It has been my experience as well as that of others in the field that many individuals conceived through gamete donation are curious about their donor and the donor’s other offspring. They may fantasize about their genetic parent and siblings. They are curious if they look like them and have similar behavioral traits. They want to know why their donor donated. They almost ubiquitously are curious to meet their donor whether they may want to have ongoing contact or not. The degree of interest is variable where some may simply be satisfied with a picture and information, others may feel comfortable with maintaining anonymity whereas still others feel a strong desire to physically meet their donor. These feelings typically change over time and may become more significant during certain stages of life, such as at the prospect of an individual starting their own family.

Donor conceived individuals may be looking to fill in the blanks in their identity. Rebecca Hamilton, conceived through donation, wrote in Behind Closed Doors: Moving Beyond Secrecy and Shame, edited by Mikki Morrissette, “It’s not a ‘Dad’ I’m after. I had a wonderful Dad who raised me. I’m not looking for a replacement. Nor, incidentally, is any other donor-conceived person I have ever met….Wanting to understand one’s genetic roots is a unique longing that remains no matter how great life is going on other levels.”

Universally, it appears that those individuals who were conceived through donation do not look at the donor as a parent. The donor does not replace the role of the parent. Instead having an open relationship with a donor can provide answers to questions many donor conceived individuals have about their own identity.

So how do I answer the question, “should I help my child find her donor?”

Professionals in the field tell us that based on research, developmental theory, and my own clinical experience, that it is best for parents to be honest with their children about their origins. In some cases I may recommend providing them with options for obtaining information about their donor. Although many sperm banks and egg donor agencies only facilitate anonymous donations. Some sperm banks offer the possibility of working with a donor who is willing to be identified to your child any time after your child turns eighteen. The sperm bank stores data and provides it upon request. Your adult child is the only one in control of this information. If she wants identity information, it is available for her. If she does not desire to know her donor’s identity, the information is never revealed.

However, it is most common at least in the Northeast that a definitive plan is not established at the outset for how a donor’s identity would be released. Most programs maintain strict anonymity. There is no guarantee that this information will be available for their child. A third party, which could be an agency, medical office, or attorney must obtain the information, and a formal contract, signed by the donor, must state when and how identity information will be released to the donor conceived individual.

Ultimately, as future parents it is vital to examine your feelings and concerns regarding disclosure of the donor’s identity. Disclosure of the donor’s identity may affect the donor conceived individual and his sense of self. Though the donor does not replace the parent there is potential for creating friction in the relationship. There is also the donor’s family to consider which will also be impacted by revealing one’s identity to the donor conceived individual. One must weigh the potential benefit of satisfying curiosities with the risk of causing harm to the relationship with the individual’s parents as well the risk of causing harm to the donor’s family.

I received this letter from a former donor egg recipient.  It made me think about what it might be like, years after the actual procedure for a child who grows up wondering about his/her donor parent.

Dear Dr. Kreiner,

I want to thank you and your wonderfully caring staff for all you did to help me have my daughter, Jessica.  There was not a moment that I did not feel supported during the process and for this I sing your praises constantly.

My daughter is truly a blessing and I will always cherish that you helped bring her into this world for me.

We informed Jessica about her genetic parentage a few years ago with the help of a psychologist who saw my husband and I first and then with Jessica for two or three more visits.  I thought it went well.  Jess seemed to understand that we loved her and that Russ and I were truly her father and mother and I cannot say that our relationship had changed in any significant way since then.

However, Jessica is now 14 years old and has recently been asking me about what I know about her genetic mom which is how she referred to her.  I, took offense to her use of the term ”mom” and immediately corrected her, saying “you mean donor, honey”.  This started a huge argument and has created a tense rift that still exists.  I know that she has been doing research to identify her donor including calling your program.  I don’t know what to do.  Did we make a mistake by telling her?  Should we seek out the donor and ask if she is willing to reveal herself to my daughter?  Is it even legal or moral for us to ask?  Should we tell my daughter that it is not possible to identify her and just leave it like that?  I am afraid not to try as it seems to be so important to her and if I appear to be resisting she will get angry with me again.

