Intrauterine insemination with donor semen (from Cryos only, editor). An evaluation of prognostic faxtors based on a review of 1131 cycles.
Mohammed Rohi Khalil MD, Per Emil Rasmussen MD, Karin Erb MSc, Steen Broch Laursen MSc, PhD, Sven Rex MD, Lars Grabow Westergaard MD, DMSci. The Fertility Clinic, Odense University Hospital, Odense, Denmark.
Acta Obstet Gynecol Scand 2001; 80: 342-348.

ABSTRACT:
Objective: To identify prognostic factors influencing the outcome of infertility treatment using intrauterine insemination with donor semen (IUI-D).
Design: Retrospective study of all patients undergoing IUI-D between august 1st, 1990 and July 31st, 1998.
Setting: University-affiliated infertility clinic.
Patients: Three hundred five couples undergoing 1131 IUI-D treatment cycles.
Main outcome measures: Type of hormonal treatment, number of follicles, length of follicular phase, endometrial pattern, female age, infertility diagnosis and semen quality related to clinical pregnancy rate, cumulative birth rate and multiple gestations.
Results: Throughout the nine year period the overall clinical pregnancy rate per cycle was 22.3% with an increase from 12.9% in 1990 to 34.6% in 1998. The multiple birth rate was 20.6%. The birth rate per couple was 61.1% after a mean of 3.2 treatment cycles. The pregnancy rate was highest in the first treatment cycle and the cumulative birth rate rose only slightly after the sixth treatment cycle.
The following parameters were positively and significantly correlated to a successful outcome of IUI-D:
i) the first treatment cycle – compared to the following up to six treatment cycles; ii) number of mature follicles – more than one - at the time of insemination, however, with an unacceptable high rate of multiple pregnancies with more than 3 mature follicles; iii) time of insemination after the 12th day in the cycle; iv) insemination after ovulation and; v) female age under 30 years.
Conclusions: IUI-D is a simple and inexpensive treatment giving acceptable pregnancy rates for up to six treatment cycles if at least 2 mature follicles have developed at the time of insemination, which implies that hormonal ovarian stimulation and induction of ovulation is used, and ovulation has occurred at the time of insemination, which ought to take place after cd 12 with at least one million motile spermatozoa.

Attitudes among sperm donors in 1992 and 2002: a Danish questionnaire survey.
Acta Obstet Gynecol Scand. 2007;86(3):327-33.
Ernst E, Ingerslev HJ, Schou O, Stoltenberg M.
Department of Gynaecology and Obstetrics, Skejby Sygehus, University Hospital of Aarhus.

Background. Sweden prohibited anonymous sperm donation in 1985 and Norway in 2005. In recent years the question of continued use of sperm from anonymous sperm donors for insemination in couples and the question of insemination of single and lesbian women have been vividly debated in Denmark. This survey examines the sperm donors' attitude towards these questions and describes any changes in attitude between 1992 and 2002. The objective is to investigate the likely consequences of abolishing anonymous sperm donation in Denmark. Methods. A questionnaire survey carried out among donors at a private Danish sperm bank, Cryos-International Sperm Bank Ltd. Over a period of 9 weeks in 2002 an anonymous questionnaire was handed out to all donors who were in contact with the sperm bank. The results were compared to a questionnaire survey carried out in 1992 at the same sperm bank. Results. In 2002, 25% (19% approved; 35% non-approved) of the donors stated that they would continue as donors if anonymity was abolished, whereas in 1992 the number was 32%. But when donors were asked whether they would accept that the children could contact them, only 22% agreed in 1992 and 13% (15% approved; 10% non-approved) in 2002. Altruistic as well as financial motives were the main factors for becoming a donor in both 1992 and 2002. Approximately 50% would accept sperm donation to lesbians in both surveys. In 2002 approximately one third was positive towards donation to single women. Conclusion. Maintaining anonymity is still important for the vast majority of the donors.

