages (58% 85%) in previous reports (5, 11, 14). Educational levels in our sample were different than those reported elsewhere. In our sample, 29% had a college degree compared with 5% 90% in other studies (5, 11, 14). None of these demographic factors were statistically significantly different between outcome groups. In our sample, 17% of women reported a history of sexual assault or trauma. Previous studies indicated rates of 6% 36% (5, 6, 11). We also found that 43% of prospective donors had had at least one previous elective abortion. This compares with rates of 31% reported by Schover et al. (5) and 29% reported by Klock et al. (11). Clinically, many women who had had a previous elective abortion reported that the donation experience helped them compensate for the loss of a pregnancy through abortion with the creation of a pregnancy through oocyte donation. In terms of psychiatric history, 10% of our sample had a history of psychoactive medication use and 34% had a history of outpatient psychological counseling. Schover et al. (5) reported that 64% of their sample of 45 donor candidates had a history of mild depressive or anxiety symptoms (they did not report rates of treatment). Klock et al. (11) reported that 24% of their sample of donors who completed one donation cycle had a history of outpatient psychotherapy. In terms of the psychological testing data, we were interested to determine whether the MMPI-2 scores would be useful in differentiating between outcome groups. On the validity scales, which indicate the test-taker s strategy toward acknowledging psychological difficulty and level of psychological defensiveness, we found statistically significant differences between groups 1 and 2 compared with 1070 Klock et al. MMPI-2 and oocyte donors Vol. 72, No. 6, December 1999

6 group 4. Group 4 (rejected) had significantly higher scores on scale F, which assesses the extent to which the test-taker is complying with test instructions and answering in a socially normative way. High scores on scale F indicate a deviant test-taking response set and are a general index of psychopathologic behavior. Although the scores of group 4 were higher than those of groups 1 and 2, they were in the normal range. The scores of group 4 on scale F indicated that the women endorsed items relevant to a particular problem area but typically functioned adequately in most aspects of their life situations (15). The lower scores on scale F obtained by groups 1 and 2 indicate the women answered items as most normal people do, were free of disabling psychopathologic behavior, were socially conforming, and may have faked good on some of the MMPI-2 items (15). On scale K, high scores can indicate psychological defensiveness but moderate scores can be associated with ego strength and psychological resources. In this study, group 4 had significantly lower scores on scale K than groups 1 and 2, although the scores of group 4 were in the normal range and those of groups 1 and 2 were moderately high (15). The score of 52 for group 4 is average and indicates that these women maintained a healthy balance between self-criticism and positive self-evaluation, were psychologically welladjusted, showed few overt signs of emotional disturbance, were independent and self-reliant, and were capable of dealing with problems in daily life. Alternatively, the scores of 57 and 60 for groups 1 and 2, respectively, are moderately high and indicate that the respondents were defensive and were trying to give an appearance of adequacy and control. The pattern of scores on scales F and K for group 4 indicates that these women freely acknowledged psychological problems but generally functioned adequately. They were aware of their strengths and weaknesses and had adequate coping skills. The score patterns on scales F and K for groups 1 and 2 are consistent with women who knew that they were being evaluated and wanted to put forth a good impression. They may have been socially conforming and aware of what the evaluator wanted to hear. The moderately high scores on scale K indicate some defensiveness but also ego strength. Instead of being considered in a negative light, these characteristics may be indicative of women who would make good oocyte donors because of their ability to defend themselves psychologically and maintain distance and boundaries with others, and their sufficient ego strength to carry them through the process. The aggregate profile on the clinical scales was 5 9. This profile indicates women who do not ascribe to traditional female roles and endorse interests in some typically masculine activities and values. It also indicates women who have a moderate amount of physical and psychological energy. This aggregate profile is different from that obtained by Schover et al. (5), who reported an average profile of 4 9 indicating impulsivity, unconventional social mores, and high energy, with low scores on scale 5 indicating strong, traditional feminine characteristics. This difference in findings may be due to differences in sample size or selection. Again, in evaluating the factors that would prompt women to be oocyte donors, one would expect that they would be unconventional in their beliefs because they are participating in an unconventional process. They may have a pragmatic view of their oocytes (e.g., if they are not using them, someone else could). They also may know their own value in a market economy. Statistically significant differences were found between groups on 5 of 10 clinical scales. On scales that assessed depression and withdrawal from social interaction and responsibilities, group 4 had mean scores significantly higher than the other three groups. On the depression scale, group 4 had higher scores than groups 1 and 2. On scales that assessed obsessive-compulsive traits and disturbances in thought and mood, group 4 had higher scores than group 1. These results are consistent with group 4 s validity profile indicating that women in