Artificial Insemination Research Paper

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Abstract

Artificial insemination is the oldest, well-established procedure in cases of untreatable male infertility which has been regulated and submitted to standard medical guidelines in most developed countries but not all.

Minimum requirements had to be respected by those running sperm banks in order to ensure safety and good medical practice for donors, recipients, and children born. The main medical risks of sperm donation are transferring infectious and genetic diseases; therefore, selection of sperm donors must include screening tests for both medical conditions. Anonymous sperm banking has been practiced for several decades. The present trend is to practice non-anonymous sperm donation because many donor-conceived persons have a desire and interest in finding out about where they came from.

Introduction

Sperm donation is the oldest noncoital technique of reproduction.

There are Bibliography : to artificial insemination from the third century AD, and there was a belief that pregnancy could occur if the unwary female bathed in water contaminated by male ejaculate (Babylonian Talmud).

Animal experiments opened the way, and in the fourteenth century, Arabs were using insemination techniques to improve breeding quality in their horses.

The first scientific record was published in 1799 when Everard Home reported that John Hunter in England had inseminated a woman with her husband’s semen. Artificial insemination continued to play its role in infertility treatment, but was not reported in the medical literature as the technique was frowned upon and many moral and ethical objections to its use were raised.

Indications

Sperm is donated primarily for fertility purposes (Mor-Yosef and Schenker 1995). It is mostly intended for women in need of a sperm from a source other than their partner for medical reasons such as suffering from sperm deficiency – azoospermia. Male infertility includes both obstructive and non-obstructive azoospermia, which may be congenital or acquired. Men with genetic disorder or for women who do not have a partner.

Sperm Banks

Lazzaro Spallanzani in 1776 noted the effects on human sperm when they were exposed to a freezing temperature, and Paolo Mantegazza in 1886 made the first proposal for a sperm bank. In the early 1960s, sperm tanking became feasible. Successful pregnancies from the use of stored frozen spermatozoa using glycerol as a sperm cryoprotective agent and liquid nitrogen, a freezing agent, were reported. Sperm were stored in straws, tubes, or pellets.

Since the late 1980s, with the emergence of acquired immunodeficiency syndrome (AIDS), artificial donor insemination has been performed exclusively with frozen and quarantined sperm for at least 6 months before being released for use. Sperm banks have resources and supply for cryopreserved donor sperm to be used in artificial insemination or in vitro fertilization (Meirow and Schenker 1997).

The sperm bank also provides services in the following cases:

Men who are interested in saving sperm due to systemic and malignant diseases

Storage due to OTA (sperm quality which is insufficient for natural fertilization)

Men who are interested in saving sperm due to personal nonmedical reasons (posthumous sperm storage)

Sperm Bank Management

Recommendations and guidelines concerning sperm donation vary among sperm banks around the world. Most guidelines come from international academic ethical committees like the International Federation of Gynecology and Obstetrics (Schenker and Cain 2004) and American Society for Reproductive Medicine (ASRM 2013), governmental regulations, laws, and religious authorities (Schenker 2005).

Sperm banks in some countries are governed by legal authorities who create rules and regulations about the collection, storage, and use of sperm donations. These rules are designed to protect the donor and the recipient and to ensure that a healthy baby is conceived.

One of the major problems for sperm banks is the recruitment of suitable donors. In most countries, donors can be either single or married. However, some countries have specific demands concerning marital status of the donor. A review of donor recruitment revealed several main groups of candidates – unsolicited volunteers informed through the media and volunteers such as medical students informed by physicians and managers of sperm banks. In case of direct donation, the donors respond to requests by the recipients. However, in most countries, the latter type of donor will not be used for the treatment of the requesting recipient.

Sperm Donation For Medical Reasons

By practicing AID, genetic material is donated, and medical indications must be clear and based on generally accepted medical criteria.

