J. biosoc. Sci. (1979) 11,473-479
SOCIAL FACTORS IN PATIENTS FOR ARTIFICIAL INSEMINATION BY DONOR (AID) R. S. LEDWARD*, L. CRAWFORD AND E. M. SYMONDS Department of Obstetrics and Gynaecology, City Hospital, Nottingham
Summary. A programme of artificial insemination, using donor semen, within the NHS began in Nottingham in 1975. Since the inception of the programme all couples have been interviewed by a senior medical social worker, either at home or, later in the programme, within the clinics. This paper reports on features including education, employment, relationship to fertility status, relationship to parents and childhood, religion and reaction to adoption or fostering from the first 147 couples interviewed. All couples have stated a willingness for follow-up assessments and further studies are planned to review their marriages and psychological make-up in later years. Introduction
In June 1975 a programme of artificial insemination using donor semen (AID) began at the Nottingham City Hospital using National Health Service facilities (Ledward et ah, 1976). At the present time (November 1978) in the programme, 214 are on the waiting list for AID and 47 are receiving treatment. An initial 147 couples form the basis of this paper. Method
All patients agreed to a medical social report being obtained by a senior medical social worker from the Nottingham City Hospital. In order to maintain the confidentiality of the service only one medical social worker was involved. The patient and her husband were introduced to her when they attended the hospital for an AID interview, at which time consent forms were completed, the service explained and evidence of female fertility status and male infertility status obtained. The medical social worker explained her function and made an appointment to visit the couple at home. With the expansion of the service, couples have been accepted from areas remote from Nottingham and a home interview has not always been possible. * Present address: PO Box 7897, Riyadh Military Hospital, Riyadh, Saudi Arabia. 473
474
R. S. Ledward, L. Crawford and E. M. Symonds Results
There were no coloured or immigrant patients in the series. The education of both partners, summarized in Table 1, shows a distribution little different from the population as a whole; of the two unspecified cases one patient had missed school owing to poor health and had been educated at a special school for the educationally retarded, later succeeding to a level of self-employment as a joiner. The other patient could not recall his education owing to a troubled background. All husbands were in full employment (Table 1), and social classes 4 and 5 appear to be under-represented. AH but 27 (18%) of the wives were in full-time Table 1. Distribution of the sample, by education and employment Husband No. Education Secondary Modern school Grammar school Public school University Other Employment Factory Teacher Clerical Management/technical Professional Cook Police Miner Own business Housewife Miscellaneous Total sample
%
108 27 4 6 2
Wife No.
%
105 38 2 2 0
42 11 4 59 10
28-6 7-5 2-7 40-1 6-8
3 4 12
20 2-7 8-2
2 147
1-4
39 13 42 5 10 3
26-6 8-8 28-6 3-4 6-8 20
27 8 147
18-4 5-4
employment (Table 1) and ten of the unemployed wives had recently stopped work voluntarily to participate in the AID programme. All applicants were in a stable marriage. They had been married for periods of 1 year to 13 years with a mode at 5 years (Table 2) and all had been trying for a family since early marriage. Most couples lived in adequate homes. One couple lived in a caravan but were in the process of buying a house, and three other couples had small council flats but stated that it was council policy to provide them with a house should a child be born. Nearly all couples maintained a close relationship with their parents and recalled a happy childhood (Table 3). Eighteen couples came from large families (more than five siblings; two have ten siblings) and
Social factors and AID
475
Table 2. Duration of marriage Years of marriage at initial consultation
No. of couples
1 2 3 4 5 6 7 8 9 10 11 12 13
4 6 13 19 23 19 19 14 12 8 3 3 4
admitted that their own happy childhood and stable background was a stimulus to their wish for their own family. Most patients stated that the realization of male infertility had been very difficult to accept and had caused stress, affecting the marriage. In three cases the couple married with the knowledge of azoospermia. One husband claimed that he came to terms with the problem in a day, and two other couples were hopeful that artificial insemination using the husband's semen would be successful but, if not, would accept AID. One couple was not unduly surprised, owing to the husband's poor health in early years. Three other couples were not unduly surprised, owing to a history of radiotherapy to the male for testicular tumours. Four patients had had genetic counselling and, as a result, had been accepted for AID; one other patient Table 3. Relationship to parents and childhood Wife
Husband
Contact with parents Regular Limited None Childhood Happy Unhappy
No.
