Artificial insemination The origins of artificial insemination are obscure. Sheik was reported to have used the procedure in the early 13th century to the detriment of his enemies: he inseminated their mares with semen from sick inferior stallions.1 The first instance of artificial insemination in humans is credited to John Hunter in the latter part of the 18th century.1 He was responsible for what was probably the first recorded pregnancy and delivery of a child conceived by artificial insemination with the husband's semen. The first instance of artificial insemination with a donor's semen is attributed to Pancbast in 1884.1 In 1954 Bunge, Keettel and Sherman2 recorded a pregnancy resulting from the use of cryopreserved semen from a human. Montegazza3 suggested the use of frozen semen banks in 1866, but it is only recently that these facilities have been developed across North America. Much infertility in men remains unresponsive to treatment. In spite of renewed interest and research in the field of andrology, this aspect of reproduction is still suffering the effects of earlier neglect. For couples who are childless because of nontreatable failure of the man's reproductive system two options remain. Adoption is favoured by many, but most areas of Canada are still experiencing a yearly decrease in the number of chiLdren available. Partly to balance this decline, but also as a result of changing public opinion, requests for artificial insemination continue to increase in number. The procedure is now common in several centres across Canada. However, it presents many unresolved problems that must be quickly clarified, as they are retarding progress of a most valuable service for the childless couple. Artificial insemination with the husband's semen has been notably unsuccessful,4 particularly when the problem is oligospermia. In such cases the overall success rate is no greater than the rate expected for untreated couples.1'5 This procedure is generally now used only in the treatment of such disorders as coital dysfunction when the semen quality is normal. For example, with prob-
lems such as penile or vaginal anatomic abnormalities, retrograde cjaculation and unresponsive psychosomatic coital difficulties, artificial insemination may help. Cryopreservation of semen for later artificial insemination can also be of value for men about to undergo orchidectomy or radiotherapy. Which couples are suitable for artificial insemination with a donor's semen? The main indication is irreversible infertility of the man when the woman is fertile. Occasionally a donor's semen is used when it is likely that the conceptus will be abnormal - for example, when the man carries a lethal or deleterious gene. Since artificial insemination with a donor's semen is still in its infancy, most centres will consider only married couples with a stable and mature relationship. Obviously this is difficult to judge, and often guidance of psychiatrists and social workers is needed. Has the medical profession the right to reject couples seeking artificial insemination with a donor's semen? Are physicians exceeding their authority in doing so? These are areas that require a great deal of professional and public debate. Many couples requesting artificial insemination with a donor's semen seem to have already "preselected" themselves, and have a stable union. Results of careful screening have shown that the divorce rate after a donor's semen has been used for artificial insemination is between 1% and 5% many times lower than the divorce rate for the general population. Some men have trouble accepting their subfertility and believe that their masculinity is threatened. In such instances adoption may be preferred. Selection of donors and use of their semen raises novel problems. Many centres rely on students as donors, particularly medical students, who are available in all large medical centres, are sympathetic and reliable, and are well informed about their own and their family's medical problems. Several centres advocate approaching husbands of obstetric patients to ensure that the donor is fertile.5 Although there is a certain
logic in using a relative as a donor, the likelihood of a subsequent emotional upheaval seems to outweigh any possible advantages, although successful instances have been recorded.5 In Canada there are no uniform guidelines for screening donors, though from a medicolegal standpoint standardization of screening procedures would be advantageous. The study group of the Royal College of Obstetricians and Gynaecologists has suggested that the donor be interviewed and a full medical and family history obtained.1 There should also be a general examination of physical characteristics. The donor should sign a document stating that he is fully aware of how the semen will be used. Investigations vary from centre to centre, but most include semen analysis and culture, VDRL, blood glucose and Rhesus factor tests, and karyotyping. The number of children that one donor should sire is also debatable because of the possibility of a subsequent accidentally consanguineous marriage. However, the report of the departmental committee on human artificial insemination6 stated that if 2000 children per year were to be born alive as a result of the use of artificial insemination with a donor's semen, and if each