Parenting - Prenatal to preschool/Parenting_PrenatalToPreschool.bin/dp/0046/00461.txt

Text File | 1993-06-14 | 46KB | 769 lines

$Unique_ID{PAR00461}
$Pretitle{}
$Title{Fertility:  Donating Sperm, Eggs, Embryos}
$Subtitle{}
$Author{
Berger, Gary S
Goldstein, Marc
Fuerst, Mark}
$Subject{DONATING SPERM EGGS EMBRYOS Donor Donors Insemination sperm banks
semen genetic screening AIDS STDs Fresh Frozen Identity Social Ethical Legal
surrogate Egg Donation Donations IVF Gamete Intra Fallopian Transfer GIFT
Zygote ZIFT Emotional Embryo Transplant transplantation Freezing Host Uterus
surrogates laws artificial insemination}
$Log{}

The Couple's Guide to Fertility


CHAPTER 11:  DONATING SPERM, EGGS, EMBRYOS


     When you have struggled through fertility treatments, possibly even in
vitro fertilization or other assisted reproductive technologies, and still
have not had a baby, you may become increasingly frustrated and desperate.  By
this time, you have to come to grips with the idea that you may never have a
child together.
     But that doesn't mean that one or the other partner can't contribute to
the birth of a baby that carries his or her genes by donating sperm, eggs, or
embryos.

Donor Insemination

     If a thorough physical evaluation reveals that a man has an untreatable
fertility problem and that his wife has no known fertility problems, then the
couple should consider donor insemination.  It has become an increasingly
important method of infertility treatment due to male factors and is far and
away the most popular and successful method for treating severe male factor
problems.  More than thirty thousand babies are conceived by donor
insemination each year in the United States.
     In most cases, donor insemination simply involves placing donor sperm in
the wife's cervical mucus at the fertile time of her cycle.  If the wife also
has fertility problems, more advanced methods, using donor sperm, may be
necessary.  If her cervical mucus is hostile to the donor sperm, the donor
sperm can be washed, concentrated, placed inside a narrow catheter and safely
inserted through the cervical canal into the uterus (IUI) or fallopian tubes
(ITI) at the time of ovulation.  Donor sperm can also replace the husband's
sperm in any of the assisted reproductive technologies, including IVF or its
"cousins."

     Finding a Donor

     If you are considering donor insemination, your fertility specialist can
help you find a suitable donor.  The donor should be carefully screened and
selected to resemble the husband as closely as possible, including his age,
education, race, height and weight, hair and eye color, blood group and type,
occupation, religion, and nationality.
     Because of the widespread availability of frozen donor sperm from a
number of sperm banks throughout the country, a suitable donor match can be
found for most men.  At some fertility centers, couples can examine lists of
donor characteristics and themselves make the selection of the sperm donor.
     When a doctor orders donor sperm from a sperm bank, he requests that the
donor have particular characteristics.  Often, the characteristics of several
donors closely resemble those of the husband.  Your doctor should give you
information about the available donors so that you can select the most
appropriate one.  The donor's identification by a code number will be kept as
a part of your permanent record.
     In the recent past, many practitioners of donor insemination did little
to protect couples from genetic disorders and infectious diseases, such as
acquired immune deficiency syndrome (AIDS), that might be passed through donor
semen.  Even now, some doctors who perform donor insemination with fresh sperm
still may not routinely test donors for antibodies to the AIDS virus or for
infections with syphilis, gonorrhea, hepatitis, and chlamydia.
     Less than half of the physicians who regularly perform donor insemination
test donors for antibodies to the AIDS virus, according to a 1988 government
survey of nearly four hundred physicians.  Also shocking is that less than
half of the responding physicians require genetic screening for donors and
only three-quarters inquire about the proven fertility of donors.  About 10
percent of the doctors who responded to the survey said they rely on
commercial sperm banks to perform the screening for them.
     The 1988 report by the Office of Technology Assessment will probably lead
couples to make more use of commercial sperm banks, since they are more likely
than individual physicians to screen donors effectively for the AIDS virus,
other STDs, and genetic defects.  Still, don't take it for granted that these
safeguards are being used without asking for, and obtaining, written
information about the screening of potential donors.

     How Good Are the Sperm?

     Rhonda, aged thirty-seven, and Owen, aged thirty-eight, chose their
     frozen semen from a large national sperm bank.  Their first attempt at
     donor insemination failed because Rhonda's cervical mucus was hostile to
     the donor's sperm, killing off most of them very rapidly.  The doctor
     suggested they try an intrauterine insemination the next month.  The day
     following her urine LH surge, Rhonda came in for an IUI.  But upon
     thawing, the donor sperm showed a very low motile sperm count, "so low
     that the doctor didn't want to use that sperm sample.  But I felt close
     to the donor.  He sounded so much like Owen," says Rhonda.  The frozen
     donor sperm were washed and inseminated into her uterus.