%
No.
%
119 18 10
80-9 120 7-0
127 15 5
86-3 10-2 3-4
142 5
96-5 3-5
140 7
95-2 4-8
Four of the applicants had divorced parents; two of the applicants had had previous marriages themselves.
476
R. S. Ledward, L. Crawford and E. M. Symonds
had had a vasectomy in a previous marriage and had now re-married, hence his request for AID. Several patients stated that they were initially despondent and distressed at the knowledge of azoospermia but later accepted the problem in the knowledge of AID availability, and three patients considered the biological background of the child to be less important than the environmental upbringing. One patient found it more difficult to accept his azoospermia owing to his own large family background and thought that marriage was incomplete without children. Six patients described their reaction to azoospermia in terms varying from 'suicidal' to 'shattering' or 'devastation' with an associated strain being imposed on the marriage. Others felt inadequate in the male role—it took a long time for them to accept the situation. Others compensated by collecting material possessions Table 4. Adoption statistics: placements made by all member agencies, and voluntary agencies only 1966 All agencies' England 11,382 Wales 434 Scotland 1,424 Voluntary agencies only England • 8,608 Wales 212 Scotland 794
1967
1968
1969
1970
1971
1972
11,982 442 1,499
11,458 413 1,545
9,584 457 1,315
7,826 437 1,261
6,858 367 1,192
6,052 365 970
8,890 253 720
8,279 247 739
6,890 215 678
5,727 4,939 184 139 606 562
4,301 128 508
1973
1974
3,827 108 448
3,455 102 409
Source: Gayes, 1975, personal communication.
around them and only later did they enquire about AID. The knowledge of AID availability had helped in several cases. The availability of babies for adoption (Table 4) has fallen (Atkins, 1978) and the difficulty of being selected puts an added strain on many applicants. Most couples had considered adoption but preferred AID for the reasons shown (Table 5). Only a few couples had considered fostering and only four had undertaken it (Table 5). Only one couple, who were regular church attenders, questioned whether the church would consider AID to be a form of adultery. They were referred to the appropriate church authorities and, after interview, they stated their conflicts had been resolved and were confident to proceed. Most couples did not consider any religious problem and several members of the Church of Rome stated that it was a matter of personal conscience. Thirty-one couples discussed the proposed AID with one or other parent. All parents either expressed no undue reaction or gave their support. One further couple were considering whether to tell their parents but all other couples considered it a private matter for the husband and wife together to resolve. Whilst
Social factors and AID
Ml
four couples stated that they were considering whether to inform any child of its origins, and two of these couples had received AID on genetic grounds, all other couples stated that they would definitely not inform any child that it had been conceived by AID. All couples were accepted for AID although the medical social worker did have reservations in three cases: one where the mother had a psychiatric history, one where the couple had failed as foster parents, and one where she was apprehensive Table 5. Reaction to adoption and to fostering Couples
Adoption Put off by long waiting list Preference for experience of childbirth and pregnancy Adoption list closed Not eligible for adoption Prefer child to have some family resemblance Vulnerability of adopting parents before courts Male sees child as own/difficulty accepting adopted child Previous adoption procedure too stressful Would consider adoption if AID unsuccessful Preference for AID (non-specific reason) Fostering Had fostered a child Decided against fostering Applied to foster Not eligible
No.