donor was responsible for 5 children, an unwittingly incestuous mamage was unlikely to occur more than once in 50 to 100 years. The risk is therefore insignificant when compared with the expected frequency of accidentally consanguineous marriage in the general population.1 The rate of success following artificial insemination with a donor's semen varies widely and depends on the method of insemination, the selection of couples and donors, and the number of menstrual cycles during which insemination is done. Generally, the rate is between 60% and 90% after six cycles.1 The rates of spontaneous abortion, ectopic pregnancy and congenital abnormalities are slightly lower than those for the general population, presumably because of the screening of donors and couples. When fresh semen is used the pregnancy rate is higher than
CMA JOURNAL/JANUARY 6, 1979/VOL. 120 11
SUDAF5 TABLETS / SYRUP Pseudoephedrine HOI Decongestant
Indications: Relief of nasal congestion associated with allergic rhinitis, acute coryza, vasomotor rhinitis, acute and subacute sinusitis, acute otitis media, asthma, postnasal drip, acute eustachian salpingitis. It may also be used as an adjunct to antibiotics, antihistamines, analgesics and antitussives in the treatment oftheaboveconditions. Contraindications: Patients receiving or having received MAO inhibitors in the preceding 3 weeks; known hypersensitivity to pressor amines. Precautions: As pseudoephedrine is a sympathomimetic amine, it should be used with caution in hypertensive and diabetic patients, patients with latent or clinically recognized angle-closure glaucoma, coronary artery disease, congestive heart failure, prostatic hypertrophy, hyperthyroidism, urinary retention. Adverse Effects: As with other sympathomimetic amines, headache, dizziness, insomnia, tremor, confusion, CNS stimulation, muscular weakness, dry mouth, nausea, vomiting, difficulty in micturition, palpitations, tightness in thechest and syncope may beencountered. Overdose: Symptoms: Increase in pulse and respiratory rate, CNS stimulation, disorientation, headache, dry mouth, nausea and vomiting. Treatment: Gastric lavage, repeated if necessary. Acidify the urine and institute general supportive measures. If CNS excitement is prominent, a short-acting barbiturate may be used. Dosage: Adults and children over 6 years: 2 teaspoonfuls of syrup or 1 tablet 3 times daily. Children 4 months to 6 years: ½ adult dose. Infants upto4 months: 1/2 teaspoonful of syrup 3 times daily. Supplied: Syrup: Each 5 ml of clear purplish-red syrup with a sweet raspberry flavor contains: pseudoephedrine HCI 30 mg. Available in 100 inland 250 ml bottles. Tablets: Each white, biconvex tablet 8.6 mm in diameter with code number WELLCOME S7A on same side as diagonal score mark contains: pseudoephedrine HCI 60 mg. Available in cartonsof 18 and bottlesof lOOand 500tablets. Additional prescribing information available on request.
. Weilcome Medcai Divieion Burroughs Welicome Ltd. LaSafle, Out. p.3
*Tmde Mark L.!J
W-8004
when cryopreserved semen is used.7 In spite of this, there is an excellent case for establishing regional sperm banks in areas where donors are difficult to find. Although many couples decide for themselves how long attempts at conception with artificial insemination should continue, it should be made clear to all couples that there is little hope of success if conception has not occurred after more than 12 menstrual cycles during which artificial insemination has been done. Before embarking on such a program each couple should be advised that there can be no guarantee of pregnancy. Artificial insemination with a donor's semen raises four main legal issues,1 and it is disheartening that these issues are still clouded in Canadian law. The first issue is the status of the offspring. A child is considered legitimate only if he or she is born to, conceived by, or presumed to have been conceived by a couple during a valid marriage. The position of a child conceived by artificial insemination with a donor's semen is therefore not clear, but it is reasonable to ask whether he or she should be considered legitimate.* One solution would be to introduce a new status of "accepted child" that would encompass legitimate, legitimated and illegitimate children. The second issue is whether artificial insemination with a donor's semen, if done without the husband's consent, amounts to adultery. In the case of Orford v. Orford in Ontario in 1921 the court ruled that it was adultery.1 Other jurisdictions have maintained that, because artificial insemination is not sexual intercourse, it is not adulterous.8 Obviously no physician would inseminate a woman without her consent, but unless written consent is given, the physician could be liable for assault. Thus, written consent of both partners is very important. The third difficulty surrounds the physician-patient relationship. This includes the standards of skill expected of the physician in selecting the donor and in performing the inse*In Ontario the legal status of a child conceived by artificial insemination is no longer questionable. As of Apr. 1, 1978. according to the Children's Law Reform Act, all children, whether or not they have been conceived by a couple during a valid marriage, have the same legal rights, and no child is to be considered illegitimate. - Ed.