With the recent development of micromanipulation methods and sperm aspiration methods testicular sperm aspiration (TESA) and microscopic epididymal sperm aspiration (MESA), new tools for the treatment of male infertility are offered. Therefore, the medical indications for the use of donor sperm in ART in order to alleviate infertility have decreased, and today donor sperm should not be used in ART before fertilization attempts with the husband’s sperm have failed following application of micromanipulation methods.

Selection Of Donor

It is the responsibility of the physician and the semen bank director to be aware of proper donor selection and screening. The donors should be in good health and free of genetic abnormalities. The screening should include medical history, familial screening for genetic disorders, physical examination, and cultures and serology for sexually transmitted diseases (STD). Ethical committees like Federation International Gynecology and Obstetrics (Schenker and Cain 2004), American Society Reproductive Medicine (ASRM 2013), governmental regulations, laws and religious authorities.

The donor should be of legal age. The preferred age is 18–40 – to minimize the potential effects of aging. In older males, a decline in sperm quality like hood of DNA mutations and higher risk of genetic abnormality in offsprings was reported.

Single men only, not married men, divorcees, or widowers (in some countries) are not allowed to be donors.

Minimal education, a matriculation certificate, and even university degree are required.

All regulatory bodies state that donors of genetic material should be healthy persons of normal reproductive age who are free from sexually transmitted diseases and hereditary disorders.

Potential donors should undergo medical examinations which include medical background and family medical health history at least for two generations of family members. Prospective donors then undergo a physical examination with screening for visible physical abnormalities, as well as testing for sexually transmitted diseases. The donors are tested for Treponema pallidum (syphilis), Chlamydia trachomatis, gonorrhea, HIV-1, HIV-2, hepatitis B surface antigen, and hepatitis C antibody. Routine blood analysis includes documentation of the donor’s blood type.

Genetic diseases can be passed on from the sperm donor to the child. It is therefore important to have as much information as possible about the donor’s family medical history, in order to rule out the possibility of genetic problems. Ideally this information should go back as far as four generations; this would include the donor’s parents, grandparents, and great-grandparents.

Comprehensive genetic testing is impractical; however, ethnically based genetic testing is standard in most sperm banks. Each sperm bank must determine what genetic diseases are most relevant in the context of the population they serve.

The following genetic testing should be considered:

  • Chromosome analysis (all donors)
  • Cystic fibrosis (all races, especially European ancestry)
  • Tay-Sachs disease (if Jewish or French Canadian)
  • Sickle cell disease (if African, Middle Eastern, Indian, South American, or Caribbean ancestry)
  • Thalassemia (if Italian, Greek, Middle Eastern, Chinese, East Indian, African, or Southeast Asian ancestry)

Particular attention is paid to the potential donor’s personal and sexual history to exclude those males who are at high risk for communicable disease including HIV, hepatitis, and other sexually transmitted diseases. The sperm donor should undergo a semen analysis, and the test sample should be thawed to evaluate post-freezing/thawing semen parameters. It is preferable that the donor should have proven fertility, or at least semen characteristics should be within normal limits following freezing for frozen-thawed semen survival of more than 50 %.

Usually donors are required to provide information about their personal habits, education, hobbies, and interests. Some banks may provide pictures of the donor. While a genetic screen, a medical history, and a physical examination must be administered for every sperm donor, certain variations exist among sperm banks.

The recipient may select donor sperm on the basis of the donor’s characteristics, such as looks, personality, academic ability, race, and many other factors.

The Insemination Technique

The intracervical or intrauterine insemination is the one commonly practiced.

Before this process can be done, the woman must have a complete medical examination to ensure that she is healthy enough to become pregnant and that there are no problems with any of her reproductive organs.

It requires sperm sample preparation like washing and addition of antibiotics. Insemination may be timed on a female’s natural cycle or following ovulation induction. There is general agreement in the literature that chances of success are better after mild ovarian stimulation and the maturation of a maximum of two or three follicles. However, the cycle must be monitored by ultrasound and hormonal analysis; if there are more than three mature follicles, the attempt should be canceled. The majority of pregnancies occur during the first six cycles.