%
42 30 7 13 9 11 9 1 5 15
29 0 20-4 4-8 8-8 60 7-9 60 0-5 3-4 10-2
4 3 3 1
about the male accepting AID. One couple (the husband aged 45 years and the wife 35 years) considered AID the last chance to start a family, for they were regarded as too old for adoption and they were not keen on fostering a child. Several others were concerned that they were relatively old and expressed dismay at the waiting list (approximately 12 months), whereas others appreciated that the delay allowed them extra time to rationalize their thoughts towards AID. Several patients have been seen at our fertility clinic with severe oligospermia and an attempt was made at concentration and freezing of spermatozoa, with subsequent AIH. This has not proved possible (Ledward et al., 1977) and they have accepted AID. One couple initially wished for an extended list of family characteristics to be typed to the donor but, after discussion of the impracticality of this, accepted AID as the study was designed. Two couples preferred AID and were not disconcerted by initial resistance against the service from general practitioners.
478
R. S. Ledward, L. Crawford and E. M. Symonds
Several couples, whilst keen on the idea of AID, stated that they understood very little of what it entailed and a handbook (Ledward & Symonds, 1978) is now given to all prospective patients and their referring general practitioners. Discussion In the initial discussions with patients, pending AID, they are reminded verbally that the child conceived by AID is illegitimate, following the Feversham Committee report (1960). That committee agreed that the AID child accepted by the husband into the family should be illegitimate—'succession through blood descent is an important element of family life and as such is at the basis of our society'. However, it has been estimated that 15-30% of babies are not the offspring of the husband (Goss, 1974; Phillips, 1975); estimates as high as 50% have been quoted, and yet these babies are registered as legitimate in the Register of Births. Illegitimacy complicates the issue for the child and for society, should divorce and maintenance suits arise, and varying views have been expressed in the courts (People versus Sorenson, cited by Curran, 1968). Dunstan (1975) has argued that the legislation of AID cases suggests that 'legitimacy' should be abolished and replaced with the concept of 'acceptance' or 'approbation', giving the status of social 'filiation' to any child accepted into the family by the husband and wife, however begotten and conceived, and assure to it all rights, privileges and duties attaching to that status. Two registers would be required: (1) the filiation register to record the social recognition of the child, and, (2) the genetic register to record its genetic descent. Such registers would provide material for an objective assessment of the practice of AID. The social reports in this study have confirmed the stability of the marriages at the time of interview, but in some couples the reaction to male infertility may lead to instability, although several couples did say their union was stronger. However, several couples elected for AID rather than adoption, preferring AID to satisfy the wife's biological wish for a pregnancy, although admitting to expected stress should a pregnancy be confirmed. Many couples also volunteered the fact that they considered environmental development to be more important than biological and genetic development, that AID would help to satisfy the mother's wish for a pregnancy and that they would consider the child 'half the father's'. Only one couple discussed the proposal with the church and several members of the Roman Catholic Church stated that it was a matter of personal conscience. Dunstan (1975) has stated that the Roman Catholic Church has pronounced authoritatively against AID, that no Christian church in the United Kingdom has explicitly favoured the practice and that the judgement of Jewish orthodoxy was hostile. The moral and religious aspects of AID have been fully discussed in our handbook (Ledward & Symonds, 1978). The social reports were prepared to ensure that patients had a stable marriage at the time of the interview, with suitable housing and financial conditions. Their attitude towards AID, including its religious aspects, was determined, and it was notable that several couples expressed an interest in AID when first offered to them but at the time of interview (after a 12-month delay in initiation of the service)
Socialfactors and AID
479
