Psychiatric Issues in Non-Anonymous Oocyte Donation Motivations and Expectations of Women Donors and Recipients JACQUELINE
A.
BARTLElT.
M.D.
When donated 8enetic material (i.e.. sperm or om) is part ofthe treatmentfor infertility. the potential for psychol08ical complexity and symptoms is increased. Details of clinical ftndin8s in both ova donors and recipients in\'Olved in non-anonymous oocyte donation are presented in this article. The donors demonstrated expectable psychiatric symptom levels. while the recipients reported sif:nificantly fewer symptoms. This may reflect denial ofsymptoms and/or concerns that treatment would be denied if symptoms were revealed. Motivations and expectations ofthe participants. which were complex. are described. Evaluatinf: symptoms and understandinf: the emotional aspects ofthis reproductive option requires clinical observation durinf: and after treatment.
N
ew reproductive technology provides the infertile couple with many new options for treating their infertility. However. while the medical aspects are well documented. the complex emotional issues experienced as a result of these novel and sometimes controversial situations are not well studied. When donated genetic material (i.e.• spenn or ova) is required for the treatment. the potential for psychological complexity and psychological symptoms is increased. Infertility itself has been reported to be accompanied by many emotional and psychiatric symplOms.1.2 Infertile women have been reported to have more anxiety and other psychiatric symptoms than fertile women.· In addition. treatment for infertility is associated with many sources of stress. including physical. financial. and emotional stresses. 3-6 Both diagnostic and treatment procedures are often "uncomfortable," replacing the pleasure of sexual intimacy as a means of conception. During in vitro fertilization. embryo transfer (IVF-ET), the regimens of treatment inVOLUME 32· NUMBER 4· FALL 1991
trude frequently upon daily life (such as having to return home or to the clinic for daily injections of honnones). The honnones utilized often have unpleasant psychological side effects. Additionally, with IVF-ET, rates of pregnancy and birth are low (16% and 12%. respectively).' and rates of miscarriage and prematurity are high. 8 The data suggest that in vitro fertilization using donor oocytes (lVF-DO) is an emotionally complicated and stressful process. The following data were collected in clinical interviews with IVF-DO participants who were seen prior to their first IVF-DO treatment cycle. Received November 7. 1990; revised February 12. 1991; accepted February 21. 1991. From the Department of Psychiatry. University of Medicine and Dentistry of New Jersey-New Jersey Medical School. Newark. Address reprint requests to Dr. Bartlett, Department of Psychiatry. UMDNJNew Jersey Medical School. 185 South Orange Avenue. Newark. NJ 07103. Copyright © 1991 The Academy of Psychosomatic Medicine.
433
Psychiatric Symptoms in Ova Donation
METHODS All gamete donors, recipients, and their respective spouses, if any, were seen during the orientation/intake process, before any IVF-DO cycle was undertaken. All patients were informed about the types of medical treatment they would undergo and the inherent medical risks before the psychiatric evaluation. The patients completed a life events checklist, the Perceived Stress Scale (PSS),9 and the Hopkins Symptom Checklist-90 (SCL-90).'0-12 They then underwent a semistructured psychiatric interview, which consisted of demographic data, a psychosocial history, a psychosexual and fertility history, a family history, and a series of questions concerning their motivations and expectations relevant to the IVF-DO process. The interview was semistructured and openended in order to obtain as much information as possible in a single interview. Less potentially anxiety-provoking topics were discussed at the beginning of the interview, and more delicate or complex issues were discussed later. Each interview required an average of 1.25 to 1.5 hours. The oocyte donation program involves nonanonymous donors. Donors are chosen by the recipient couple or woman. They are not paid for their participation. All participants are asked about their relationships with each other and what, if any, change they expect in that relationship. A comparison sample of 16 consecutive women patients scheduled to undergo IVF-ET (not requiring exogenous gametes) also was evaluated using the self-report items only. The women were compared to the donors and recipients with respect to the number of reported life events, level of perceived stress, and the SCL-90. These subjects were not interviewed. RESULTS The findings reported here pertain to the first 14 infertile recipient women and their 16 donors, who were seen over a 2-yearperiod (1987-1989). The oocyte donors were chosen by the recipients and were personally known to them prior to their 434
