Donor insemination: Israel as a representative case of a competitive market examining the possibility of policy reform.

AIM: To measure the private and social benefits of donor insemination (DI). METHODS: An empirical model investigates the general public and DI clients' willingness to pay (WTP) for DI, and the willingness of potential donors to become altruistic or paid sperm donors. RESULTS: The general public and DI clients value DI and have a positive WTP for it, whereas willingness to donate, altruistically or for payment, is either low or very low. CONCLUSION: The general public's and DI clients' WTP for DI is in average above actual cost, so the government should consider funding or subsidizing DI. The government should encourage altruistic gamete donation through information and education of all parties involved directly and indirectly in the process of donation whose ultimate goal is the birth of a child.

[Extension of assisted reproductive technologies with donor sperm (ARTD) to non-medical indications]. / Ouverture de l'assistance médicale à la procréation avec sperme de donneur (AMPD) à des indications non médicales.

In France as in other countries, more and more single women and lesbian couples wish to become mothers. To carry through their parenting project they may consult a physician in France and often go abroad in order to get Assisted Reproductive Technologies with donor sperm (ARTD). Should ARTD be available to those women in France? The physician has not to take the decision. In such situations ARTD has no medical indication or contraindication. This assisted procreation raises many questions on children development and well-being. The results of studies made in other countries are often reassuring but their methodologies do not allow any conclusion to be drawn and grey areas persist. Therefore it should be necessary to develop a research effort in the field as it recently started in France. Would ARTD access to women without a male partner be legalized, the law should respect the ethical principles of non-payment and anonymity associated with donation of all body components. In any case, it should also allow an efficient medical care to be performed to ensure under the best conditions the well-being of the children and their mothers.

Avoiding legal pitfalls in surrogacy arrangements.

The goal of this article is to discuss the legal pitfalls that reproductive endocrinologists face when participating in gestational surrogacy contracts. This paper was composed using Westlaw and LexisNexis commercial legal search engines to perform a review of statutes and cases pertaining to gestational surrogacy. The search results demonstrated that in the absence of suitable preparation, there is significant potential for litigation while participating in gestational agreements. Providers caring for gestational carriers have been named as parties in lawsuits for failure to provide psychological screening, failure to screen for infectious disease and participation in gestational contracts that are not compliant with state law. There is great disparity in state laws and court rulings pertaining to gestational agreements. When legal disputes arise, individual state laws and court rulings are controlling over the Uniform Parentage Act. Likewise, recommendations by the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine do not supersede state laws. The failure to abide by individual state laws unnecessarily exposes reproductive endocrinologists and their IVF facilities to potential litigation. In order to lessen exposure to litigation, an understanding of individual state legislation or historical court rulings is advised.

The ethical debate on donor insemination in China.

This article gives an overview of the ethical thinking about donor insemination among Chinese ethicists. We analysed the ethical arguments dedicated to the use of donor spermatozoa published in the important bioethics journals of China of the last 15 years. On the one hand, the general Confucian values strongly favour the genetic link as it fits with the traditional importance attached to the continuation of the family line. Therefore, artificial insemination by donor (AID) is highly controversial in China because the involvement of a third party (the donor) severs the genetic link between the husband and his family. On the other hand, procreation is regarded as an important aspect of Confucian filial piety and it is a basic right of every human being to enjoy a family life. AID should be thought of as a means to help infertile couples to overcome infertility. Nowadays, Chinese bioethicists are trying to reinterpret Confucianism in order to adapt it to modernity. One such reinterpretation focuses on the affectionate rather than the genetic tie between parents and child. As the application is still new in China, more discussion and open debate on ethical aspects is needed.

Use of frozen semen to avoid human immunodeficiency virus type 1 transmission by donor insemination: a cost-effectiveness analysis.