What should we do Dr. Kreiner?

Still thankful but with some remorse,

Former donor egg recipient

I have been involved in these donor egg cases since 1985 and this type of question is rare for me to receive but now I wonder if that is because patients do not feel close enough to me to discuss these problems years after my services have been performed.

It is not uncommon for potential donor egg recipients to say to me ”I’m not going to tell my child about the donor. I’m going to carry him. I’m the mom”.  We have always recommended that parents disclose that they had utilized donation to their child since it is thought that honesty is better than trying to shoulder “the big lie” which ultimately would be found out and lead to much larger problems.
If you are planning to build a family with a sperm or egg donor, you may be thinking about these very issues. Many patients believe that by disclosing their child’s donor origins will damage the parent-child bond that is so precious to them. They fear that a genetic connection to a donor could trump their relationship with their child. Most commonly, my patients plan to tell their child about the donor but want the donor’s identity to remain anonymous. They worry that an identified donor could disrupt the integrity of their family by inserting herself or himself into it.

Professionals in the field of infertility tell us that patients who need help to have a child often feel vulnerable and may view donors as threatening.

To Disclose or Not to Disclose That is The First Question

Unlike heterosexual couples, same sex couples and single individuals understand that from the moment they decide to build their family that they require assisted reproduction. These families openly disclose their children’s donor origins because it is the only way to explain their conception and birth.  Inevitably, the children look at other families around them and wonder if they have a mommy or a daddy.   It does not appear that disclosure in these cases has a negative impact on the families.

However, the heterosexual couples seek assistance only after failed attempts to have a child on their own and sometimes even after multiple IVF attempts using the woman’s own eggs.  These couples typically experience incredible loss, frequently feel inadequate, and often become clinically depressed. Assisted reproduction with outside help with their family building was not something they ever imagined. Many feel a sense of shame that may add additional motivation to keep the donor parentage a secret from their child. We are told by those professionals in the field who study this that many former donor recipients turned parents fear their child will see the donor as the “real” mom or dad and believe they are preventing potential problems by keeping the secret from their child.

Interestingly, many individuals who are the result of gamete donation report feeling like they don’t fit in with their families. I have heard that when they ultimately are informed of their donor origin that it often makes sense to them and not infrequently is received by the child with a degree of relief to explain their uniqueness from their family.  Sometimes donor conceived individuals inadvertently learn about their origins under less than ideal circumstances such as from a family friend or relative. Nondisclosure, in these cases, usually undermines trust and honesty within a family and may lead to psychological harm.

Professionals studying donation tell us that when children have been told about their donor origins, they are typically accepting of the recipient moms and dads. In fact, it appears that when children learn of their donor origins at a young age, they are more likely to have a more positive experience. Their donor conception is integrated from the beginning into their life story.   It becomes who they are at an early stage when they develop their own identity and sense of self.  Individuals told later in life are more likely to have more negative feelings about their donor conception than those told earlier. They may become angry about being deceived and often feel betrayed by the very people they thought were the most trustworthy in their lives, their moms and dads.  Hence, disclosure at an early age is recommended by professionals studying this issue.

I will address the question of disclosing the identity of the donor in my next blog.

We are approaching a time that freezing eggs will be a standard option for an IVF program much like Embryo freezing is today.  Despite the fact that hundreds of babies have been born apparently without an increase in defects or abnormalities, the American Society for Reproductive Medicine (ASRM) has proclaimed that Egg freezing is still considered experimental.

This is not just a scientific decision but is a philosophical and political one as well.  In the 1980’s, IVF was being performed likewise on an experimental basis.  Insurance companies denied that it had become standard of care until recently.  In fact, there are insurance providers who in an effort to deny claims continue to call IVF experimental despite the million babies already born without significant increases in abnormalities or defects noted.  However, the ASRM is afraid to push the envelope and take a risk that may make them appear to be promoting a procedure that could theoretically be associated with increased problems with the children created after egg freezing.