volunteered a nervousness in that the moment of decision had arrived. One couple did defer attending for AID at the time of commencement of insemination and later declined the service, and other couples did state that they expected some stress in the subsequent realization of pregnancy. All but one couple have stated willingness to continue with follow-up assessments, and further studies are planned to review their marriages and psychological make-up in later years. The question of whether the couples should tell the child his background will be determined. We agree with Lamson, Pinard & Meaker (1951) and David & Avidan (1976) that the sociological and psychological contraindications to donor insemination are numerous and important. Incalculable harm will be done if practitioners neglect these. The formula for accomplishing the most good, together with the least harm, is careful study of all applicants and refusal to accept unsuitable cases. We would advise that a medical social worker's report should be available to the doctor to help him/her assess the suitability of applicants for artificial insemination using donor semen. References ATKINS, N. (1978) Is adoption dead? J. mat. child Hlth, September, 296. CURRAN, W J . (1968) Public health and the law: artificial insemination. Am. J.publ. Hlth, 58,1460. DAVID, A. & AVIDAN, D. (1976) Artificial insemination donor: clinical and psychologic aspects. Fert. Steril. 27, 528. DUNSTAN, G.R. (1975) Law and Ethics of AID and Embryo Transfer. Ciba Foundation Symposium 17. Elsevier-Excerpta Medica-North Holland, Amsterdam. FEVERSHAM COMMITTEE (1960) Human artificial insemination. Br. med. J.2, 379. Goss, D.A (1974) Current status of artificial insemination with donor semen. Am. J. Obstet. Gynec. 122, 246. LAMSON, H.D., PINARD, W J . & MEAKER, S.R. (1951) Sociologic and psychological aspects of
artificial insemination with donor semen. J. Am. med. Ass. 145,1062. LEDWARD, R.S., CRICH, J., SHARP, P., COTTON, R.E. & SYMONDS, E.M. (1976) The establishment
of a programme of artificial insemination by donor semen within the National Health Service. Br. J. Obstet. Gynaec. 83, 917. LEDWARD, R.S., CRICH, J., SYMONDS, E.M. & COTTON, R.E. (1977) The management of oligo-
spermia by freezing and concentration of semen. IRCS med. Sci. 5, 537. LEDWARD, R.S. & SYMONDS, E.M.S. (1978) Donor Insemination—Your Questions Answered. University of Nottingham Handbook. PHILLIPS, E.E. (1975) Law and Ethics of AID and Embryo Transfer. Elsevier-Excerpta MedicaNorth Holland, Amsterdam. Received \4th December 1978
SOCIAL FACTORS IN PATIENTS FOR ARTIFICIAL INSEMINATION BY DONOR (AID) R. S. LEDWARD*, L. CRAWFORD AND E. M. SYMONDS Department of Obstetrics and Gynaecology, City Hospital, Nottingham
Summary. A programme of artificial insemination, using donor semen, within the NHS began in Nottingham in 1975. Since the inception of the programme all couples have been interviewed by a senior medical social worker, either at home or, later in the programme, within the clinics. This paper reports on features including education, employment, relationship to fertility status, relationship to parents and childhood, religion and reaction to adoption or fostering from the first 147 couples interviewed. All couples have stated a willingness for follow-up assessments and further studies are planned to review their marriages and psychological make-up in later years. Introduction
In June 1975 a programme of artificial insemination using donor semen (AID) began at the Nottingham City Hospital using National Health Service facilities (Ledward et ah, 1976). At the present time (November 1978) in the programme, 214 are on the waiting list for AID and 47 are receiving treatment. An initial 147 couples form the basis of this paper. Method
All patients agreed to a medical social report being obtained by a senior medical social worker from the Nottingham City Hospital. In order to maintain the confidentiality of the service only one medical social worker was involved. The patient and her husband were introduced to her when they attended the hospital for an AID interview, at which time consent forms were completed, the service explained and evidence of female fertility status and male infertility status obtained. The medical social worker explained her function and made an appointment to visit the couple at home. With the expansion of the service, couples have been accepted from areas remote from Nottingham and a home interview has not always been possible. * Present address: PO Box 7897, Riyadh Military Hospital, Riyadh, Saudi Arabia. 473
474
R. S. Ledward, L. Crawford and E. M. Symonds Results
There were no coloured or immigrant patients in the series. The education of both partners, summarized in Table 1, shows a distribution little different from the population as a whole; of the two unspecified cases one patient had missed school owing to poor health and had been educated at a special school for the educationally retarded, later succeeding to a level of self-employment as a joiner. The other patient could not recall his education owing to a troubled background. All husbands were in full employment (Table 1), and social classes 4 and 5 appear to be under-represented. AH but 27 (18%) of the wives were in full-time Table 1. Distribution of the sample, by education and employment Husband No. Education Secondary Modern school Grammar school Public school University Other Employment Factory Teacher Clerical Management/technical Professional Cook Police Miner Own business Housewife Miscellaneous Total sample
%
108 27 4 6 2
Wife No.