entrance in the program. Two of the oocyte recipients had two potential donors, a fact that accounts for the difference in the number of subjects seen in each group. The prospective oocyte recipients all had been diagnosed as having premature ovarian failure. Demographic data are summarized in Table I. The oocyte donors were somewhat younger then the recipients, and fewer of them were married. One donor also was undergoing IVF-ET for her own fertility problem (tubal occlusion). The majority of the recipients chose a sister (36%) or a close friend (36%) to be the donor. Smaller numbers chose either another genetic relation such as a cousin (14%) or an acquaintance (14%). In only one instance was the potential donor selected by the recipient's husband and not well known to the recipient. With respect to psychiatric symptomatology, 16 IVF-ET patients were compared to both the oocyte donors and recipients (Table 2). The mean scores of each patient sample were within normal ranges. 9.12 Motivations of the ova recipients for choosing IVF-DO fell into four basic categories: the simple desire to have a child, the desire to experience pregnancy, a longing to provide the spouse with genetic offspring, and a desire to have genetically related offspring. Twenty-one percent reported that they were responding primarily to their spouses' desire for a child that would be genetically related to the father. Forty-three percent reported that they wanted to be able to experience the pregnancy, expressing the opinion that being pregnant was a way to nurture the unborn child and to make it more one's own than is possible in adoption. Another 21 % reported that simply obtaining a child was their primary motive. Despite the fact that half of the recipients had arranged for a blood relative to be their donor, only 14% spontaneously reported that having a genetic link oftheir own to the child was their primary motive. However, when this issue was further discussed, all of these recipients did acknowledge that the genetic factor had played a significant role in their choice of an ova donor. Motivations of the ova donors were initially reported by the majority (94%) as being altruistic PSYCHOSOMATICS
Bartlett
T ABI.E l.
Demographic data oflVF-DO recipients and donors
Characteristic Age. mean±SD Single. % Married. ~k Separated/divorced. % Widowed. 'k Childless. %
IVF-DO Recipients
IVF-DO Donors
(n=14)
(n=16)
36±6 7 93
31±6 25 44 25
o o
6
44
116
NOll': IYF-DO=in vitro fertilization using donor
oocytes.
TABLE 2.
Psychological data comparisons or IVFET patients with IVF-DO recipients and donors
Variable Life events Perceived stress test SCL·90 Somatization Depression Anxiety': Hostility
..
IVF·ET Patients
IVF-DO Recipients
IVF·DO Donors
(n=161
(n=141
(n=16)
2±2
2±1.3
3±3
25±1l
17±65
16±6
54±9 57±7 55±9 57±1O
47± 10 51±7 47±9 411±1l
45±7 47±9 45±1l 49±6
NOlI': All values are means±SD. IYF-ET=in vitro fertilization with embryonic transfer; IYF-DO=in vitro fertilization using donor oocytes; SCL·9O=Symplom Checklist-90. ·,KO.05; --,,«).Ol
ones. They viewed this as an opportunity to give a gift to someone. often stating that they did not need or have use for their eggs. which were just being wasted every month. Only one subject spontaneously reported that she felt she now would be able to do something special that would be of particular significance to her and would affect her feelings about herself. However, during the interview with the donors. other factors emerged as having influenced the donors in their decision to participate in the donor process. Almost one-third of the donors reported having had a prior voluntary abortion and stated that ova donation seemed somehow to "make up" for that. Two of the donors said that this would be a way to "test" their own genetic pool. One subject VOLUME 32· NUMBER 4· FALL 1991
herself had been adopted. and the other had a younger male sibling with an autistic-like condition that she worried might be inheritable. For yet another donor, participating in this process made her feel special and alleviated some feelings of inferiority to the recipient, a feeling that had bothered her in the past. Half of the donors also reported feeling "flattered" at being asked to donate genetic material to the infertile couple. Expectations concerning changes in the donor-recipient relationship were common. Of the recipients. 30% reported that they expected no change in their relationship. Almost half (43%) felt that their relationship. which often was described as a close one to begin with. would become closer. Another 14% reported that they expected to feel grateful or indebted to the donor. Half of the donors expected the relationship with the recipient to become a closer one. while 25% expected no change. Two of the donors (12.5%) expressed concern that this process might complicate or disturb their relationship with the recipient. One stated that she was afraid she might be blamed if something was wrong with the child. The other, who was herself undergoing straight IVF, reported that she might be jealous if the recipient became pregnant and she did not. DISCUSSION The women involved in the non-anonymous ova donor program reported low levels of distress and other emotional symptoms prior to treatment. Although they had been informed that treatment would be physically and emotionally demanding and that it might influence many spheres of the patient's life. at pretreatment interviews the participants did not report distress or other emotional symptoms. (A recent review of the Iiterature l3 reported that this paucity of expected symptoms also had been found in IVF-ET patients.) One possible explanation for this in the IVF-DO patients is that they simply did not experience any distress. The availability of treatment for their fertility problem may have ameliorated any symptoms the infertile subjects might have otherwise felt. Another explanation may be that 435