     You should ask your doctor whether the donated sperm came from a
commercial sperm bank that is a member of the American Association of Tissue
Banks, which has set criteria and professional standards for screening donors.
If possible, try to find out the sperm bank's success rate.  This is often
hard to obtain, since many sperm banks often don't collect information from
their physician-clients regarding the number of pregnancies achieved.  Ask the
doctor how many pregnancies he has had from this bank and how successful donor
insemination has been, in his experience, for couples with similar fertility
problems.
     You should know how many motile sperm per ml are contained in the donor
samples received by your doctor.  The success of donor insemination correlates
with the number of motile sperm inseminated.  A quality sperm bank will
provide straws or vials containing at least 20 million motile sperm or more
per ml.  The doctor should check the sperm count and the rapidly progressive
forward motility upon thawing the sample and preparing it for insemination.

     The Medical Aspects of Donor Insemination

     "At our second attempt, Owen and I were both really excited," Rhonda
     says.  "The ultrasound exam showed that I had four follicles.  Everything
     felt right."  An IUI was performed on the day of the LH surge.  The
     following day, Rhonda came back for an insemination of more sperm into
     her uterus and, after lying on her back with her hips elevated for about
     forty-five minutes, she and Owen went home.  Four days after the
     inseminations, she felt sick to her stomach, and "I knew I was pregnant,"
     Rhonda says.  A few days later, Owen suggested she take a home pregnancy
     test, which was positive.  She went to the doctor's office the next day,
     and he confirmed the pregnancy by checking her blood hormone levels.  A
     week later, a vaginal ultrasound examination showed that her pregnancy
     was developing normally.  She and Owen plan to name their baby girl
     Terri.

     If you have chosen donor insemination to overcome a male factor problem,
your chances for a pregnancy will correlate with the number of fertility
problems the wife has.  Women who have two healthy fallopian tubes, no
endometriosis, need no medication to stimulate ovulatory cycles, and are under
age thirty-five have an excellent chance of becoming pregnant within three to
six cycles.  Women with no apparent fertility problems have approximately a 90
percent chance of pregnancy, if they continue with donor insemination for up
to twelve cycles.  Women with ovulation problems during donor insemination
cycles may take longer to conceive.  If a woman hasn't conceived within four
to six well-timed donor insemination cycles, she should consider another donor
and have further fertility evaluation.
     A combination of basal body temperature monitoring, cervical mucus
monitoring, and detection of the luteinizing hormone surge leads to the best
timing for insemination.  Most doctors inseminate sperm either once or twice
each cycle near the time of ovulation.
     Before performing donor insemination, Dr. Berger obtains cervical
cultures to check for infection or bacteria in the wife's reproductive tract,
and the couple goes through the basic screening blood tests.  Some couples
prefer donor insemination without any further fertility evaluation; others
will have a hysterosalpingogram and ovulation monitoring to check that the
wife has open tubes and normal hormone levels and follicle development.
     The donated sperm can cost the couple from $125 to $250 per sample.
Unfortunately, most insurance companies will not reimburse for donated sperm.
They maintain that this isn't a treatment for an infertile man.

     Fresh versus Frozen Semen

     Since the ever-growing epidemic of AIDS, more couples undergoing donor
insemination have been opting for frozen semen.  (Donor insemination has also
been called artificial insemination by donor, or AID, in the past.  To avoid
confusion with the disease AIDS, most fertility specialists now use the terms
"Therapeutic Donor Insemination" or "Donor Insemination" instead.)  Before
being used, frozen donor semen should be quarantined for at least six months
to ensure that the donor hasn't developed antibodies to the AIDS virus during
that time.
     To prevent the possible transmission of the AIDS virus (as well as other
infectious conditions such as gonorrhea, chlamydia, and hepatitis) through
donated semen, the American Fertility Society, the Food and Drug
Administration, and the Centers for Disease Control have collaborated on
revised guidelines for donor insemination.  The guidelines call for a
potential donor to be interviewed to determine whether he has a history of
risk factors for infection with the AIDS virus; to have a physical exam to
document any obvious signs of AIDS infection; and to have a blood test for
infection with the AIDS virus or the development of antibodies to the
virus--both when he donates semen and six months later before the frozen semen
is released for use.  The federal government may institute a mandatory system
to ensure that all semen used for donor insemination is adequately screened
and tested and that standards are enforced.
     Frozen semen has the advantage of being able to be shipped anywhere, be
stored in a liquid nitrogen tank, and be immediately available at the fertile
time of the woman's cycle.  The major disadvantage of a frozen semen sample is
that it reduces the number of motile sperm so that it takes, on average, more
inseminations to achieve a pregnancy than with fresh semen.  It may take six
or more inseminations with frozen semen for a woman to become pregnant,
compared with only three or four tries using fresh semen.
     Taking into account lower sperm motility, some fertility specialists
perform intrauterine insemination with thawed frozen semen.  Dr. Berger
performs an intracervical insemination on the day of the wife's LH surge, if
she has fertile mucus that day.  The following day, he can also perform an IUI
with a second thawed sample, which has been washed, allowed to "swim up" and
concentrated into a small volume.  He has found that more women become
pregnant with both inseminations in a single cycle than with an intracervical
insemination alone.