Wiews gained through the operation of a large sperm bank.
By Ole Schou, MBA, Managing Director, Cryos International Sperm Bank, Denmark. Email: cryos@cryos.dk
A.R.T. & Science, Vol. 1, No. 1, June 2001. ISSN 1444-8971. Ladybrook Publishing.

When operating a sperm bank there are several ethical issues that must be taken into consideration.
There are two kinds of clients in a sperm bank for whom the ethical considerations are different:

• Depositors for Artificial Insemination by Husband (AIH).
• Semen donors for Donor Insemination (DI).

Depositors are typically cancer patients whose fertility is threatened (prior to chemotherapy, operation or radiation). Other likely clients are males facing a vasectomy, males that cannot be present at the time of ovulation, males that cannot ejaculate on command, or in relation to ICSI treatment, etc. The main ethical question to be considered for depositors is: who will have access to the semen?
Clearly, it should only be the depositor himself who should make decisions regarding the future use or disposal of the semen. The semen should be destroyed upon the depositor’s death unless legislation in the country in question permits testamentary wishes of this nature.
It is important to write up a contract with the depositor covering questions concerning access as well as all other legal questions involved - i.e.: ID verification, conditions of payment, procedure regarding change of address, responsibility for damage to or destruction of the semen by mistake, scientific experiments etc.

The ethical considerations regarding Semen donors (for DI) are more complex. How these questions should be treated depends to a large extent on whose point of view you are considering: that of society in general, the doctor, the recipients, the donors, or the resulting children. The main questions are:

a) Should single women and lesbians have access to DI-treatment? For social, moral, and religious reasons this question cannot be addressed in a general manner. One thing is certain though: If single women and lesbian couples do not have access to legal DI-treatment they will find other solutions and "fertility tourism" and the "grey market" will appear.

"Fertility Tourism" (FT), is when patients travel abroad to find available treatment or when frozen donor semen is imported.
The "Grey Market" (GM), which is made up of (unauthorized) sperm banks or private persons offering their services at a lower or non-existent level of screening, with the risk of Sexually Transmitted Diseases (STDs) and possible legal complications.

b) How many pregnancies or babies per donor? The reason to limit the offspring number is to reduce the risk of inbreeding, which would result in an increased incidence of inherent diseases in the following generation. The knowledge that they have a large number of half-siblings may also be a psychological problem for some of the children and perhaps the donors too though these assumptions have not been investigated. The inbreeding risk criterion is not the total number of children born but the number of children created via DI per capita in each community. In cosmopolitan communities a higher number of offspring from the same donor is possible than in smaller communities. Legal limits differ greatly from for instance 5 in South Africa (total population approx. 45,000,000) to 1 per 100,000 in the USA. If the limit is set too low it will result in a price increase and/or a reduction in the availability of DI, leading to FT and GM.

c) Payment for donation or not? From society’s point of view it is usually considered unethical to pay for donated human tissue. Donation should be mainly altruistic and only the donor’s travel expenses should be covered. But recipients generally feel that sufficient economic compensation to the donor should be provided to secure an adequate supply of donor semen. The donor is usually interested in as high a payment as possible. A questionnaire among our donors in 1992 and 1998 showed that nobody would continue without payment. Consequently FT and GM will arise if no adequate payment.

d) Should the child have the right to know the identity of the donor? Hypothesis: It is possible that the child will suffer from identity problems and a feeling of being betrayed if it is not able to find its genetic father. DI-children should be given this right, which adopted children already have. The United Nations Convention on the Rights of the Child (UNCC) says so.