Psychiatric Symptoms in Ova Donation
symptoms were underreported, either consciously or unconsciously. Concerns or fears about being accepted into the oocyte donor program might have contributed to this. Participants did acknowledge at the end of the interview that they were concerned about acceptance into the program. It is important to note that denial of symptoms does not predict higher levels of psychiatric disorder. 14 Therefore, these low levels of reported symptomatology did not constitute a serious clinical concern. However, levels of symptoms may change over the course of treatment. WiIlingness to report or the need to suppress symptoms also may change when the threat of rejection is removed. These findings suggest that clinical and research investigations need to take place over the course of treatment. The reasons for utilizing IVF-DO might simply be the desire to have a child. However, more subtle and complex motivations also seem to influence both the recipient and donor in making this treatment choice. Such motivations and expectations, along with the degree to which the outcome meets these expectations, will likely influence the well-being of the participants during and after the completion of treatment. The participants in this program were found to be influenced by several motivating factors that went beyond the simple, though strong, desire to produce a child. The reasons recipients choose oocyte donation are similar to those reported by recipient couples who utilize artificial insemination by donorsperm. ls . '6 IVF-OO recipients want a child, preferably of "their own," a child that is genetically related to at least one parent. In IVF-OO the child has a biological relationship with both parents. The father has a genetic relationship and the mother a gestational one. Children conceived from non-anonymous ova donation also may have a genetic relationship to both parents when the donor is related to the mother. This ability to have a child conceived from the same genetic pool appears to enhance the recipient woman's expectations of relatedness to the child. All of the participants were self-selected, a fact that might bias the results; people who do not care about 436
genetic relatedness for the mother or who prefer anonymous ova donation are not likely to choose this type of treatment setting. For the women whose donor was a relative, however, the added potential of genetic relatedness to the infant was a consistent positive motivating factor. Donation of female gametes or oocytes is medically more complicated and carries more inherent medical risks than sperm donation. Studies of women about to undergo voluntary sterilization have reported that many of them are willing to undergo ovarian stimulation and to donate their eggs anonymously. 17 The women in this sample, however, were willing to be ova donors, although they did not want or require medical procedures. The reasons given by these ova donors for becoming a gamete donor are reminiscent of the motivations suggested in the literature both by sperm donors 18-20 and surrogate mothers. 2 1.22 The majority of both surrogates and sperm donors report altruistic reasons. However, additional psychological motivations, such as desires to "father" a child or to ensure that one's genes are passed on to the next generation, are reported by sperm donors. As noted earlier, the ova donors also reported other reasons for undergoing this process, such as the desire to test their genetic pool or to "make up for" a voluntary abortion. These data suggest that in addition to altruism, more subtle psychodynamic processes may also be influencing the decision to become an ova donor. Further evidence suggesting that the motivation for participation in a gamete donor program is complex and subtle is found in the expectation of increased closeness in the relationship between donors and recipients. This expectation may represent a hope or wish for a closer relationship. The distress surrogate mothers have reported after relinquishing the child they bore is related in part to their sadness at losing the relationship that they had developed before and during the pregnancy with the parenting couple. After the surrogate mother gives birth and surrenders the child, the parenting couple tend to withdraw from the surrogate,leaving her with an even greater sense of loss.22 These findings suggest that there are potential emotional consequences PSYCHOSOMATICS
Bartlett
that must be documented carefully. Counselling for all patients prior to entering these treatments should include an exploration of these motivations and a discussion of the possibility that the outcome will be quite different from what they hope for. The new reproductive technologies have had a significant impact on the lives of many infertile
couples. It is apparent that such procedures are psychologically complex. Whether or not these procedures are successful in producing offspring. there are many potential ramifications for all of the individuals involved. More investigation needs to be undertaken to delineate both the acute and long-term psychological impact of these reproductive options.