     Tracking Down a Donor's Identity

     Typically, your doctor receives a code number along with the donor semen
from the sperm bank.  The sperm bank usually has no information about you.  At
least two sperm banks holding so-called "extraordinary" sperm from
intellectually or athletically outstanding donors now screen the couple, but
in a manner that still keeps the identities of the sperm donor and the couple
from each other.
     Most doctors who keep records that could lead to identification of the
donor will not release this information, unless the couple or a court order
instructs them to do so.  This may be necessary if, for example, the child
needs to know about his or her chances of having a hereditary disease.

     Emotional Factors

     "The most difficult thing for me was the way I was informed that I had a
     low sperm count," recalls Phil, a forty-four-year-old government employee
     who lives in New York.  "One of the urologist's staff came out to the
     waiting room, and in front of everyone there, said, 'You have practically
     no sperm.'  That attacked my foundations as a man."  Once Phil and his
     wife, Ann, a thirty-eight-year-old tennis pro, decided to try donor
     insemination, Phil says, "I didn't feel so humiliated as when I first got
     the semen analysis results.  Once the decision was made, it felt okay."
       Even though his family's blood line faced extinction, Phil had no
     problem accepting donor insemination.  "It all depends on how crucial it
     is to have a genetic link to the future," he says.  "Neither my sister
     nor I could have our own biological children, but I felt that a child was
     a child."
       Over a three-year period, Phil and Ann tried donor inseminations, with
     all the ups and downs of starting a new cycle of treatment over and over
     again.  During that time, they took a break for six months while Ann took
     medication for endometriosis.  Then their fertility specialist found that
     she had sperm antibodies in her mucus, and Phil began wearing condoms
     during sex.  Meanwhile, they tried more donor inseminations without
     success.  When they finally concluded that donor insemination would not
     work for them, they decided to stop trying to have a baby.

     Donor insemination is readily accepted by many couples, but it can be
stressful for them.  How well you may feel depends on you and your spouse's
individual personalities and attitudes.  Studies of couples who attempt donor
insemination have found them to be as well adjusted psychologically and
sexually as "normal" fertile couples, whether or not they achieve a pregnancy.
Most couples who have gone through donor insemination say that they are
satisfied with their marriages and that the procedure even helped bring them
closer together.  Yet, for some couples the experience of uncorrected
infertility adds such a strain to the relationship that their marriage may not
survive.
     Being conceived through donor insemination doesn't appear to affect the
child's emotional development.  The children conceived through donor
insemination most often are well adjusted, do well in school, and don't seem
to have identity crises.  The majority of couples don't tell their children
that they were conceived using a donor's sperm.

     Social and Ethical Issues

     Donor insemination raises many complex issues for the couple.  You may
wonder whether the decision to let friends and family know may some day cause
your child to ask about his biological father.  You also have to consider
insensitive things family and friends might say to you and the child.
Essentially, you have to address the question, "If we let people know now, are
we likely to regret it later?"
     Your decision to use donor insemination carries implications that reach
far into the future.  Some other questions you must consider:  What if our
child is born with a birth defect?  Will we regret our decision?  Can our
marriage stand the strain?
     There are no pat answers to such questions.  Certainly, there are no
answers applicable to everyone.  Each couple must be able to explore these
questions freely with each other, and answer them as best they can.  If you
are having difficulty, a professional counselor may be able to help.
     Some people compare children born through donor insemination to children
who were adopted.  But the experience a couple goes through in conceiving a
child, and the actual nine months of pregnancy with donor insemination
offspring, is quite different than that of an adoptive couple, who don't
experience the process of pregnancy.  And if you adopt, you can't keep it a
secret from family and friends, as you can with donor insemination.