%
105 38 2 2 0
42 11 4 59 10
28-6 7-5 2-7 40-1 6-8
3 4 12
20 2-7 8-2
2 147
1-4
39 13 42 5 10 3
26-6 8-8 28-6 3-4 6-8 20
27 8 147
18-4 5-4
employment (Table 1) and ten of the unemployed wives had recently stopped work voluntarily to participate in the AID programme. All applicants were in a stable marriage. They had been married for periods of 1 year to 13 years with a mode at 5 years (Table 2) and all had been trying for a family since early marriage. Most couples lived in adequate homes. One couple lived in a caravan but were in the process of buying a house, and three other couples had small council flats but stated that it was council policy to provide them with a house should a child be born. Nearly all couples maintained a close relationship with their parents and recalled a happy childhood (Table 3). Eighteen couples came from large families (more than five siblings; two have ten siblings) and
Social factors and AID
475
Table 2. Duration of marriage Years of marriage at initial consultation
No. of couples
1 2 3 4 5 6 7 8 9 10 11 12 13
4 6 13 19 23 19 19 14 12 8 3 3 4
admitted that their own happy childhood and stable background was a stimulus to their wish for their own family. Most patients stated that the realization of male infertility had been very difficult to accept and had caused stress, affecting the marriage. In three cases the couple married with the knowledge of azoospermia. One husband claimed that he came to terms with the problem in a day, and two other couples were hopeful that artificial insemination using the husband's semen would be successful but, if not, would accept AID. One couple was not unduly surprised, owing to the husband's poor health in early years. Three other couples were not unduly surprised, owing to a history of radiotherapy to the male for testicular tumours. Four patients had had genetic counselling and, as a result, had been accepted for AID; one other patient Table 3. Relationship to parents and childhood Wife
Husband
Contact with parents Regular Limited None Childhood Happy Unhappy
No.
%
No.
%
119 18 10
80-9 120 7-0
127 15 5
86-3 10-2 3-4
142 5
96-5 3-5
140 7
95-2 4-8
Four of the applicants had divorced parents; two of the applicants had had previous marriages themselves.
476
R. S. Ledward, L. Crawford and E. M. Symonds
had had a vasectomy in a previous marriage and had now re-married, hence his request for AID. Several patients stated that they were initially despondent and distressed at the knowledge of azoospermia but later accepted the problem in the knowledge of AID availability, and three patients considered the biological background of the child to be less important than the environmental upbringing. One patient found it more difficult to accept his azoospermia owing to his own large family background and thought that marriage was incomplete without children. Six patients described their reaction to azoospermia in terms varying from 'suicidal' to 'shattering' or 'devastation' with an associated strain being imposed on the marriage. Others felt inadequate in the male role—it took a long time for them to accept the situation. Others compensated by collecting material possessions Table 4. Adoption statistics: placements made by all member agencies, and voluntary agencies only 1966 All agencies' England 11,382 Wales 434 Scotland 1,424 Voluntary agencies only England • 8,608 Wales 212 Scotland 794
1967
1968
1969
1970
1971
1972
11,982 442 1,499
11,458 413 1,545
9,584 457 1,315
7,826 437 1,261
6,858 367 1,192
6,052 365 970
8,890 253 720
8,279 247 739
6,890 215 678
5,727 4,939 184 139 606 562
4,301 128 508
1973
1974
3,827 108 448
3,455 102 409
Source: Gayes, 1975, personal communication.