However, we should be aware that:
• DI-children have their mother as a genetic parent, which makes the situation regarding their identity different from that of adopted children. DI-children are fundamentally highly wanted while adopted children start their life as unwanted or unplanned, which makes the two situations quite different.
• The UNCC, Art 7.: "The child shall have … the right to know … his or her parents." But the term "parents" has never been conclusively defined. These could be the social parents, the adoptive parents, the foster parents, two females, etc. Who are the parents? Is it always the genetic father and mother? What is best for the child’s welfare?
• A significant number of children are not genetically related to their social father (5-8% in Denmark according to the J. F. Kennedy Institute, Denmark). As early as 500 B.C. the Romans introduced the "Pater est" principle, implying that "the man who is married to the woman is the father of the child". It has always been a problem to determine paternity. This is the reason why the term parents as laid down by the UNCC, cannot apply solely to the genetic parents.
• Many surveys show that the recipients (especially the social fathers) do not want the child to have the opportunity of finding the genetic father (Snowden et al., 1993, Amuzu et al. 1999, Golombok et al. 1995 etc.). Recipients prefer anonymous donors. These surveys also show that few of the DI-children (0-14%) are actually told, and this is mainly important to lesbian couples and singles where the there is no obvious father.

The problem is that it is not possible to hire (enough) non-anonymous semen donors. A questionnaire among our donors in 1992 and 1998 illustrated this, as only 8% of the donors would continue if anonymity were not secured. In Sweden non-anonymity has been a reality since 1985 resulting in an 85% reduction in the former donor corps and a similar reduction (officially) in the number of DI-children. The Swedes now resort to FT and GM and are forced to go abroad (mainly to Denmark).

e) How far should we go in selection and screening? By selection we mean the rejection of donors. The main reason for rejecting a donor is sperm quality that does not recover well after freezing (80-85% are rejected on this criterion). Also donors belonging to an undesirable group (unsafe sexual behavior, drug use, age, mental disease, number of DI-offspring, etc.) are rejected. Rejection is mandatory in case of STDs or of being carrier of a known Genetic Disease (GD). There seem to be few ethical problems in this general selection. The only problem is - and this is mostly a cost-benefit consideration - if we tighten the level of minimum screening to a certain extent (to include, for instance, CMV or other less harmful diseases) the costs for such screening would be excessive in relation to the benefit and would lead to a shortage of donors, and the consequence of this would be FT and GM. There is an outstanding difference between screening for GD without having specific knowledge or suspicion of the actual disease and screening with a suspicion or a known risk of the GD disease ("conditional screening"). The latter seems ethically correct, but if there were no actual knowledge or suspicion, we would be practicing positive eugenics. So the question is whether we want to practice positive eugenics or not? Whatever we do, there will be a conflict of interests. Recipients generally want as extensive GD-screening as possible. Donors are usually against GD-screening, as it would be traumatic for them to receive positive results and consequent rejection. In order to avoid practicing positive eugenics society should require MAXIMUM screening standards. Donor rejection should only be enforced where there is a known risk of GD greater than that in the general population.


CONCLUSION

There seem to be few ethical problems related to depositors (mainly regarding legal access to the semen).
As for donor semen, in many societies the conflict of interests between recipients, physicians, donors, society in general, and unconceived DI-children is not fully recognized. Legal regulatory intervention seems to decrease the supply, which leads to FT and the GM. If a society wants to prevent free market forces, positive eugenics, low supply, higher costs, FT and GM, they should observe these mechanisms.
It is considered medically and ethically correct to have a certain MINIMUM screening standard, but if society wants to prevent positive eugenics a MAXIMUM screening policy for GD is necessary. If recipients want a higher level of GD-screening they must do it themselves (carrier status) or by prenatal screening.

Cryos is the largest sperm bank in the world with more than 250 donors available and nearly 1,000 pregnancies reported per year from clinics in more than 30 countries worldwide. Today there are many thousand sperm banks around the world but only 8-10 are major sperm banks - all located in the USA except for two, which are in Europe (the French CECOS co-operation and Cryos in Denmark).
There is a tendency towards a more centralized sperm bank and away from ‘each clinic having its own sperm bank. This is because of the need for higher levels of security and administration, greater expertise and more donors to select from, and because of the complicated legislation involved. It is predicted by the Managing Director of Cryos, Ole Schou, that within the next 10-20 years there will only be 2-3 large sperm banks in Europe, the same in the USA and maybe just 20 worldwide. Cryos is in the process of developing a franchising concept with the focus on quality, a concept which can be copied internationally in order to fulfill these requirements.