Home Insemination

Some clinics provide to women, private customers the possibility of home insemination irrespective of their marital status or sexual orientation. The private customer can order sperm from all sperm donors on the sperm bank donor list, i.e., anonymous and non-anonymous donor sperm. Sperm banks ship tested and screened donor sperm. Instructions accompany all shipments of donor sperm to private customers, including handling, thawing, emptying of straws, and safety instructions. Since legislation regarding sperm donation only applies to treatment by doctors and other healthcare professionals, home insemination is not covered by any of the above legislative restrictions and may raise legal problems.

Natural Insemination

Insemination may be achieved by a donor having sexual intercourse with a woman for the sole purpose of initiating conception.

Donor Insemination Success Rates

The success of intrauterine insemination with donor semen is likely to be influenced by a number of variables, including age and ovarian stimulation regime. Donor sperm pregnancy success rates with insemination are highest for the following groups:

  • Women who have no fertility problems
  • Women under age 35

A retrospective cohort study among all eight sperm banks in the Netherlands (Kop et al. 2015) showed that in women inseminated with cryopreserved donor sperm in the natural cycle aged 33–34, the cumulative ongoing pregnancy rate after up to six treatment cycles was 40.5 %.

In women aged 40 using donor spermatozoa, the crude delivery rate after six intrauterine insemination cycles was 24 % (De Brucker et al. 2013).

UK data (HFEA 2008) showed that 10–15 % of women achieved pregnancy per menstrual cycle using intracervical insemination (ICI) and 15–20 % per cycle for intrauterine insemination (IUI). About 60–70 % have achieved pregnancy after six cycles of treatment.

These results indicate that the use of ovarian stimulation with either CC or hMG in women without ovulatory dysfunction does not improve the pregnancy rate during donor insemination. The only factor associated with reduced effectiveness of fertility treatment was age.

Pregnancy rate also depends on the total sperm count or, more specifically, the total motile sperm count used in a cycle.

The average success rate for donor insemination treatment was 13.6 % for women under age 35, 9.2 % for women aged 35–39, and only 4.5 % for women aged 40–42 (HFEA 2008).

The progress and outcome of pregnancies conceived with donor inseminations are no different from those achieved from sexual intercourse with the same risks of miscarriage and birth defects.

Use Of Sperm Donation: Recipients

Recipients must be informed on the donor recruitment and screening, the risks of treatment, the legislation, the procedures, and the success rates of the center. Counseling must be offered to the recipients (Pennings 1995).

Free informed signed consent must be obtained from the recipient.

Sperm donation must not be used for eugenic purposes.

Matching of donor and recipient phenotypic characteristic should be done.

Anonymous Donation

When the donation is anonymous, the donor does not know the identity of the sperm recipient(s). The sperm recipient(s) does not know the identity of the donor. The donor signs that he is barred from receiving information on pregnancies and live births, and the sperm bank commits to safeguard the donor’s anonymity. The donor signs to confirm that the medical details he has provided are correct. Usually the sperm donor is notified that he may not donate at other sperm banks after having donated sperm at a specific sperm bank.

The recipient and the donor-conceived person can only access non-identifying information provided by the donor at the time of donation.

A survey in Scandinavia showed that maintaining anonymity was important for the vast majority of the donors. When the law is passed for non-anonymous sperm donation, shortage of donors was noted. It was observed that the social, rearing father prefers to keep the donation as a private matter.

Non-Anonymous Sperm Donation

Non-anonymous sperm donation means that when the child who was conceived by sperm donation reaches the age of 18, he/she can receive the identifying information of the donor and meet his/her genetic parent.

The present trend is to practice non-anonymous sperm donation because many donor-conceived persons have a desire and interest in finding out about where they came from (Daniels et al. 2006 and Lampic et al. 2014). Human beings have a fundamental legal right to know their biological origins; similarly, the interest donors have in finding out about children born from their donation has also been recognized. Therefore, in many Western countries, the law was changed. Children should know where they came from. Most couples are not in favor of putting the information on birth certificates.

Many parents needed help to disclose the truth. Psychological counseling should be provided to all sperm donors; complex relationships are developed via sperm donation.

