Ethical issues in Donor Conception

1. Introduction
Beyond the scientific progress in assisted reproductive technologies (ART), it is necessary to
discuss the ethical considerations behind these advances. Ethical issues concerning donor
conception have been considered and discussed by government and non-governmental agencies,
the public, media and academic institutions in many countries.
The diversity of policies shows that each country has its unique set of guidelines tailored toward
its own specific needs.

2. Definitions
 Donated Sperm: Collection of ejaculated sperm from voluntary donor used to fertilize
egg in human host or in vitro.
 Donated Egg: Transfer of pre-ovulatory oocytes from voluntary donor to a suitable
host. Oocytes are collected through an invasive procedure, fertilized in vitro, and
transferred to the host.
 Donated Embryo: Embryo that has been created through in vitro fertilization in excess
of what was used by the gestating woman. Often frozen for further use, recent trend to
donate for adoption by others.
 Surrogacy: an arrangement, often supported by a legal agreement, whereby a woman
(the surrogate mother) agrees to bear a child for another person or persons, who will
become the child's parent(s) after birth.

3. History of Donor conception

The history of donor conception dates back to 1884, when the first case of donor insemination was
documented. At that time, physicians were using their own sperm for conception.
In 1977, Steptoe and Edwards successfully carried out a pioneering
conception which resulted in the birth of the world's first baby to be
conceived by IVF, Louise Brown on 25 July 1978, in Oldham General
Hospital, Greater Manchester, UK. My own extended family greeted Lola
(on the photo) into the word only last week. Lola was conceived via IVF in
Prague and born in Belgrade.
The first documented case of egg donation was in 1983, and embryo
placement and adoption began in 1997.
Donor conceptions are provided for couples with male or female infertility,
individuals who have a genetic disorder they do not want to pass on to a
child, second marriages where there was a vasectomy in the first marriage, single women, and the
lesbian and gay population.
4. Types of donor conception
a. In vitro fertilization
IVF, although not donor conception per se, being prerequisite for donor conception, deserves some
comments here.
One of the most important ways of coping with infertility is in vitro fertilization (IVF). The spread
and availability of IVF technology are to a great extent dependent on the policy of financing of its
very costly procedures. From the first successful IVF to the present day there has existed an
increasing need to introduce appropriate legislative measures and norms, which have been under
constant changes.
The situation in Serbia in this respect has dynamically changed since 2006, the year when the
Republic Fund for Health Insurance (RFHI) started to finance IVF. In 2006, the RFHI financed
one trial for women aged to 38 years. Presently, the situation is that RFHI covers costs of three
IVF trials for women to 42 years old.
As IVF becomes more popular, ethical considerations surrounding the use of these technologies
becomes increasingly important.
b. Sperm and egg donation
The importance of limiting the number of donor offspring from a single sperm/egg donor relates
to preventing accidental consanguinity between donor offspring. All countries agree that the
potential for consanguinity is a problem, but different countries have developed different
guidelines for limiting the number of donor offspring. Recently The New York Times broke the
story of one man who is believed to have fathered 150 children via anonymous sperm donation.
Considerations include the size of the country's population, density of population and mobility of
population. For example, in Mainland China, each sperm donor can only impregnate five women
through AID or in vitro fertilization (IVF), whereas the American Society for Reproductive
Medicine (ASRM) recommends a limit of 25 children per population of 800 000 for a single donor.
Age requirements for sperm donors differ, but generally it is required that donor should be of legal
age and, ideally, less than 40 years of age, because increased male age is associated with a
progressive increase in the prevalence of aneuploid sperm.
Anonymous versus non-anonymous sperm donation is an important issue to both the recipient and
the donor. Sometimes, donors will try to find out who the recipient will be. More often, recipients
want to know as much about the donor as possible before undergoing AID. Donor offspring may
later inquire about the identity of his or her genetic father as well. A key but long unresolved
question in sperm donation is whether the offspring should be informed of their biological or
genetic father and, if so, how much and when the information about donors should be revealed.
c. Embryo donation
Embryo donation, as one of the novel assisted reproductive technologies (ART), has remained a
controversial issue. This is due to this method’s need for individuals from outside the family circle.
Their presence can cause many ethical issues and complicate the designing and planning of the
embryo donation process.
 d. Surrogacy
The growing surrogacy phenomenon in which women agree to have their bodies used to undergo
a pregnancy and give birth to the resulting baby is becoming a major issue of the 21st century.
It is filled with complexity and controversy surrounding the implications for women’s health and
human rights generally. Since the surrogate usually has no biological relationship to the child, she
has no legal claim and the surrogate’s name does not appear on the birth certificate.
A few of the many issues raised by surrogacy include: the rights of the children produced; the
ethical and practical ramifications of the further commodification of women’s bodies; the
exploitation of poor and low income women desperate for money; the moral and ethical
consequences of transforming a normal biological function of a woman’s body into a commercial
transaction.