OBJECTIVE: Reappraisal of current guidelines mandating frozen-thawed semen. DESIGN: Cost-effectiveness analysis comparing the use of frozen semen with the use of fresh semen from the same donors without a second antibody test. SETTING: A Markov model computer simulation. PATIENT(S): A theoretical cohort of 80000 women whose husbands are azoospermic. INTERVENTION(S): Simulation with calculation of costs and payoffs. MAIN OUTCOME MEASURE(S): Total lifetime direct health care costs, costs per live birth, life expectancy, quality adjusted life years (QALY), marginal cost effectiveness (dollar/QALY). RESULT(S): If all 80000 women who undergo donor insemination in the United States each year chose to use fresh semen from donors screened according to the current practice guidelines but without semen cryopreservation, there would be 8881 more births and the mean cost per live birth would be US dollars 15501 less. One recipient would become infected with HIV-1 every 5.1 years, during which time over 180000 noninfected children would be born. The average life expectancy of recipients would be reduced by 2 days, but their quality-adjusted life expectancy would increase by over 1 month. Medicolegal costs to physicians would need to exceed US dollars 780 million per infection to equalize the cost effectiveness of the fresh and frozen policies. CONCLUSION(S): The guidelines should be revised to allow the use of fresh semen by informed recipients.

[Is the limitation to 6 cycles of insemination with donor sperm justified?]. / La limitation à six cycles d'inséminations en AMP avec don de sperme est-elle justifiée?

OBJECTIVE: To evaluate the effect of the limitation at 6 cycles of artificial insemination in a program of sperm donation. STUDY DESIGN: 266 couples included in a program of sperm donation underwent 1,354 cycles including 532 intracervical insemination (ICI), 678 intrauterine insemination (IUI) and 133 in vitro fertilization (IVF). RESULTS: The birth rate by cycle was 10.8% in ICI, 18% in IUI, 21.9% in IVF. The risk of multiple pregnancies was 0% in ICI, 13% in IUI, 33% in IVF. The authors feign then two strategies, the first one with 6 ICI followed by 6 IUI, and the other one with 6 IUI alone. The birth rate, the risk of multiple pregnancies and the cost of these two strategies is discussed. CONCLUSION: The restriction to 6 IA Cycles in a donor semen program does not change the birth rate, but increases the multiple pregnancy rate and the cost of the treatment of these patients.

[Can donor insemination be optimised?]. / Peut-on optimiser l'insémination avec donneur?

OBJECTIVE: To compare the different donor insemination technics. MATERIAL AND METHOD: Analysis of the published studies about donor insemination which value the effectiveness of Intra Cervical Insemination (ICID) and Intra Uterine Insemination (IUID), the interest of ovulation induction, the possible complications, and the cost-effectiveness ratio. RESULTS: The meta-analysis of the Cochrane data base (10 comparative studies IUID versus ICID, 2568 donor insemination cycles) lead to a pregnancy rate per cycle (PRC) 17.77% with IUID versus 7.68% with ICID. The odds ratio is 2.63 (CI from 1.85 to 3.73). With these PRC, the direct cost per evolutive pregnancy is 54,780 F with ICID and 25,675 F with IUID. CONCLUSION: If it is possible to propose ICID to patient with an excellent regularity of ovulation. IUID with ovulation induction by gonadotropins is today the gold standard, and more especially as the law restrict the number of donor inseminations. Indeed, the IUID is two or three times more effective than ICID, consume the half of sperm straws, use a semen of moderate quality, there is no complication provided that the cycle is cancelled if there is more than two mature follicles and the cost-effectiveness ratio is greatly in favour with IUID.

Donor insemination: the gifting and selling of semen.

The authors examine the implications for individuals and society of how semen is provided for use in donor insemination treatment. In particular, they focus on whether 'donors' make a gift of their semen or are paid. The role of health professionals in shaping the nature and meaning of semen provision is also explored. The currently predominant practice of buying semen is compared with other reproductive and biomedical exchanges: oocyte and embryo donation, surrogacy, and blood, organ and fetal tissue donation. The authors suggest that the commercialisation of semen determines and reflects the type of men frequently recruited to provide semen. This in turn influences the meaning that donors themselves, recipients, offspring, health professionals and society at large attribute to the provision of semen.

Donor insemination and human immunodeficiency virus: a risk/benefit analysis.