References I. Eisner BG: Some psychological differences between fertile and infertile women. J C/in Psychol 19:391-395. 1963 2. Mai F. Munday R. Rump E: Psychiatric interview comparisons between infertile and fertile couples. Psycho· som Med 34:431-440.1972 3. Callan VJ. Hennessey JF: Emotional aspects and support in IVF/ET prognlms. J In Vitro Fen Emhryo Transf 5:290-295. 1988 4. Dennerslein L. Morse C: Psychological issues in IVF.
Clinics in Ohstetrics and GynaecolollY 12:835-846. 1985 5. Garner CH. Arnold EW. Grey H: The psychological aspects of in vitro fertilization (abstracl1. Fenil Steril 41(suppl):13. 1984 6. Mahlstedt PP. MacduffS. Bernstein J: Emotional factors and the IVF/ET process. J In Vitro Fen Emhryo Transf 4:232-236. 1987 7. Medical Research International and the Society of Assisted Reproductive Technology: In-vitro fertilization/embryo transfer in the United States: 1988 results from the nationallVF-ET registry, Fenil Steril 53: 1320. 1990 8. Yovich JL. Parry TS. French NP. et al: Developmental assessment of 20 IVF infants at their first birthday. J In Vitro Fert Emhryo Transf3:253-257. 1986 9. Cohen S. Kawarak T. Mermelstein R: A global measure of perceived stress. J Health Soc Behal' 24:385-396. 1983 10. Derogatis LR. Lipman RS. Covi L: SCL-9O: an outpatient psychiatric rating scale. Psychopharmacol Bull 9:13-28.1973 II. Derogatis LR. Lipman RS. Rickels K. et al: The Hopkins
VOLUME 32· NUMBER 4· FALL 1991
Symptom Checklist: a self-report symptom inventory. Behal' Sci 19:1-15. 1974 12. Derogatis L: The SCL-90 Manual I: Scorinll. Adminis· tration and Procedures for the SCL-90-R, Baltimore. Clinical Psychometrics Research. 1977 13. Mazure CM. Greenfield DA: Psychological studies of IVF/ET participants. J In Vitro Fert Emhryo Transf 6:242-256. 1989 14. Lane RD. Merikangas KR. Schwartz GE. et al: Inverse relationship between defensiveness and lifetime prevalence of psychiatric disorder. Am J Psychiatry 147:573578. 1990 15. Brand HJ: Complexity of motivation for artificial insemination by donor. Psychol Rep 60:951-955.1987 16. Daniels KR: Artificial insemination using donor semen and the issue of secrecy. Soc' Sci Med27:377-383. 1988 17. Templeton AA. Glasier A. Angell RR. etal: What potential ova donors think [Ielter). Lancet I: 1081-1082. 1984 18. Sauer MV. Gorrill MJ. Zeffer KB. et al: Altitudinal survey of sperm donors at an artificial insemination clinic. J Reprod Med 34:362-364. 1989 19. Handelsman OJ. Dunn SM. Conway AJ. et al: Psychological and altitudinal profiles in donors for artificial insemination. Fmil Steril43:95-1O I. 1985 20. Kovacs GT. Clayton CEo McCowan P: The altitudes of semen donors. Clinical Reproduction and Fertility 12:73-75.1983 21. Parker PJ: MOlivalion of surrogate mothers: initial findings. Am J Psychiatry 140: 117-118. 1983 22. Parker PJ: The psychology of the pregnant surrogate mother: a newly updated report of a longitudinal pilot sludy. Presented at the American Orthopsychiatric Association. Toronto. April 1984
437
A.