5. Genetic screening of gamete donors: ethical issues

a. Minimize the risk of infection and genetics from sperm donors
There is general agreement that sperm donors should undergo rigorous medical evaluation or
screening to ensure that no diseases (specifically, sexual or genetic diseases) are passed on to
potential offspring.
b. Medical history of the donor
The donor should not have (or have had) any significant hereditable condition, including major
Mendelian disorders, major malformations of complex cause, significant familial disorders with a
major genetic component or a chromosomal rearrangement that may result in unbalanced gametes.
An issue of divergence regards candidate donors known to be heterozygous for an autosomal
recessive disorder.
Donors should not only be healthy, but also young, given that maternal age is a known risk factor
for aneuploidy in oocytes, and paternal age may give a higher risk for a range of complex disorders.
c. Family history
The family history should establish that the candidate donor's first-degree relatives (parents,
siblings and offspring) are free of major Mendelian disorders, major malformations of complex
cause and significant familial disorders with a major genetic component.
d. Genetic tests
In addition to taking a medical and family history, donor screening may also include genetic testing
for specific conditions. Professional guidelines differ with regard to what this should include
(standard karyotyping or carrier status of autosomal recessive disorders, such as cystic fibrosis, ,
etc) of gamete donors.
Under the European Union (EU) Directive on human tissues and cells, gamete donors should be
screened for autosomal recessive genes known to be prevalent in the donor's ethnic background.
This general requirement has been translated into testing recommendations for donors from
specific populations in the professional guidelines of different EU countries.
6. General ethical principles
Gamete donation raises questions regarding all four of the basic principles of medical ethics:
autonomy, justice, beneficence, and non-maleficence. Infertility specialists, donor recruitment
agencies, donors, medical ethicists, patients, and health insurers must consider these conflicts of
interest when formulating and evaluating policies regarding gamete donation.
a. Autonomy
Medical ethicists often question the quality of consent involved in the gamete donation process.
For donors who receive payment for their participation, high financial incentives may provide
pressure clouding the ability to make clear, informed decisions. While most egg donors in the US
receive around $4,000 as compensation, current advertisements offer up to $100,000 for young,
healthy donors with "desirable" characteristics. Studies show that women who donate for financial
reasons suffer more emotional harm from the procedure and are more likely to regret their decision
than women with altruistic motivations.
b. Justice
Because of the current shortage of qualified egg donors, infertility treatments are subject to
distributive injustice. In the USA approximately 1,000 women conceive each year with the use of
donor eggs, while many more must postpone treatment until an acceptable donor becomes
available. Women who can afford higher payments are more likely to receive treatment than
women from lower socioeconomic levels, leading to ethical conflicts.
c. Beneficence
In principle donor conception is a morally sound reproductive option for individuals or couples
who have a fertility problem that makes it impossible for them to reproduce with their own sperm
or oocytes, who are at risk of transmitting a genetic disorder if using their own gametes, or whose
sexual orientation precludes them from having children through natural conception.
d. Non-maleficence
There is an inherent aspect of maleficence in respect to donors, who undergo the risks of an
invasive surgical procedure without clinical benefit.
This concept of harm-avoidance is especially problematic because the side effects of ovulation
enhancing drugs on donors are not completely known. The use of these drugs began fairly recently,
and longitudinal studies about their effects in later life have yet to be performed. Of concern is the
increasing frequency of clinical reports linking ovarian stimulation regimes with ovarian cancer,
ovarian trauma, infection, infertility and lacerations.
Doctors and legislative bodies must decide whether placing a young, fertile donor at risk for harm
is justifiable for the benefit of an older, infertile patient.

7. Legal issues
Gamete (sperm and egg) donor anonymity has become an increasingly active area of legislative,
bioethical, and empirical interest over the last decade.
Legal issues with donor conception are evolving. Many countries have legislation regarding sperm
donor insemination, some have legislation regarding egg donation, and even lower number
regarding embryo placement.
In Serbia new Law on Biomedical Assisted Fertilization was adopted on 5/5/2017. The novelties
it brings are: donation of reproductive cells and embryos, establishment of the Bank for
Reproductive Cells and Embryos, possibility that a woman living alone is able to enable parental
duty to be entitled to BMPO procedures, etc. Surrogacy was not mentioned in it.
Surrogacy as the newest addition to donor conception is not legal in many countries, including
Serbia. Below is the map regarding legal regulation of surrogacy in the world:

Both gainful and altruistic forms are legal

No legal regulation
Only altruistic is legal
Allowed between relatives up to second degree of consanguinity
Banned
Unregulated/uncertain situation

8. Conclusion
When helping patients, health professionals should avoid as much as possible the infliction of
harm. In this context, the ethical principle of ‘primum non nocere’ not only refers to possible harms
to the donor and recipients of gametes, but also to possible welfare affecting consequences for the
children that may be born with donor gametes.
Parents who use donor gametes should feel firm and entitled to say they are this child’s parents.
Their decision to bring a child into the world creates continuous consequences for the whole
family.
I strongly believe that keeping origins secret can be detrimental to a child’s mental health, and that
open donation, similar to open adoption, is most helpful in the healthy family system. Children’s
rights and best interests must be at the center of decision-making about donor conception.