In 1988 the American Fertility Society revised its guidelines for the use of semen in donor insemination by stating that "the use of fresh semen for donor insemination is no longer warranted." Although the consequences of this recommendation include an approximate doubling of the patient's cost of treatment, a 50% reduction in both cycle fecundity and 3-month life-table pregnancy rates, a reduction in the number of pregnancies because of patient dropout, and an ethically troubling increase in physician income as a direct result of the diminished efficacy of treatment, an analysis of the risk of transmission of human immunodeficiency virus through donor insemination has not been presented. All available data suggest that neither safety nor efficacy need be sacrificed in the current practice of donor insemination by offering patients the choice of appropriately screened fresh or frozen sperm.

Therapeutic donor insemination: a prospective randomized study of scheduling methods.

OBJECTIVE: To compare basal body temperature (BBT) graphs and urinary luteinizing hormone (LH) monitoring in scheduling therapeutic donor insemination. DESIGN: Participants were prospectively randomized to the BBT or LH groups. SETTING: Participants were private patients of the Reproductive Endocrine Division at Washington University School of Medicine. PATIENTS: Inclusion criteria were designed to assure an isolated male factor. Seventy-four of 113 patients completed the study; 18 had ongoing treatment at the end of the study. INTERVENTIONS: Basal body temperature graphs were physician interpreted and appointments prospectively chosen. Luteinizing hormone patients monitored daily urine samples and scheduled an appointment the day after the detected surge. MAIN OUTCOME MEASURES: Fecundity rates, cumulative pregnancy rates, and cost per pregnancy were all prospectively evaluated. RESULTS: Life table analysis yielded a 6-month cumulative probability of pregnancy of 36.3% in the LH group and 65.1% in the BBT group (P less than 0.025). The total cost per pregnancy was lower in the BBT group (+6,212 versus +3,997; P less than 0.001). CONCLUSIONS: This randomized prospective study demonstrates significant therapeutic and economic advantages when therapeutic donor insemination is prospectively scheduled by BBT graphs.

Fathers anonymous: beyond the best interests of the sperm donor.

Current AID practices are based primarily on consideration of protecting the interests of practitioners and donors rather than recipients and children. The most likely reason for this is found in exaggerated fears of legal pitfalls. It is suggested that policy in this area should be dictated by maximizing the best interests of the resulting children. The evidence from the Curie-Cohen survey is that current practices are dangerous to children and must be modified. Specifically, consideration should be given to the following: 1. Removing AID from the practice of medicine and placing it in the hands of genetic counselors or other nonmedical personnel (alternatively, a routine genetic consultation could be added for each couple who request AID); 2. Development of uniform standards for donor selection, including national screening criteria; 3. A requirement that practitioners of AID keep permanent records on all donors that they can match with recipients; I would prefer this to become common practice in the profession, but legislation requiring filing with a governmental agency may be necessary; 4. As a corollary, mixing of sperm would be an unacceptable practice; and the number of pregnancies per donor would be limited; 5. Establishment of national standards regarding AID by professional organizations with input from the public; 6. Research on the psychological development of children who have been conceived by AID and their families. Dr. S.J. Behrman concludes his editorial on the Curie-Cohen survey by questioning the "uneven and evasive" attitude of the law in regard to AID, and recommending immediate legislative action: The time has come--in fact, is long overdue--when legislatures must set standards for artificial insemination by donors, declare the legitimacy of the children, and protect the liability of all directly involved with this procedure. A better public policy on this question is clearly needed. I have suggested that agreement with the need for "a better public policy" is not synonymous with immediate legislation. The problem with AID is that there are many unresolved problems with AID, and few of them are legal. There is no social or professional agreement on indications, selection of donors, screening of donors, mixing of donor sperm, or keeping records on sperm donations. Where there is agreement, such as in requiring the signature of the donor's wife on a "consent" form, the reasons for such agreement are unclear. It is time to stop thinking about uniform legislation and start thinking about the development of professional standards. Obsessive concern with self-protection must give way to concern for the child.