BARTLElT.
M.D.
When donated 8enetic material (i.e.. sperm or om) is part ofthe treatmentfor infertility. the potential for psychol08ical complexity and symptoms is increased. Details of clinical ftndin8s in both ova donors and recipients in\'Olved in non-anonymous oocyte donation are presented in this article. The donors demonstrated expectable psychiatric symptom levels. while the recipients reported sif:nificantly fewer symptoms. This may reflect denial ofsymptoms and/or concerns that treatment would be denied if symptoms were revealed. Motivations and expectations ofthe participants. which were complex. are described. Evaluatinf: symptoms and understandinf: the emotional aspects ofthis reproductive option requires clinical observation durinf: and after treatment.
N
ew reproductive technology provides the infertile couple with many new options for treating their infertility. However. while the medical aspects are well documented. the complex emotional issues experienced as a result of these novel and sometimes controversial situations are not well studied. When donated genetic material (i.e.• spenn or ova) is required for the treatment. the potential for psychological complexity and psychological symptoms is increased. Infertility itself has been reported to be accompanied by many emotional and psychiatric symplOms.1.2 Infertile women have been reported to have more anxiety and other psychiatric symptoms than fertile women.· In addition. treatment for infertility is associated with many sources of stress. including physical. financial. and emotional stresses. 3-6 Both diagnostic and treatment procedures are often "uncomfortable," replacing the pleasure of sexual intimacy as a means of conception. During in vitro fertilization. embryo transfer (IVF-ET), the regimens of treatment inVOLUME 32· NUMBER 4· FALL 1991
trude frequently upon daily life (such as having to return home or to the clinic for daily injections of honnones). The honnones utilized often have unpleasant psychological side effects. Additionally, with IVF-ET, rates of pregnancy and birth are low (16% and 12%. respectively).' and rates of miscarriage and prematurity are high. 8 The data suggest that in vitro fertilization using donor oocytes (lVF-DO) is an emotionally complicated and stressful process. The following data were collected in clinical interviews with IVF-DO participants who were seen prior to their first IVF-DO treatment cycle. Received November 7. 1990; revised February 12. 1991; accepted February 21. 1991. From the Department of Psychiatry. University of Medicine and Dentistry of New Jersey-New Jersey Medical School. Newark. Address reprint requests to Dr. Bartlett, Department of Psychiatry. UMDNJNew Jersey Medical School. 185 South Orange Avenue. Newark. NJ 07103. Copyright © 1991 The Academy of Psychosomatic Medicine.
433
Psychiatric Symptoms in Ova Donation
METHODS All gamete donors, recipients, and their respective spouses, if any, were seen during the orientation/intake process, before any IVF-DO cycle was undertaken. All patients were informed about the types of medical treatment they would undergo and the inherent medical risks before the psychiatric evaluation. The patients completed a life events checklist, the Perceived Stress Scale (PSS),9 and the Hopkins Symptom Checklist-90 (SCL-90).'0-12 They then underwent a semistructured psychiatric interview, which consisted of demographic data, a psychosocial history, a psychosexual and fertility history, a family history, and a series of questions concerning their motivations and expectations relevant to the IVF-DO process. The interview was semistructured and openended in order to obtain as much information as possible in a single interview. Less potentially anxiety-provoking topics were discussed at the beginning of the interview, and more delicate or complex issues were discussed later. Each interview required an average of 1.25 to 1.5 hours. The oocyte donation program involves nonanonymous donors. Donors are chosen by the recipient couple or woman. They are not paid for their participation. All participants are asked about their relationships with each other and what, if any, change they expect in that relationship. A comparison sample of 16 consecutive women patients scheduled to undergo IVF-ET (not requiring exogenous gametes) also was evaluated using the self-report items only. The women were compared to the donors and recipients with respect to the number of reported life events, level of perceived stress, and the SCL-90. These subjects were not interviewed. RESULTS The findings reported here pertain to the first 14 infertile recipient women and their 16 donors, who were seen over a 2-yearperiod (1987-1989). The oocyte donors were chosen by the recipients and were personally known to them prior to their 434