12 CMA JOURNAL/JANUARY 6, 1979/VOL. 120
mination. However, until these matters are litigated, it is difficult to determine the minimum required standards. A final question arises as to whether a child conceived by artificial insemination with a donor's semen should be able to ascertain the identity of his natural father. In many countries an adopted child is legally able to ascertain the identity of his natural parents, in spite of the fact that many of the latter do not wish it. If such an opportunity is given to an adopted child, it is arguable that it should also be given to the child conceived by artificial insemination with a donor's semen. For many couples who are infertile artificial insemination is the only hope of realizing the full potential of family life. Through medical and public debate the many intriguing practical, legal and moral problems must be resolved. P.R. GARNER, MA, M SC, MB, B CHIR, FRCP[C]
Reproductive endocrinology and infertility unit Ottawa Civic Hospital Ottawa, Ont.
References 1. BRUDENELL M, MCLAREN A, SHORT
R, et al: Artificial Insemination. Proceedings of the Fourth Study Group of the Royal College of Obstetricians and Gynaecologists, Royal College of Obstetricians and Gynaecologists, London, 1976 2. BUNGE RG, KEETrEL WC, SHERMAN JK: Clinical use of frozen semen; re-
port of 4 cases. Fertil Steril 5: 520, 1954
3. MONTEGAZZA J: Fisiologia sullo sperma umans. Rendic Reale instit Lomb
3: 183, 1866
4. DixoN RE, BUTrRAM VC: Artificial insemination using donor semen: a review of 171 cases. Fertil Steril 27: 130, 1976 S. SCHOYSMAN R: Problems of selecting donors for artificial insemination. I
Med Ethics 1: 34, 1975 6. LORD FEVERSHAM (chmn): Report of
the Departmental Committee on Human Artificial Insemination. Presented to Parliament by the Secretary of State for the Home Department and the Secretary of State for Scotland, July 1960, HMSO, London, 1960 7. SMITH KD, STEINBERGER E: Survival
of spermatozoa in a human sperm bank. Effects of long-term storage in
liquid nitrogen. JAMA 223: 774, 1973 8. MacLennan v. MacLennan. 1958 ses-
sions, case no. 105. Scots Law Times 12: 1958
lems such as penile or vaginal anatomic abnormalities, retrograde cjaculation and unresponsive psychosomatic coital difficulties, artificial insemination may help. Cryopreservation of semen for later artificial insemination can also be of value for men about to undergo orchidectomy or radiotherapy. Which couples are suitable for artificial insemination with a donor's semen? The main indication is irreversible infertility of the man when the woman is fertile. Occasionally a donor's semen is used when it is likely that the conceptus will be abnormal - for example, when the man carries a lethal or deleterious gene. Since artificial insemination with a donor's semen is still in its infancy, most centres will consider only married couples with a stable and mature relationship. Obviously this is difficult to judge, and often guidance of psychiatrists and social workers is needed. Has the medical profession the right to reject couples seeking artificial insemination with a donor's semen? Are physicians exceeding their authority in doing so? These are areas that require a great deal of professional and public debate. Many couples requesting artificial insemination with a donor's semen seem to have already "preselected" themselves, and have a stable union. Results of careful screening have shown that the divorce rate after a donor's semen has been used for artificial insemination is between 1% and 5% many times lower than the divorce rate for the general population. Some men have trouble accepting their subfertility and believe that their masculinity is threatened. In such instances adoption may be preferred. Selection of donors and use of their semen raises novel problems. Many centres rely on students as donors, particularly medical students, who are available in all large medical centres, are sympathetic and reliable, and are well informed about their own and their family's medical problems. Several centres advocate approaching husbands of obstetric patients to ensure that the donor is fertile.5 Although there is a certain