     Legal Issues

     If you choose donor insemination, clearly, you want the maximum
protection under the law for you and your child.  Yet, only a few states
require that donors be screened for disease, and twenty states have no laws at
all regulating donor insemination.
     The legal issue of paternity is much more clearly defined.  Thirty states
have laws covering paternity with donor insemination, and provide that the
offspring is the legal child of the birth mother and her husband.  Many laws
specifically state that a man who provides his semen to a doctor for use in
donor insemination isn't the child's legal father.  In all states, the husband
of the woman who delivers the child is presumed to be the child's legal
father.  This legally makes donor insemination a much more straightforward
procedure than surrogate motherhood.

Egg Donation

     Egg donation, analogous to sperm donation, is the process by which the
doctor uses the husband's sperm to fertilize an egg donated by a woman other
than his wife--usually through an assisted reproduction technique, such as IVF
or one of its "cousins."  In the case of IVF, the doctor transfers the
fertilized egg into the wife's uterus, which has been primed with hormones to
accept the developing embryo.
     This technique is particularly useful for women who don't produce eggs,
such as after premature menopause, or women who have had their ovaries removed
or have had radiation therapy for cancer that destroyed their ovarian
function.  It also has become an alternative for women who want to avoid
passing along a genetically defective trait in the wife's family, such as
hemophilia.
     More than 150,000 women in the United States can't bear children because
of ovarian problems.  Premature menopause has become more of a problem in
recent years with many women deferring pregnancy until their thirties.  In
some cases, women with premature menopause can be treated hormonally and
ovulate again.  For those who don't ovulate, even after hormone treatments,
fertility specialists can now offer the egg donation alternative.
     Donor egg programs, once on the outer edge of infertility research, are
growing in popularity and availability.  The Cleveland Clinic fielded hundreds
of phone calls after it advertised that it was opening a donor egg bank.  Now
the clinic has a pool of potential egg donors from healthy young women aged
eighteen to thirty-five who have no known genetic or sexually transmitted
diseases and have normal menstrual cycles, enabling doctors to match the
physical characteristics of recipients with those of carefully selected
donors.  About a half-dozen IVF programs now have established similar egg
donation programs.
     The donor eggs can be retrieved by laparoscopy or by using a transvaginal
ultrasound guided approach.  While the egg donors take superovulatory hormones
for about a week to increase their egg production, the recipient also receives
hormones--first to synchronize her cycle with that of the donor and then to
prepare her uterus for pregnancy.  These hormones include estrogen, which can
be taken orally or administered in patches that attach to the skin, and
progesterone administered by pills, vaginal suppositories, or injections.
     Fertilization of the donor eggs with the husband's sperm usually takes
place in the IVF lab.  As with IVF, up to four fertilized eggs may be
transferred to increase the couple's chances of pregnancy.  At present, only
fresh donor eggs are used because unfertilized eggs are too fragile to
withstand freezing.  A couple's chances of pregnancy are about the same as if
they were using the wife's own eggs.
     Donor eggs can also be fertilized in the recipient woman's fallopian
tubes via Gamete Intra Fallopian Transfer (GIFT).  Also, fertilized eggs or
zygotes have been transferred to a recipient's fallopian tubes via
laparoscopy, known as Zygote Intra Fallopian Transfer (ZIFT).

     Finding Egg Donors

     The usual sources of donated eggs have included women undergoing an IVF
or GIFT procedure who have an overabundance of eggs, the wife's sister, other
relatives, or a woman having a tubal ligation.
     Some egg donation programs accommodate only recipients who provide their
own donors.  Others rely on women who are having tubal ligations--during which
eggs can be retrieved without additional surgery.  Most egg donation programs
offer donors from $500 to $1,200 for their time and inconvenience, which
usually includes undergoing psychological screening, blood tests, and
ultrasound exams, as well as superovulation and egg retrieval.
     Embryo freezing allows the doctor to synchronize the donor and recipient
cycles more easily.  If the recipient's uterus isn't ready to receive the
fertilized eggs, the donated eggs can be fertilized and then frozen and
transferred at a more appropriate time.  The extra eggs retrieved from IVF and
GIFT cycles are now often fertilized and the embryos frozen for later use by
the infertile couple, who may decide, after they have had their own successful
treatment, to donate their embryos to another infertile couple.
     In this era of new reproductive technology, if you are seeking an egg
donor, you must know your state laws.  For example, Louisiana law forbids
payment for eggs or embryos recovered through IVF.  Some states--Illinois,
Florida, Louisiana--specifically forbid freezing embryos even if it's for
clinical treatment and not for research purposes.