entrance in the program. Two of the oocyte recipients had two potential donors, a fact that accounts for the difference in the number of subjects seen in each group. The prospective oocyte recipients all had been diagnosed as having premature ovarian failure. Demographic data are summarized in Table I. The oocyte donors were somewhat younger then the recipients, and fewer of them were married. One donor also was undergoing IVF-ET for her own fertility problem (tubal occlusion). The majority of the recipients chose a sister (36%) or a close friend (36%) to be the donor. Smaller numbers chose either another genetic relation such as a cousin (14%) or an acquaintance (14%). In only one instance was the potential donor selected by the recipient's husband and not well known to the recipient. With respect to psychiatric symptomatology, 16 IVF-ET patients were compared to both the oocyte donors and recipients (Table 2). The mean scores of each patient sample were within normal ranges. 9.12 Motivations of the ova recipients for choosing IVF-DO fell into four basic categories: the simple desire to have a child, the desire to experience pregnancy, a longing to provide the spouse with genetic offspring, and a desire to have genetically related offspring. Twenty-one percent reported that they were responding primarily to their spouses' desire for a child that would be genetically related to the father. Forty-three percent reported that they wanted to be able to experience the pregnancy, expressing the opinion that being pregnant was a way to nurture the unborn child and to make it more one's own than is possible in adoption. Another 21 % reported that simply obtaining a child was their primary motive. Despite the fact that half of the recipients had arranged for a blood relative to be their donor, only 14% spontaneously reported that having a genetic link oftheir own to the child was their primary motive. However, when this issue was further discussed, all of these recipients did acknowledge that the genetic factor had played a significant role in their choice of an ova donor. Motivations of the ova donors were initially reported by the majority (94%) as being altruistic PSYCHOSOMATICS
Bartlett
T ABI.E l.
Demographic data oflVF-DO recipients and donors
Characteristic Age. mean±SD Single. % Married. ~k Separated/divorced. % Widowed. 'k Childless. %
IVF-DO Recipients
IVF-DO Donors
(n=14)
(n=16)
36±6 7 93
31±6 25 44 25
o o
6
44
116
NOll': IYF-DO=in vitro fertilization using donor
oocytes.
TABLE 2.
Psychological data comparisons or IVFET patients with IVF-DO recipients and donors
Variable Life events Perceived stress test SCL·90 Somatization Depression Anxiety': Hostility
..
IVF·ET Patients
IVF-DO Recipients
IVF·DO Donors
(n=161
(n=141
(n=16)
2±2
2±1.3
3±3
25±1l
17±65
16±6
54±9 57±7 55±9 57±1O
47± 10 51±7 47±9 411±1l
45±7 47±9 45±1l 49±6
NOlI': All values are means±SD. IYF-ET=in vitro fertilization with embryonic transfer; IYF-DO=in vitro fertilization using donor oocytes; SCL·9O=Symplom Checklist-90. ·,KO.05; --,,«).Ol
ones. They viewed this as an opportunity to give a gift to someone. often stating that they did not need or have use for their eggs. which were just being wasted every month. Only one subject spontaneously reported that she felt she now would be able to do something special that would be of particular significance to her and would affect her feelings about herself. However, during the interview with the donors. other factors emerged as having influenced the donors in their decision to participate in the donor process. Almost one-third of the donors reported having had a prior voluntary abortion and stated that ova donation seemed somehow to "make up" for that. Two of the donors said that this would be a way to "test" their own genetic pool. One subject VOLUME 32· NUMBER 4· FALL 1991
herself had been adopted. and the other had a younger male sibling with an autistic-like condition that she worried might be inheritable. For yet another donor, participating in this process made her feel special and alleviated some feelings of inferiority to the recipient, a feeling that had bothered her in the past. Half of the donors also reported feeling "flattered" at being asked to donate genetic material to the infertile couple. Expectations concerning changes in the donor-recipient relationship were common. Of the recipients. 30% reported that they expected no change in their relationship. Almost half (43%) felt that their relationship. which often was described as a close one to begin with. would become closer. Another 14% reported that they expected to feel grateful or indebted to the donor. Half of the donors expected the relationship with the recipient to become a closer one. while 25% expected no change. Two of the donors (12.5%) expressed concern that this process might complicate or disturb their relationship with the recipient. One stated that she was afraid she might be blamed if something was wrong with the child. The other, who was herself undergoing straight IVF, reported that she might be jealous if the recipient became pregnant and she did not. DISCUSSION The women involved in the non-anonymous ova donor program reported low levels of distress and other emotional symptoms prior to treatment. Although they had been informed that treatment would be physically and emotionally demanding and that it might influence many spheres of the patient's life. at pretreatment interviews the participants did not report distress or other emotional symptoms. (A recent review of the Iiterature l3 reported that this paucity of expected symptoms also had been found in IVF-ET patients.) One possible explanation for this in the IVF-DO patients is that they simply did not experience any distress. The availability of treatment for their fertility problem may have ameliorated any symptoms the infertile subjects might have otherwise felt. Another explanation may be that 435