But why should we be interested in egg freezing anyway when we have IVF that is successful and known to be relatively safe after 33 years of experience?  The reasons are multiple.  A young woman who develops cancer and will have radiation therapy or chemotherapy that may affect her eggs or have her ovaries removed would with egg freezing have an option to preserve her fertility and still have her cancer treated.  In the past, the loss of a woman’s future ability to bear children was sometimes more emotionally depressing for her than the cancer itself.  The prospect of offering hope to such affected women is spreading throughout the community in part through the efforts of the Lance Armstrong Fund supported group, Fertile Hope.  They are attempting to educate not just affected individuals but oncologists and other physicians who come into contact with patients who may be able to take advantage of new IVF technologies to preserve their fertility while undergoing cancer treatment.

Another great potential use for frozen eggs is in the donor egg program.  Currently, our egg donors go through fresh IVF cycles coordinated in time with the recipients so that the eggs are fertilized fresh when they are retrieved.  This is highly successful in achieving pregnancies in approximately 80% of donations.  However, cycles can be delayed in trying to synchronize patients.   If programs can achieve similar success rates using frozen eggs it will allow recipient patients to choose donor eggs much like they select donor sperm today.

Yet, another benefit of the ability to bank frozen eggs is for women who either because of their career or lack of finding a suitable partner need to put off their childbearing until a time when they would otherwise put their future fertility at significant risk.  This is a more controversial use of this technology but a practical concern for countless women today for whom conceiving before age 35 is unrealistic.

Needless to say, egg freezing will be a great benefit for many when it becomes a safe acceptable IVF standard.  That time for consideration by patients is rapidly approaching and is something that the public needs to be made aware of.

As a reproductive endocrinologist (and, therefore, a supposed expert on heredity), I’m often asked how much of a child’s development and ultimate personality is a result of genetics (nature) and how much is a result of its environment (nurture). Typically, this question arises when dealing with patients contemplating using donor sperm or donor egg.

I don’t have the answer to this question; it’s one I, myself, have spent much time considering. I’m one of five children and I have four children of my own and, so far, three grandchildren. Though the environment and the genetics of my siblings and and my children doesn’t appear to be so different, each of us has developed unique characters and personalities. Some are significantly different.

I think the nature vs. nuture question is like a Jackson Pollack painting. When you raise a child, different colors of nature and nurture are tossed randomly up in the air and what we call “life” dresses the canvas below. Sometimes the picture it creates is breathtakingly beautiful and other times you wish you could start with a new canvas.

Now, if you are a conscientious parent, then you are most careful about how and what colors of nurture you toss. With nature however, even with that which comes from you, there is no control.

So, I tell my patients who are screening donors and are so concerned that their donor has a particular color hair, eye color or even personality type, that they are putting too much faith in just one can of paint that they get to choose to toss up in the air. People with blue eyes and blonde hair have other colors from ancestors that randomly did not appear on their body. But their gametes contain them and these cans of paint will potentially have more impact on the canvas that the blue eyes and blonde hair that the recipient is hoping for.

The characteristics I prefer in a donor are healthy with good odds for successful conception and a generally appropriate mix of physical and behavioral characteristics to match the recipient.

Then I pray for G-d’s blessing.

There has been a lot of negative press recently about “reproductive tourism” – or cross-border reproductive care; that is traveling abroad for fertility services. However, the fact remains that in some areas couples struggling to start a family sometimes have no other option but to seek help away from their homes. This is the case for couples in the U.K. who must turn to egg donation as their only hope in order to conceive. For them, there is a three year wait for donor eggs. This is a huge obstacle for those anxious to start their families and for women already of an age where they can not afford to wait. In the U.S. the wait is much shorter. In fact, at many programs such as mine at East Coast Fertility we have a donor database with immediate availability. In an ideal world, patients wouldn’t have to leave their country and their local doctors to get the treatment they need in a timely fashion. But the reality in the UK is that many couples cannot afford to wait until a donor egg becomes available there.