Known Donors (Directed Donations)

Requests of directed sperm donation are infrequent due to the availability of advanced assisted reproductive technologies like micromanipulation.

In developing countries, the higher cost and limited availability of advanced technologies are the reasons for requests of directed donations. Directed donations may be requested for reasons which include the donor’s known health status, genetic makeup, character, and social and cultural background. The issues of confidentiality in directed donations differ from anonymous donations in that the facts concerning the genetic origin of the potential child are known not only by the healthcare professionals involved but also at least by the donor and the recipient.

A major issue in known sperm donations is protection of the interests of the potential child as well as of those of the recipient(s) and the donor and his or her partner.

The informed consent from the donor and the recipient(s) is more complicated. There is a need to address the specific problems that arise from the fact that both the donor and the recipient(s) know the genetic parent of the child. The donor should be knowledgeable about any plans that may exist for the degree of disclosure and for future contact between the donor, the recipient(s), and the potential child.

The interest of the child calls for a profound discussion of the effects of this kind of family secret on the psychological development of the child as child’s genetic origin is known to both the donor and the recipient. The physician involved should attempt to determine whether known donors are motivated by undue pressure, coercion, or financial benefits; in such cases, the physician should decline to proceed with the donation. Informing children resulting from directed gamete donations of their origins is an important protection against inadvertent consanguinity.

Payment For Sperm Donation

Most international ethical committees’ statements stressed that semen donors should not be reimbursed for their donation (Flowers 2010). Commercial sperm banks exist in many countries public and private by which sperm donors were directly compensated. The amount of money paid to donors differed significantly from country to country. The shortage of semen donors has generated an increased interest in the motivations of donors. It is accepted to solve this ethical and practical dilemma by paying to donors only for time and expenses directly associated with the donation.

The payments vary in each country from the situation in the United Kingdom where donors are only entitled to their expenses in connection with the donation to the situation in US sperm banks where a donor receives a set fee of 50–100$ for each donation plus an additional amount for each vial stored.

Sperm recipients pay to sperm bank which varies in different countries. The main business of a particular sperm bank is to process and store sperm rather than to use it in fertility treatments.

The price level of donor sperm depends on a range of factors such as donor type (anonymous or non-anonymous), donor profile (basic or extended), motility, and type of straw. The price per straw increases with higher motility, if it is an extended profile and if it is a non-anonymous donor.

The Number Of Donor Offspring

The International Federation of Gynecology and Obstetrics (FIGO) guidelines recommend to limit the number of donor offspring in order to avoid the future danger of consanguinity and/or incest. Practically it is difficult to control the number of donor donations over the years.

Some sperm banks would not accept as a donor an individual who has previously donated at another center.

Preventing consanguinity and/or incest is a primary health concern. Different countries have developed varying guidelines to achieve this goal. The most important factors in determining this limit on donor offspring are the size, density, and mobility of the country’s population.

Sperm Donation: Religious Aspects

Religion, being concerned with affairs that are regarded as extraordinary and having unique importance in life, is an intrinsic part of the cultural fabric of each society (Schenker 2005). Moreover, developments in reproductive medicine raise new ethical questions for different religions that do not always have clear answers. Accordingly, the role of theology in bioethics, and perceived attitudes toward new developments within respective religious communities, must be clarified.

It is important for practitioners in the field of reproductive medicine to understand attitudes toward sperm donation that are derived from different religions.

Jewish Law

Therapeutic insemination with donor spermatozoa (AID) is accepted by a portion of the Jewish population in Israel. Experts agree that using the semen of a Jewish donor for AID is forbidden. Jewish law prohibits AID for a variety of reasons: incest, lack of genealogy, and problems related to inheritance. In addition, donors and the physicians who use the semen are violating the severe prohibition against masturbation. Many rabbinical scholars consider a child conceived through AID as having the status of mamzer (bastard).

Some rabbinical authorities permit AID if the donor is a non-Jew. This eliminates some of the legal complications related to the personal status of the offspring.