Psychiatric Symptoms in Ova Donation
symptoms were underreported, either consciously or unconsciously. Concerns or fears about being accepted into the oocyte donor program might have contributed to this. Participants did acknowledge at the end of the interview that they were concerned about acceptance into the program. It is important to note that denial of symptoms does not predict higher levels of psychiatric disorder. 14 Therefore, these low levels of reported symptomatology did not constitute a serious clinical concern. However, levels of symptoms may change over the course of treatment. WiIlingness to report or the need to suppress symptoms also may change when the threat of rejection is removed. These findings suggest that clinical and research investigations need to take place over the course of treatment. The reasons for utilizing IVF-DO might simply be the desire to have a child. However, more subtle and complex motivations also seem to influence both the recipient and donor in making this treatment choice. Such motivations and expectations, along with the degree to which the outcome meets these expectations, will likely influence the well-being of the participants during and after the completion of treatment. The participants in this program were found to be influenced by several motivating factors that went beyond the simple, though strong, desire to produce a child. The reasons recipients choose oocyte donation are similar to those reported by recipient couples who utilize artificial insemination by donorsperm. ls . '6 IVF-OO recipients want a child, preferably of "their own," a child that is genetically related to at least one parent. In IVF-OO the child has a biological relationship with both parents. The father has a genetic relationship and the mother a gestational one. Children conceived from non-anonymous ova donation also may have a genetic relationship to both parents when the donor is related to the mother. This ability to have a child conceived from the same genetic pool appears to enhance the recipient woman's expectations of relatedness to the child. All of the participants were self-selected, a fact that might bias the results; people who do not care about 436
genetic relatedness for the mother or who prefer anonymous ova donation are not likely to choose this type of treatment setting. For the women whose donor was a relative, however, the added potential of genetic relatedness to the infant was a consistent positive motivating factor. Donation of female gametes or oocytes is medically more complicated and carries more inherent medical risks than sperm donation. Studies of women about to undergo voluntary sterilization have reported that many of them are willing to undergo ovarian stimulation and to donate their eggs anonymously. 17 The women in this sample, however, were willing to be ova donors, although they did not want or require medical procedures. The reasons given by these ova donors for becoming a gamete donor are reminiscent of the motivations suggested in the literature both by sperm donors 18-20 and surrogate mothers. 2 1.22 The majority of both surrogates and sperm donors report altruistic reasons. However, additional psychological motivations, such as desires to "father" a child or to ensure that one's genes are passed on to the next generation, are reported by sperm donors. As noted earlier, the ova donors also reported other reasons for undergoing this process, such as the desire to test their genetic pool or to "make up for" a voluntary abortion. These data suggest that in addition to altruism, more subtle psychodynamic processes may also be influencing the decision to become an ova donor. Further evidence suggesting that the motivation for participation in a gamete donor program is complex and subtle is found in the expectation of increased closeness in the relationship between donors and recipients. This expectation may represent a hope or wish for a closer relationship. The distress surrogate mothers have reported after relinquishing the child they bore is related in part to their sadness at losing the relationship that they had developed before and during the pregnancy with the parenting couple. After the surrogate mother gives birth and surrenders the child, the parenting couple tend to withdraw from the surrogate,leaving her with an even greater sense of loss.22 These findings suggest that there are potential emotional consequences PSYCHOSOMATICS
Bartlett
that must be documented carefully. Counselling for all patients prior to entering these treatments should include an exploration of these motivations and a discussion of the possibility that the outcome will be quite different from what they hope for. The new reproductive technologies have had a significant impact on the lives of many infertile
couples. It is apparent that such procedures are psychologically complex. Whether or not these procedures are successful in producing offspring. there are many potential ramifications for all of the individuals involved. More investigation needs to be undertaken to delineate both the acute and long-term psychological impact of these reproductive options.