     Emotional Issues

     Most egg donation programs accept only married couples in good mental and
physical health who have a stable marriage.  You will undergo a psychological
evaluation that usually includes a screening interview and psychological
testing.  If you provide your own donor, then the psychological evaluation
looks at the possible effects on a child who grows up in a family where an
aunt or a friend is the child's genetic mother.
     Like sperm donation, egg donation from an anonymous donor offers you the
possibility of concealing the fact of the egg donation from friends and
relatives as well as the child.  You should openly discuss with each other
your feelings about what to tell others before undertaking egg donation, and
then stick to your decision, revealing as much information as you wish in
whatever way suits you best.

     The Couple's Concerns

     If you are seeking an egg donor, you probably have a long history of
infertility and have tried a wide range of fertility treatments.  You may
choose egg donation over adoption or surrogate motherhood to give the wife the
opportunity to become pregnant and deliver the baby.
     There are no uniform standards for screening egg donors.  Just as with
sperm donors, you should be informed about various characteristics of the
donor to determine how closely she matches the wife's characteristics, that
she is in good health and has no known family history of genetically
transmitted physical or mental illnesses.  You may ask a donor for an AIDS
antibody test before allowing her eggs to be fertilized with the husband's
sperm.  You should also consider whether you agree as a couple about egg
donation and have the personal and financial resources to cope with the
stresses of the treatment.
     If you receive eggs from a known donor, you should have a consent form
signed by the donor stipulating that she would never pursue any court action
seeking access to any child resulting from the egg donation.  If the egg donor
is anonymous, as with sperm donation, neither the donor nor the recipient
knows each other's identity.  This probably provides the best protection for
the child against the possibility of a custody dispute later on.

     Egg Donors and Their Concerns

     Egg donors, often recruited through announcements in the media, generally
are younger, less affluent, and less well-educated than egg recipients.  They
may volunteer to donate eggs to help another couple have a child.  Some egg
donors also use the experience as a way of dealing with their own unresolved
fertility issues; they previously may have had an induced abortion, which also
is a reason why some women volunteer to become surrogate mothers.
     The primary concern of most potential donors is whether you can provide a
good home environment for a baby.  Donors want assurance that the recipients
of their eggs are physically healthy and psychologically well-adjusted, that
their marriages are stable, and that the husband and wife are committed to
being good, supportive parents.

     Ethical Principles

     Some people fear that compensating egg donors will lead to
commercialization, and tempt women to sell their eggs, as is often the case
with sperm donors.  (Some sperm banks, however, don't pay donors for their
samples.)  Others, including the Catholic Church, contend that egg donation
and sperm donation violate the sanctity of marriage by bringing a third party
into the conjugal relationship.
     A great deal of debate has arisen about third-party collaboration in
reproduction.  The ethical and legal ramifications become murky when the
collaboration breaks down and the donor wants to claim "rights" to the child.
There's more confusion regarding egg donation than sperm donation, although
the two situations are analogous and future laws will probably specify that an
egg donor, like a sperm donor, is not the legal parent of any offspring
conceived.

Embryo Transplant

     Another donor technique involves using a husband's sperm to artificially
inseminate a woman other than his wife.  The resulting embryo is then flushed
out of the other woman's uterus and placed into his wife's uterus.  The couple
may pay a fee of up to $5,000 to the surrogate for her part in conceiving and
nurturing the early development of the embryo.  Recruits for embryo donors are
carefully screened for genetic diseases and emotional problems.
     The embryo transplant technique can only be used when the woman has a
uterus and therefore can carry a fetus.  It enables a woman with ovarian
failure or one who might risk passing on a genetic disease to be the birth
mother, although not the genetic mother, of her child.
     In this situation, the woman who will donate the embryo receives
inseminated sperm from the recipient's husband.  Five days after
fertilization, the doctor flushes the embryo out of the pregnant donor's
uterus and transfers it to the uterus of the infertile wife to carry to birth,
if the embryo implants successfully.
     If the husband is also infertile, the couple can use donor sperm to
inseminate the donor egg.  In this case, neither partner of the infertile
couple contributes genes, since both the sperm and egg come from donors.  But
the wife carries and gives birth to the child, and her husband is the legal
father, so they do not have to adopt the child, as in the case of surrogate
motherhood.
     One of the keys to embryo transplantation is synchronizing the recipient
woman's menstrual cycle with the donor's cycle by using hormone treatments.
The development of the wife's endometrium must be synchronized with the
embryo's stage of development.  If the endometrium isn't ready, the embryo
won't implant.
     Some embryo transplant programs rely on "superovulated" women as their
egg donors.  Others use fertile volunteers who receive compensation each cycle
to cover their own expense and inconvenience.  The procedure carries the
potential risks of an infection and an ectopic pregnancy, but these risks are
small.  The donor's risk of exposure to a sexually transmitted infection from
the recipient's husband is minimized or eliminated with proper medical
screening and testing of the involved parties beforehand.