logic in using a relative as a donor, the likelihood of a subsequent emotional upheaval seems to outweigh any possible advantages, although successful instances have been recorded.5 In Canada there are no uniform guidelines for screening donors, though from a medicolegal standpoint standardization of screening procedures would be advantageous. The study group of the Royal College of Obstetricians and Gynaecologists has suggested that the donor be interviewed and a full medical and family history obtained.1 There should also be a general examination of physical characteristics. The donor should sign a document stating that he is fully aware of how the semen will be used. Investigations vary from centre to centre, but most include semen analysis and culture, VDRL, blood glucose and Rhesus factor tests, and karyotyping. The number of children that one donor should sire is also debatable because of the possibility of a subsequent accidentally consanguineous marriage. However, the report of the departmental committee on human artificial insemination6 stated that if 2000 children per year were to be born alive as a result of the use of artificial insemination with a donor's semen, and if each donor was responsible for 5 children, an unwittingly incestuous mamage was unlikely to occur more than once in 50 to 100 years. The risk is therefore insignificant when compared with the expected frequency of accidentally consanguineous marriage in the general population.1 The rate of success following artificial insemination with a donor's semen varies widely and depends on the method of insemination, the selection of couples and donors, and the number of menstrual cycles during which insemination is done. Generally, the rate is between 60% and 90% after six cycles.1 The rates of spontaneous abortion, ectopic pregnancy and congenital abnormalities are slightly lower than those for the general population, presumably because of the screening of donors and couples. When fresh semen is used the pregnancy rate is higher than
CMA JOURNAL/JANUARY 6, 1979/VOL. 120 11
SUDAF5 TABLETS / SYRUP Pseudoephedrine HOI Decongestant
Indications: Relief of nasal congestion associated with allergic rhinitis, acute coryza, vasomotor rhinitis, acute and subacute sinusitis, acute otitis media, asthma, postnasal drip, acute eustachian salpingitis. It may also be used as an adjunct to antibiotics, antihistamines, analgesics and antitussives in the treatment oftheaboveconditions. Contraindications: Patients receiving or having received MAO inhibitors in the preceding 3 weeks; known hypersensitivity to pressor amines. Precautions: As pseudoephedrine is a sympathomimetic amine, it should be used with caution in hypertensive and diabetic patients, patients with latent or clinically recognized angle-closure glaucoma, coronary artery disease, congestive heart failure, prostatic hypertrophy, hyperthyroidism, urinary retention. Adverse Effects: As with other sympathomimetic amines, headache, dizziness, insomnia, tremor, confusion, CNS stimulation, muscular weakness, dry mouth, nausea, vomiting, difficulty in micturition, palpitations, tightness in thechest and syncope may beencountered. Overdose: Symptoms: Increase in pulse and respiratory rate, CNS stimulation, disorientation, headache, dry mouth, nausea and vomiting. Treatment: Gastric lavage, repeated if necessary. Acidify the urine and institute general supportive measures. If CNS excitement is prominent, a short-acting barbiturate may be used. Dosage: Adults and children over 6 years: 2 teaspoonfuls of syrup or 1 tablet 3 times daily. Children 4 months to 6 years: ½ adult dose. Infants upto4 months: 1/2 teaspoonful of syrup 3 times daily. Supplied: Syrup: Each 5 ml of clear purplish-red syrup with a sweet raspberry flavor contains: pseudoephedrine HCI 30 mg. Available in 100 inland 250 ml bottles. Tablets: Each white, biconvex tablet 8.6 mm in diameter with code number WELLCOME S7A on same side as diagonal score mark contains: pseudoephedrine HCI 60 mg. Available in cartonsof 18 and bottlesof lOOand 500tablets. Additional prescribing information available on request.