group 4 were more willing to endorse items indicative of psychopathologic behavior and less psychological defensiveness. The absolute differences in mean scores between groups on these scales were not large (between 4 and 8 points), which makes individual interpretation of profiles difficult. Additional studies are needed with large samples of prospective donors to demonstrate whether there is any stability and predictive validity to these scoring differences between outcome groups. In the current study, we found that fewer than half (47%) the prospective donors were accepted and completed a donation cycle. This is similar to the acceptance and donation rates reported by other investigators (5, 12). It is lower than the 82% (50 of 61 prospective donors) donation rate reported by Sauer and Paulson (13) and the 73% (69 of 95 prospective donors) reported by Lessor et al. (6). Psychological bases for rejection in the current study included a current psychiatric disorder, inappropriate motivation for donation, unrealistic expectations of the donation process, and chaotic lifestyle. This led to the rejection of 21% of prospective donors. Sauer and Paulson (13) reported rejection because of motivational or psychological reasons for 5% of prospective donors (3/61) and Schover et al. (5) reported rejection because of psychological concerns for 6% (3/45). These different rates of rejection for psychological reasons may be attributable to different recruitment and screening methods across studies. In previous studies, word of mouth and indirect recruitment were the most common methods used to initiate contact with the prospective donor. In the current study, most prospective donors were recruited by newspaper ads placed by professional donor recruiters. This may have yielded a higher percentage of women with existing psychological problems. Last, Sauer and Paulson (13) reported rejection rates for both anonymous and known prospective donors. It is likely that known prospective do- FERTILITY & STERILITY 1071

7 nors are screened informally by the recipient couple and those with psychological problems are screened out before they reach the clinic. One of the most surprising findings in the current study was the large number of women in outcome group 2 (accepted, no donation-medical) and group 3 (accepted, no donation-noncompliant). Thirty-two percent of the total number of donor applicants were in these two groups. The group 2 outcome (no donation because of a medical problem or inability to be matched to a recipient couple) cannot be anticipated on the basis of psychological screening. However, it would be desirable if the group 3 outcome (no donation because of noncompliance) could be identified in advance during the psychological screening. Unfortunately, the results of the current study indicate that there are not any MMPI-2 scores that reliably differentiate this group from the others. The 12% of noncompliant donors in this sample represent a failure in the information and education or screening process and an area of inefficiency in the donor selection process. This highlights the need for prospective donors to be fully informed at the time of their initial inquiry about the physical invasiveness, time demands, and psychological issues related to donation. After a realistic education and information discussion with the prospective donor, a period of 1 2 weeks could be allowed to elapse before the psychological screening appointment to give the prospective donor time to think about whether she wants to participate. This may allow for natural self-selection of prospective donors that would decrease the professionals time spent in evaluation. References 1. Sauer M, Paulson RJ, Lobo RA. Reversing the natural decline in human fertility. J Am Med Assoc 1992;268: Society of Assisted Reproductive Technology assisted reproductive technology success rates. Washington, D.C.: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, Braverman AM, Ovum Donation Task Force of the Mental Health Professional Group. Survey results on the current practice of ovum donation. Fertil Steril 1993;59: Ovum Donor Task Force, Mental Health Professional Group. Guidelines for the assessment of oocyte donors and recipients. Birmingham, Alabama; American Society for Reproductive Medicine, Schover L, Colins RL, Quigley MM, Blankstein J, Kanoti G, et al. Psychological follow-up of women evaluated as oocyte donors. Hum Reprod 1991;6: Lessor R, Cervantes N, O Connor N, Balmaceda J, Asch RH. An analysis of social and psychological characteristics of women volunteering to become oocyte donors. Fertil Steril 1993;59: Butcher JN, Graham JR, Dahlstrom WG, Tellegen A, Kaemmer B. Minnesota Multiphasic Personality Inventory-2 (MMPI-2): manual for administration and scoring. Minneapolis (MN): University of Minnesota Press, Butcher JN, Morfitt RC, Rouse SV, Holden R. Reducing MMPI-2 defensiveness: the effect of specialized instruction on retest validity in a job applicant sample. J Per Assess 1997;68: Borum R, Stock HV. Detection of deception in law enforcement applications. Law Hum Behav 1993;17: Bartol CR. Predictive validation of the MMPI for small town police officers who fail. Profess Psychol Res Prac 1991;22: Klock SC, Braverman AM, Rausch DT. Predicting anonymous egg donor satisfaction: a predictive study. J Womens Health 1998;7: Sauer M, Bustillo M, Gorrill MJ, Louw J, Marshall J, Buster J. An instrument for the recovery of preimplantation uterine ova. Obstet Gynecol 1988;71: Sauer M, Paulson RJ. Oocyte donors: a demographic analysis of women at the University of Southern California. Hum Reprod 1992;7: Power M, Baber R, Abdalla H, Kirkland A, Leonard T, Studd J. A comparison of the attitudes of volunteer donors and infertile patient donors on an ovum donation programme. Hum Reprod 1990;5: Graham J. MMPI-2: assessing personality and psychopathology. 2nd ed. New York: Oxford University Press, Klock et al. MMPI-2 and oocyte donors Vol. 72, No. 6, December 1999