     Potential Legal Problems

     In most states, "baby bartering" is illegal, and might be interpreted to
include paid egg donors who bear a child for someone else.  Anti-slavery laws
also prohibit the buying or selling of people, including newborns.  Sixteen
states now prohibit payment for embryos.
     You should also be concerned about the donor's behavior both before and
during the conception cycle.  Specifically, the donor should agree to refrain
from sex, and not use any drugs or consume alcohol during the treatment cycle.
You should obtain a signed consent agreement with the donor stating these
conditions, although like any contract, simply signing an agreement doesn't
always guarantee that the parties involved will live up to it.

Egg Freezing

     Egg freezing unquestionably presents fewer legal, moral, and ethical
problems than freezing, and then transferring, embryos.  It holds potential
for young women going through early menopause or women prone to other ovarian
disorders that severely impair their fertility.  Fertility researchers have
encountered numerous technical problems associated with freezing and thawing
eggs, however.
     One freezing method holds the egg in suspended animation by slowing down
its metabolism.  But during the cooling down process, ice crystals tend to
form on the membrane surrounding the egg.  These crystals can pierce and
disrupt the egg's membranes so that when the egg is thawed it may not be
viable.  Some researchers also worry that the trauma of freezing and thawing
may genetically damage eggs.
     Sperm, much smaller than eggs, are less prone to ice crystal formation,
and have survival rates of about 40 percent after freezing and thawing.  The
survival rate of thawed frozen eggs is 15 percent, at best.  So far, a dozen
or more children have been born from thawed frozen eggs.
     Another freezing method, which quickly moves an egg into an
antifreeze-like chemical, leads to few or no ice crystals.  But this
experimental technique is all-or-nothing:  either the egg survives the
thawing, or it dies.
     An egg, like a sperm, is a single cell, not a human being or even a
potential person yet.  But some people have argued against embryo freezing
because they believe life begins precisely when sperm meets egg.  Freezing
eggs for future use would avoid this ethical problem.  If researchers can get
more eggs to survive freezing and thawing, then more couples might opt for egg
freezing over embryo freezing.

Host Uterus

     The host uterus enables you to have your own genetic offspring even
though the wife may be unable to carry a child to term.  Her eggs can be
fertilized by her husband's sperm in the IVF laboratory and the embryo
transferred into another woman's uterus, where it is carried until birth.
     This may provide a solution for women without a uterus, those who can't
risk pregnancy because of a health problem, and those with conditions that
would put a fetus at severe risk, such as Rh incompatibility with a mother who
has high levels of anti-Rh antibodies.

     The Host Uterus Contract

     At the outset, you sign a contract with a carefully screened woman to be
the life-support system for your growing embryo.  Since this other woman is
carrying the husband's and wife's baby, there is a reduced risk of her
refusing to hand the child over to the true biologic parents--one of the
dangers of surrogate motherhood.  Even though you are the genetic parents, you
will likely have to adopt the baby legally from the woman who carries and
delivers it.  In most states, the woman who gives birth is legally presumed to
be the child's mother and, if she is married, her husband is considered the
child's legal father.
     The "host uterus" gives a woman who has ovaries but is incapable of
carrying her own baby a chance to have a child that is genetically her own and
her husband's by having another woman carry the pregnancy.  This differs from
surrogate motherhood, in which the wife is neither the genetic nor the birth
mother.
     The host uterus concept carries fewer ethical and legal problems than
surrogate motherhood, where the woman who is inseminated by the husband's
sperm contributes half of the genes to the baby, which she then carries to
birth.  While the host may form an emotional bond with the baby she has
carried for nine months, she is likely to feel less of a loss than a surrogate
mother, who has to give up her own genetic baby for adoption to the infertile
couple.
     Naturally, any woman who carries a baby to term for you is likely to
develop a close relationship with the baby.  A woman who provides a host
uterus, and changes her mind and wants to keep the child, could argue that her
contribution was just as vital to the child's development, and birth, as you
and your mate's sperm and egg.  The contract between you and the woman
providing the host uterus should address this issue.  But if either party
broke the contract, you probably would be embroiled in legal confusion.
     A woman offering to carry another couple's pregnancy may be placing
herself at physical and psychological risk.  It's important for you that she
receive counseling to ensure that she fully understands the risks and
voluntarily consents.  This will help avoid the potential of her being
exploited by others.
     With the uncertain legal situation across the country regarding these new
varieties of third-party reproduction, including the host uterus technique,
you should think carefully about this type of "frontier" baby and seek
professional and legal counseling before entering into a relationship with a
woman who is willing to serve as a host uterus or surrogate mother.