around them and only later did they enquire about AID. The knowledge of AID availability had helped in several cases. The availability of babies for adoption (Table 4) has fallen (Atkins, 1978) and the difficulty of being selected puts an added strain on many applicants. Most couples had considered adoption but preferred AID for the reasons shown (Table 5). Only a few couples had considered fostering and only four had undertaken it (Table 5). Only one couple, who were regular church attenders, questioned whether the church would consider AID to be a form of adultery. They were referred to the appropriate church authorities and, after interview, they stated their conflicts had been resolved and were confident to proceed. Most couples did not consider any religious problem and several members of the Church of Rome stated that it was a matter of personal conscience. Thirty-one couples discussed the proposed AID with one or other parent. All parents either expressed no undue reaction or gave their support. One further couple were considering whether to tell their parents but all other couples considered it a private matter for the husband and wife together to resolve. Whilst
Social factors and AID
Ml
four couples stated that they were considering whether to inform any child of its origins, and two of these couples had received AID on genetic grounds, all other couples stated that they would definitely not inform any child that it had been conceived by AID. All couples were accepted for AID although the medical social worker did have reservations in three cases: one where the mother had a psychiatric history, one where the couple had failed as foster parents, and one where she was apprehensive Table 5. Reaction to adoption and to fostering Couples
Adoption Put off by long waiting list Preference for experience of childbirth and pregnancy Adoption list closed Not eligible for adoption Prefer child to have some family resemblance Vulnerability of adopting parents before courts Male sees child as own/difficulty accepting adopted child Previous adoption procedure too stressful Would consider adoption if AID unsuccessful Preference for AID (non-specific reason) Fostering Had fostered a child Decided against fostering Applied to foster Not eligible
No.
%
42 30 7 13 9 11 9 1 5 15
29 0 20-4 4-8 8-8 60 7-9 60 0-5 3-4 10-2
4 3 3 1
about the male accepting AID. One couple (the husband aged 45 years and the wife 35 years) considered AID the last chance to start a family, for they were regarded as too old for adoption and they were not keen on fostering a child. Several others were concerned that they were relatively old and expressed dismay at the waiting list (approximately 12 months), whereas others appreciated that the delay allowed them extra time to rationalize their thoughts towards AID. Several patients have been seen at our fertility clinic with severe oligospermia and an attempt was made at concentration and freezing of spermatozoa, with subsequent AIH. This has not proved possible (Ledward et al., 1977) and they have accepted AID. One couple initially wished for an extended list of family characteristics to be typed to the donor but, after discussion of the impracticality of this, accepted AID as the study was designed. Two couples preferred AID and were not disconcerted by initial resistance against the service from general practitioners.
478
R. S. Ledward, L. Crawford and E. M. Symonds
Several couples, whilst keen on the idea of AID, stated that they understood very little of what it entailed and a handbook (Ledward & Symonds, 1978) is now given to all prospective patients and their referring general practitioners. Discussion In the initial discussions with patients, pending AID, they are reminded verbally that the child conceived by AID is illegitimate, following the Feversham Committee report (1960). That committee agreed that the AID child accepted by the husband into the family should be illegitimate—'succession through blood descent is an important element of family life and as such is at the basis of our society'. However, it has been estimated that 15-30% of babies are not the offspring of the husband (Goss, 1974; Phillips, 1975); estimates as high as 50% have been quoted, and yet these babies are registered as legitimate in the Register of Births. Illegitimacy complicates the issue for the child and for society, should divorce and maintenance suits arise, and varying views have been expressed in the courts (People versus Sorenson, cited by Curran, 1968). Dunstan (1975) has argued that the legislation of AID cases suggests that 'legitimacy' should be abolished and replaced with the concept of 'acceptance' or 