Christianity

The Catholic Church – Heterologous artificial fertilization is contrary to the unity of marriage, to the dignity of the spouses, to the vocation proper to parents, and to a child’s right to be conceived and brought in to the world through marriage.

As mentioned, this method of conception also violates the rights of the child, compromises his or her parental origins, and can interfere with the development of personal identity. This position eliminates any use of donor semen for artificial insemination. Furthermore, artificial fertilization of a woman who is unmarried or a widow, whoever the donor may be, cannot be morally justified.

The Eastern Orthodox Church – The Church opposes gamete donation, especially AID, on the grounds that it constitutes an adulterous act.

The Protestant Church – All denominations of the Protestant Church oppose IVF with donated gametes.

Islam

A third party is not acceptable, whether in providing the egg, spermatozoon, embryo, or uterus. Islamic law strictly condemns the practice of AID on the grounds that it is adulterous. According to Islam, a man’s infertility should be accepted if it is beyond cure.

Conclusion

It seems to be difficult to standardized guidelines for recruiting donors or access to the programs and indications for artificial insemination by donor. Nevertheless, standardization of practice and regulations is necessary not only for medical reasons but also because of movement of people over the borders into the world.

Bibliography :

  1. Daniels, K., Feyles, V., Nisker, J., Perez-y-Perez, M., Newton, C., Parker, J. A., Tekpetey, F., & Haase, J. (2006). Sperm donation: Implications of Canada’s Assisted Human Reproduction Act 2004 for recipients, donors, health professionals, and institutions. Journal of Obstetrics and Gynaecology Canada, 7, 608–615.
  2. De Brucker, M., Camus, M., Haentjens, P., Verheyen, G., Collins, J., & Tournaye, H. (2013). Assisted reproduction using donor spermatozoa in women aged 40 and above: The high road or the low road? Reproductive Biomedicine Online, 26, 577–585.
  3. Ethics Committee of American Society for Reproductive Medicine (ASRM). (2013). Informing offspring of their conception by gamete or embryo donation: A committee opinion. Fertility and Sterility, 100, 45–49.
  4. Flower, D. (2010). Assisted reproduction: Should egg and sperm donors be paid? The Journal of Family Health Care, 20, 69–71.
  5. Human Fertilization Embryonic Authority (HFEA). (2008). Patients information. London: Human Fertilization Embryonic Authority.
  6. Kop, P. A., van Wely, M., Mol, B. W., de Melker, A. A., Janssens, P. M., Arends, B., Curfs, M. H., Kortman, M., Nap, A., Rijnders, E., Roovers, J. P., Ruis, H., Simons, A. H., Repping, S., van der Veen, F., & Mochtar, M. H. (2015). Intrauterine insemination or intracervical insemination with cryopreserved donor sperm in the natural cycle: A cohort study. Human Reproduction, 30, 503–507.
  7. Lampic, C., Skoog Svanberg, A., & Sydsjö, G. (2014). Attitudes towards disclosure and relationship to donor offspring among a national cohort of identity-release oocyte and sperm donors. Human Reproduction, 9, 1978–1986.
  8. Meirow, D., & Schenker, J. G. (1997). The current status of sperm donation in assisted reproduction technology: Ethical and legal considerations. Journal of Assisted Reproduction and Genetics, 10, 133–138.
  9. Mor-Yosef, S., & Schenker, J. G. (1995). Sperm donation in Israel. Human Reproduction, 10, 965–967.
  10. Pennings, G. (1995). Should donors have the right to decide who receives their gametes? Human Reproduction, 10, 2736–2740.
  11. Schenker, J. G. (2005). Assisted reproductive practice: Religious perspectives. Reproductive Biomedicine Online, 10, 310–319.
  12. Schenker, J. G., & Cain, J. M. (2004). FIGO committee for the Ethical Aspects of Human Reproduction and Women’s Health. International Journal of Gynaecology and Obstetrics, 86, 267–275.
  13. Schenker, J. G. (2011). Ethical dilemmas in assisted reproductive technologies. Berlin: De Gruyter.

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