Surrogate Motherhood

     One of the most controversial areas of the new reproductive technology is
surrogate motherhood.  Dozens of brokers across the country have established
surrogate counseling centers offering infertile couples a "womb for rent."
Despite the highly publicized Baby M case, most surrogate motherhood
arrangements go smoothly when the parties involved take the proper precautions
and have the surrogate mother thoroughly evaluated.
     A surrogate mother is inseminated with the sperm of a man whose wife
can't conceive or carry a child to term.  Once the baby is born, the surrogate
allows the biological father and his infertile wife to adopt the baby.

     Who Are the Candidates?

     Surrogate motherhood is usually reserved for rare circumstances.  For
some couples, it represents the last hope of having a child who's genetically
related to at least one spouse.  In particular, surrogate motherhood may be
suitable for women who don't produce eggs, whose eggs aren't fertilized by
their husband's healthy sperm because of an egg problem, who are afraid of
passing on a genetic defect, who have been advised not to get pregnant because
of a medical condition, or who have had a hysterectomy.

     How to Find a Surrogate

     You can explore various avenues to find an appropriate surrogate.  One
way is to ask family members or friends if they are willing to become a
surrogate.  Remember the case of the mother who carried a triplet pregnancy
conceived via IVF with her daughter's eggs and her son-in-law's sperm.  She
ended up giving birth to her own grandchildren! Some couples advertise in the
newspaper for surrogates; others go to their fertility expert or a lawyer or a
center that specializes in finding surrogates.
     Surrogate agencies look for physically and psychologically healthy women
who would like to serve as a surrogate for an infertile couple.  These
agencies put the potential surrogate through a battery of psychological and
medical tests, match her with a prospective couple, negotiate a contract,
acquire informed, legal consent of the surrogate and the infertile couple, and
work with the doctors who will perform the insemination.

     Who Becomes a Surrogate?

     A typical surrogate mother is twenty-eight years old, married with two
children, has a high school education, and a full-time job.  These women
usually become surrogates because they empathize with an infertile couple and
want to help them have a child.  Being a surrogate may provide some women with
a sense of accomplishment.  Some do it because they had a previous abortion
and believe that creating a child for someone else may help them resolve their
own feelings.  Others may be motivated by financial considerations, since the
surrogate may receive $10,000 to $25,000 for her involvement.  Yet, most women
decide to become surrogates for altruistic reasons.

     Meeting the Surrogate

     Whether you meet the surrogate depends on your individual choice.  Some
couples feel that keeping the surrogate anonymous or distant puts them in a
better frame of mind to develop a strong relationship with the newborn, with
less likelihood of interference by the surrogate.  They feel better about
communicating with the surrogate only through their doctor, lawyer, or
surrogate center.  Others want to have frequent contact with the surrogate
before, during, and after the pregnancy and birth.  If the surrogate is a
friend or family member, you already have a very close relationship with her.
     You should ascertain whether the potential surrogate can cope with
carrying the baby and giving it up.  Even if she does have her family's and
friends' support, the surrogate should have counseling arranged for her after
the baby is born (as well as before she becomes a surrogate and during the
pregnancy).  Once they have given the baby to the adoptive couple, most
surrogates say they feel fulfilled and more satisfied about themselves.
     Both the surrogate and the adoptive couple usually say that they perceive
the child as the couple's, not the surrogate's.  But this isn't always the
case, and various disputes have arisen over who should be the legal guardians
of the child born through surrogate motherhood.

     The Surrogate Motherhood Contract

     The rights of the genetic father, his infertile wife, the surrogate, and
the surrogate's husband should be agreed-upon in writing beforehand.
     The clear, detailed surrogacy agreement should specify that the child
will become the legitimate, adopted child of the infertile couple, the
intended parents.  Despite this safeguard, late changes of mind occasionally
occur.  Some legal experts have suggested that after the child is born, the
surrogate should be given a limited grace period, similar to those provided in
many adoption laws, in which she can give notice that she has changed her
mind.  If there is a dispute between the surrogate and the intended parents,
then legal proceedings will probably determine who keeps the child.  That
decision should be guided by the child's best interests.