'approbation', giving the status of social 'filiation' to any child accepted into the family by the husband and wife, however begotten and conceived, and assure to it all rights, privileges and duties attaching to that status. Two registers would be required: (1) the filiation register to record the social recognition of the child, and, (2) the genetic register to record its genetic descent. Such registers would provide material for an objective assessment of the practice of AID. The social reports in this study have confirmed the stability of the marriages at the time of interview, but in some couples the reaction to male infertility may lead to instability, although several couples did say their union was stronger. However, several couples elected for AID rather than adoption, preferring AID to satisfy the wife's biological wish for a pregnancy, although admitting to expected stress should a pregnancy be confirmed. Many couples also volunteered the fact that they considered environmental development to be more important than biological and genetic development, that AID would help to satisfy the mother's wish for a pregnancy and that they would consider the child 'half the father's'. Only one couple discussed the proposal with the church and several members of the Roman Catholic Church stated that it was a matter of personal conscience. Dunstan (1975) has stated that the Roman Catholic Church has pronounced authoritatively against AID, that no Christian church in the United Kingdom has explicitly favoured the practice and that the judgement of Jewish orthodoxy was hostile. The moral and religious aspects of AID have been fully discussed in our handbook (Ledward & Symonds, 1978). The social reports were prepared to ensure that patients had a stable marriage at the time of the interview, with suitable housing and financial conditions. Their attitude towards AID, including its religious aspects, was determined, and it was notable that several couples expressed an interest in AID when first offered to them but at the time of interview (after a 12-month delay in initiation of the service)
Socialfactors and AID
479
volunteered a nervousness in that the moment of decision had arrived. One couple did defer attending for AID at the time of commencement of insemination and later declined the service, and other couples did state that they expected some stress in the subsequent realization of pregnancy. All but one couple have stated willingness to continue with follow-up assessments, and further studies are planned to review their marriages and psychological make-up in later years. The question of whether the couples should tell the child his background will be determined. We agree with Lamson, Pinard & Meaker (1951) and David & Avidan (1976) that the sociological and psychological contraindications to donor insemination are numerous and important. Incalculable harm will be done if practitioners neglect these. The formula for accomplishing the most good, together with the least harm, is careful study of all applicants and refusal to accept unsuitable cases. We would advise that a medical social worker's report should be available to the doctor to help him/her assess the suitability of applicants for artificial insemination using donor semen. References ATKINS, N. (1978) Is adoption dead? J. mat. child Hlth, September, 296. CURRAN, W J . (1968) Public health and the law: artificial insemination. Am. J.publ. Hlth, 58,1460. DAVID, A. & AVIDAN, D. (1976) Artificial insemination donor: clinical and psychologic aspects. Fert. Steril. 27, 528. DUNSTAN, G.R. (1975) Law and Ethics of AID and Embryo Transfer. Ciba Foundation Symposium 17. Elsevier-Excerpta Medica-North Holland, Amsterdam. FEVERSHAM COMMITTEE (1960) Human artificial insemination. Br. med. J.2, 379. Goss, D.A (1974) Current status of artificial insemination with donor semen. Am. J. Obstet. Gynec. 122, 246. LAMSON, H.D., PINARD, W J . & MEAKER, S.R. (1951) Sociologic and psychological aspects of
artificial insemination with donor semen. J. Am. med. Ass. 145,1062. LEDWARD, R.S., CRICH, J., SHARP, P., COTTON, R.E. & SYMONDS, E.M. (1976) The establishment
of a programme of artificial insemination by donor semen within the National Health Service. Br. J. Obstet. Gynaec. 83, 917. LEDWARD, R.S., CRICH, J., SYMONDS, E.M. & COTTON, R.E. (1977) The management of oligo-
spermia by freezing and concentration of semen. IRCS med. Sci. 5, 537. LEDWARD, R.S. & SYMONDS, E.M.S. (1978) Donor Insemination—Your Questions Answered. University of Nottingham Handbook. PHILLIPS, E.E. (1975) Law and Ethics of AID and Embryo Transfer. Elsevier-Excerpta MedicaNorth Holland, Amsterdam. Received \4th December 1978