Other reasons for patients seeking treatment abroad include limitations on medical technology, cost or even government restrictions on treatment that drives people to leave their home land for treatment.
The interesting thing about Cross Border reproductive care is that the currents of travelers go both ways in the United States. We have Americans who travel to India because they cannot afford the surrogacy fees in the United States, and to places like Israel, South America and Mexico for less expensive IVF.

Patients from countries such as Spain are traveling to the United States for procedures such as surrogacy which is outlawed in their country.

The flow of patients knows no borders. Everyone wishes that patients could receive treatment in their own country. Adding in the pressure of leaving one’s job, families, traveling to a country that you don’t know and perhaps even having language difficulties can make treatments that are already stressful – more so. But the desire to have a child also knows no borders – and patients will do what they need to do to achieve their dreams of parenthood.

Maria de Carmen Bousada

This is one of the hardest things about being a doctor in a cutting edge field such as reproductive medicine. We are often put in the position of making decisions with our patients that have even bigger implications to society than the individual patient. I do my best to look at each patient, and each situation individually, but I do rely on my patients to treat me as honestly as I treat them. It is a two way street – and unfortunately, Maria lied to the clinic about her age, telling them she was only 53 years of age.

Questions are being raised regarding the responsibility of the IVF program to verify the veracity of information supplied to them by their patients in addition to confirming their health condition to carry a pregnancy.

Others, add that beyond a certain age, it is unnatural to become a mother and it puts the family at risk that she may not be around to help raise the child as what occurred in this case, or even if she is perhaps she lacks the energy and stamina to raise the child properly.

At East Coast Fertility, we have a cutoff of age 50 which is admittedly random and that limit is often broken when faced with an energetic couple with a woman who passes her stress test, medical and high risk maternal fetal medicine clearances. We recently celebrated our latest 54 year old patient’s delivery of a healthy baby that was highly reported in the press.

As I said, it is a struggle to separate my own personal feelings about the proper age to have a child which may be inappropriate for others who have a completely different perspective. My responsibility as the physician offering assistance to patients in need of help with procreation is to the health of my patients, the well being of the child and for the good of society.

Many women in their 50’s have the health and energy to carry a pregnancy and bear a child with no more increased risk than many woman 10-20 years younger whose interest in achieving pregnancy we would never consider questioning. That being said what about the risk that the mother may not still be around to raise the child to maturity. There is no question that a young healthy couple with sufficient financial support and emotional maturity is ideal for raising a family. But, happy, successful families can take on many different faces. Single parent families exist, survive and often thrive. One can never be certain that the condition of the couple at the time of conception will continue through the child’s birth or for that matter until the child has reached maturity. We do not know that a healthy woman of 30, 40 or 50 may not develop a lethal disease before a child has grown up. In addition, at least 50% of couples in the United States become divorced. One can argue that couples at risk of divorce should not get pregnant. I do not think that society is ready to conclude that any of these women should not be allowed to procreate.

So, what about the clinic’s responsibility regarding confirming that a patient is giving them truthful information? We have been deceived in the past that a couple who is requesting fertility assistance was unmarried when in fact at least one partner was married to someone else. This issue is especially acute as it can raise potential liability to the clinic. As in the case of Maria de Carmen Bousada, she lied about her age and perhaps was beyond the limit the doctors and society was comfortable assisting.

For me, and for our program we have raised our bar to do the proper due diligence realizing that we will not be able to get the truth in all cases but minimize the risk that we missed picking up a crucial lie. But I don’t want to be “The Fertility Police”. I am a fertility doctor – and my job is to help people have families no matter how different those families may look to you and me.