     Legal Issues

     The highly publicized Baby M case set the legal precedent in New Jersey.
Other states may follow suit or decide the issue on their own.  Most state
laws view a woman who bears a child as the mother, and the baby born by a
surrogate must be given up willingly by the surrogate mother (and her husband,
if she is married) for adoption to the infertile couple, even though the
infertile woman's husband is the true biological father.
     Other laws that have been applied to surrogate motherhood cases include
those concerning artificial insemination, private adoption, family laws,
step-parent laws, even anti-slavery laws.  It's now possible for couples to
skirt some state laws by choosing a surrogate from a state with a more
favorable legal climate.
     The legal waters of surrogate motherhood will continue to be murky.  More
than half the states in the country are considering legislation to legalize,
regulate, or ban surrogate motherhood.  Among the pending laws, some states
would ban surrogacy altogether, while others would ban only paid
surrogacy--allowing unpaid surrogacy, but regulating the practice.
     When problems arise, the courts will have to decide upon the
appropriateness of the various aspects of the surrogacy contract.  The
competing rights of the biological father (the sperm provider) and the
biological mother (the surrogate), their spouses, and the child must be sorted
out.  Surrogate motherhood court cases have had mixed results, some ruling in
favor of the surrogate, others for the biological father and his wife.
     Counseling the surrogate mother beforehand may help to avoid subsequent
custody disputes.  Surrogate screening should provide the surrogate with
information about her own health status and the risks of surrogacy.  The
counseling should ensure that both the surrogate mother and the intended
parents know what they are getting into.  The directors of surrogate
motherhood centers are attempting to develop some standards, including
criteria for the screening and testing of couples and surrogates.

     Surrogate Publicity

     In the United States about a hundred babies are born to surrogate mothers
each year.  Although the publicity surrounding the Baby M decision has caused
some couples to reconsider surrogate motherhood, others still consider it
their best option.  There was a similar heated reaction--and publicity--years
ago about donating sperm.  Despite the adverse publicity surrounding surrogate
motherhood, infertile couples are still calling surrogacy centers.  There is
also a growing underground market aimed at infertile couples wishing to hire
surrogate mothers.
     There remain many questions and issues--legal, ethical, medical,
religious--that need clarification.  Surrogate motherhood and other
reproductive technologies invite doctors, lawyers, and legislators to intrude
on the private, intimate experience of conception and birth.  Advocates of
women's rights have had to confront whether the cost of gaining this fertility
option may cause women to lose reproductive control.  Some fear that
motherhood will be denigrated by separating a woman's genetic and birth
functions, and that this may make it more difficult for a woman to retain
control over her body.
     Many are concerned about the possibility that a poor woman might be
coerced into carrying a rich man's child.  They think commercial arrangements
reduce surrogates to paid baby-carriers.  Yet, if sperm donors are paid and
surrogates aren't, this might be considered another example of women doing
more work for less money than men.
     Surrogate motherhood is a dramatic example of how medical technology has
outrun society's established definitions and laws.  We currently have a crazy
quilt of state laws concerning who controls decisions about the family, how to
deal with surrogates who have second thoughts, and what is best for the
children produced by these technologies.  New hybrid family relationships,
often the last hope of infertile couples, deserve your careful consideration,
but also require close scrutiny.

Questions to Ask Your Doctor About Artificial Insemination by Donor

  -  How do you screen potential semen donors?  (Such screening should
     include tests for the AIDS virus, hepatitis virus, and other sexually
     transmitted diseases and genetic disorders.)

  -  What choice of sperm banks do we have?  Are the sperm banks members of
     the American Association of Tissue Banks?

  -  How many motile sperm does the donor sample contain?

  -  What are our chances of a pregnancy, given our fertility problems?

  -  How many attempts do you expect it will take us to achieve a pregnancy?

  -  Do you use frozen or fresh semen?  (Accept only frozen semen from a donor
     that has been tested for the AIDS virus or antibodies to the AIDS virus
     and the semen quarantined for at least six months until the donor has
     been retested.)

  -  How much will the donor semen cost us?

  -  Will we be able to track down the identity of the sperm donor if
     necessary for medical reasons?

  -  What is the medical and genetic history of the donor?

  -  What is the law in our state regarding donor insemination?

Questions to Ask Your Doctor About Egg Donation

  -  Can you provide us with donor eggs, or refer us to an IVF program that
     can?

  -  Can we bring in our own egg donor?

  -  How will the donor be screened?

  -  What hormones will I (the wife) have to take, and how will they be
     administered?

  -  What are our chances of achieving a pregnancy, given our particular
     fertility problems?

  -  Does our state have any laws prohibiting egg donation?

  -  How much will we have to pay for donor eggs?

  -  Do you have a contract for us to sign with the egg donor?

Questions to Ask Your Doctor About Embryo Transplant, Host Uterus, or
Surrogate Motherhood

  -  Are we good candidates for this procedure?

  -  Will you perform this procedure or refer us to a specialist who will?

  -  How do you recruit potential donors or surrogates?  How are they
     screened?

  -  What is the donor's or surrogate's fee?

  -  What are the laws in our state regarding this procedure?

  -  Do you have a contract for us and the donor or surrogate to sign?