References I. Eisner BG: Some psychological differences between fertile and infertile women. J C/in Psychol 19:391-395. 1963 2. Mai F. Munday R. Rump E: Psychiatric interview comparisons between infertile and fertile couples. Psycho· som Med 34:431-440.1972 3. Callan VJ. Hennessey JF: Emotional aspects and support in IVF/ET prognlms. J In Vitro Fen Emhryo Transf 5:290-295. 1988 4. Dennerslein L. Morse C: Psychological issues in IVF.
Clinics in Ohstetrics and GynaecolollY 12:835-846. 1985 5. Garner CH. Arnold EW. Grey H: The psychological aspects of in vitro fertilization (abstracl1. Fenil Steril 41(suppl):13. 1984 6. Mahlstedt PP. MacduffS. Bernstein J: Emotional factors and the IVF/ET process. J In Vitro Fen Emhryo Transf 4:232-236. 1987 7. Medical Research International and the Society of Assisted Reproductive Technology: In-vitro fertilization/embryo transfer in the United States: 1988 results from the nationallVF-ET registry, Fenil Steril 53: 1320. 1990 8. Yovich JL. Parry TS. French NP. et al: Developmental assessment of 20 IVF infants at their first birthday. J In Vitro Fert Emhryo Transf3:253-257. 1986 9. Cohen S. Kawarak T. Mermelstein R: A global measure of perceived stress. J Health Soc Behal' 24:385-396. 1983 10. Derogatis LR. Lipman RS. Covi L: SCL-9O: an outpatient psychiatric rating scale. Psychopharmacol Bull 9:13-28.1973 II. Derogatis LR. Lipman RS. Rickels K. et al: The Hopkins
VOLUME 32· NUMBER 4· FALL 1991
Symptom Checklist: a self-report symptom inventory. Behal' Sci 19:1-15. 1974 12. Derogatis L: The SCL-90 Manual I: Scorinll. Adminis· tration and Procedures for the SCL-90-R, Baltimore. Clinical Psychometrics Research. 1977 13. Mazure CM. Greenfield DA: Psychological studies of IVF/ET participants. J In Vitro Fert Emhryo Transf 6:242-256. 1989 14. Lane RD. Merikangas KR. Schwartz GE. et al: Inverse relationship between defensiveness and lifetime prevalence of psychiatric disorder. Am J Psychiatry 147:573578. 1990 15. Brand HJ: Complexity of motivation for artificial insemination by donor. Psychol Rep 60:951-955.1987 16. Daniels KR: Artificial insemination using donor semen and the issue of secrecy. Soc' Sci Med27:377-383. 1988 17. Templeton AA. Glasier A. Angell RR. etal: What potential ova donors think [Ielter). Lancet I: 1081-1082. 1984 18. Sauer MV. Gorrill MJ. Zeffer KB. et al: Altitudinal survey of sperm donors at an artificial insemination clinic. J Reprod Med 34:362-364. 1989 19. Handelsman OJ. Dunn SM. Conway AJ. et al: Psychological and altitudinal profiles in donors for artificial insemination. Fmil Steril43:95-1O I. 1985 20. Kovacs GT. Clayton CEo McCowan P: The altitudes of semen donors. Clinical Reproduction and Fertility 12:73-75.1983 21. Parker PJ: MOlivalion of surrogate mothers: initial findings. Am J Psychiatry 140: 117-118. 1983 22. Parker PJ: The psychology of the pregnant surrogate mother: a newly updated report of a longitudinal pilot sludy. Presented at the American Orthopsychiatric Association. Toronto. April 1984
437