. Weilcome Medcai Divieion Burroughs Welicome Ltd. LaSafle, Out. p.3
*Tmde Mark L.!J
W-8004
when cryopreserved semen is used.7 In spite of this, there is an excellent case for establishing regional sperm banks in areas where donors are difficult to find. Although many couples decide for themselves how long attempts at conception with artificial insemination should continue, it should be made clear to all couples that there is little hope of success if conception has not occurred after more than 12 menstrual cycles during which artificial insemination has been done. Before embarking on such a program each couple should be advised that there can be no guarantee of pregnancy. Artificial insemination with a donor's semen raises four main legal issues,1 and it is disheartening that these issues are still clouded in Canadian law. The first issue is the status of the offspring. A child is considered legitimate only if he or she is born to, conceived by, or presumed to have been conceived by a couple during a valid marriage. The position of a child conceived by artificial insemination with a donor's semen is therefore not clear, but it is reasonable to ask whether he or she should be considered legitimate.* One solution would be to introduce a new status of "accepted child" that would encompass legitimate, legitimated and illegitimate children. The second issue is whether artificial insemination with a donor's semen, if done without the husband's consent, amounts to adultery. In the case of Orford v. Orford in Ontario in 1921 the court ruled that it was adultery.1 Other jurisdictions have maintained that, because artificial insemination is not sexual intercourse, it is not adulterous.8 Obviously no physician would inseminate a woman without her consent, but unless written consent is given, the physician could be liable for assault. Thus, written consent of both partners is very important. The third difficulty surrounds the physician-patient relationship. This includes the standards of skill expected of the physician in selecting the donor and in performing the inse*In Ontario the legal status of a child conceived by artificial insemination is no longer questionable. As of Apr. 1, 1978. according to the Children's Law Reform Act, all children, whether or not they have been conceived by a couple during a valid marriage, have the same legal rights, and no child is to be considered illegitimate. - Ed.
12 CMA JOURNAL/JANUARY 6, 1979/VOL. 120
mination. However, until these matters are litigated, it is difficult to determine the minimum required standards. A final question arises as to whether a child conceived by artificial insemination with a donor's semen should be able to ascertain the identity of his natural father. In many countries an adopted child is legally able to ascertain the identity of his natural parents, in spite of the fact that many of the latter do not wish it. If such an opportunity is given to an adopted child, it is arguable that it should also be given to the child conceived by artificial insemination with a donor's semen. For many couples who are infertile artificial insemination is the only hope of realizing the full potential of family life. Through medical and public debate the many intriguing practical, legal and moral problems must be resolved. P.R. GARNER, MA, M SC, MB, B CHIR, FRCP[C]
Reproductive endocrinology and infertility unit Ottawa Civic Hospital Ottawa, Ont.
References 1. BRUDENELL M, MCLAREN A, SHORT
R, et al: Artificial Insemination. Proceedings of the Fourth Study Group of the Royal College of Obstetricians and Gynaecologists, Royal College of Obstetricians and Gynaecologists, London, 1976 2. BUNGE RG, KEETrEL WC, SHERMAN JK: Clinical use of frozen semen; re-
port of 4 cases. Fertil Steril 5: 520, 1954
3. MONTEGAZZA J: Fisiologia sullo sperma umans. Rendic Reale instit Lomb
3: 183, 1866
4. DixoN RE, BUTrRAM VC: Artificial insemination using donor semen: a review of 171 cases. Fertil Steril 27: 130, 1976 S. SCHOYSMAN R: Problems of selecting donors for artificial insemination. I
Med Ethics 1: 34, 1975 6. LORD FEVERSHAM (chmn): Report of
the Departmental Committee on Human Artificial Insemination. Presented to Parliament by the Secretary of State for the Home Department and the Secretary of State for Scotland, July 1960, HMSO, London, 1960 7. SMITH KD, STEINBERGER E: Survival
of spermatozoa in a human sperm bank. Effects of long-term storage in
liquid nitrogen. JAMA 223: 774, 1973 8. MacLennan v. MacLennan. 1958 ses-
sions, case no. 105. Scots Law Times 12: 1958
