Submitted by FertilityLab Fri 07/13/2012
Craig Sweet, MD, a reproductive endocrinologist, recently published a thought provoking article which argues for reducing the minimum recommended age for egg donation from 21 (as ASRM Guidelines recommend) to 18. You can read his entire piece here. He argues persuasively that women of 18 years (and younger) are able to make decisions about their own health care including difficult decisions about pregnancy, contraception and abortion. At 18, women are able to vote, are able to join the armed forces and are considered financially accountable. The only thing an 18 year old woman can’t do is drink alcohol and donate their eggs. A dear friend of mine, who is both an IVF lab director and an ethics expert reminded me about pediatric ethics rules: “In the decision-making of pediatric patients, we sometimes follow the 7 year rule. Up to age 7, parental assent and a more paternalistic, yet best interests standard, between 7-14, more direct involvement with the child in decision-making. Keep in mind that some 7-14 year olds undergoing cancer treatments, are very capable of understanding and should absolutely be involved in the decision-making, 14-21 it really depends on the individual, and we should not paint with too wide a brush.” So there are many medical examples in which even very young children are asked to make adult decisions about their healthcare. Interestingly, Dr. Sweet points out that there appears to be a double standard for egg donors and sperm donors. Most sperm banks will permit sperm donation between 18-19 years of age as the minimum cut-off. Dr. Sweet suspects this apparent gender discrimination may be based on a misplaced cultural stereotype that women have a greater attachment to their offspring than men and thus would be more likely to suffer psychological harm or regret regarding egg donation. in his own words, Dr. Sweet says “I suspect the real concern is that some fear we are taking advantage of a young woman who will have offspring conceived from her eggs and that the potential for psychological damage may be greater for her than a man who donates sperm at the same age.” I don’t disagree with his analysis. Gender stereotypes abound. Both of my esteemed colleagues suggest that in order to sort out whether a potential donor is “old enough”, it is appropriate to require a consultation between a mental health professional and the potential donor to discuss potential psychological harms. I would agree that requiring a potential donor to meet with a counselor to discuss all the implications of donation prior to donating is a step in the right direction. Where I differ from my colleagues is that I think age is not the issue at all. It is life experience. Ruth Ragan, an egg donor who wrote about questions arising years after her donation says, “Over the years, thoughts about the happiness, safety and well-being of any donor-conceived children have slowly crept into my head, but it wasn’t until I became a mother that they invaded. Between age 24 and 39 I changed; I became more loyal, more responsible, more patient and less of a risk-taker. I imagine that most anonymous egg donors, young women in their 20s, also change and grow in the years following their donation. Do many of them then look back on their decision to donate, as I do, with worry and ambivalence? My growing concern has developed into an increasingly persistent nagging worry as I search for information about the eggs that I donated and about the retrospective emotions of other anonymous egg donors. It has led me on a journey from altruistic donor to worried former donor.” You can read the entire article here. In case you think only women feel this way, here is an article from a sperm donor who regrets his donation years later. This is what concerns me. Both women and men experience huge shifts in their attitudes regarding the meaning of family when they have children of their own. Since most donors are young adults and don’t yet have kids, parenthood is a theoretical abstraction far in the future. I would argue that the only person who can truly understand/assess their own risk of future regret regarding donating their gametes are the potential donors who already have children of their own. Why? Because it is crystal clear to a biological parent what their own sperm or egg can produce. They see the actual living evidence in front of them in their own child. Any gametes donated now would produce half-siblings to this child. If that is where you stand in life, I say “Go for it!” You totally know what you are giving up and what precious gift you have to donate. Why not just let the mental health professionals sort out these issues and decide whether someone is mature enough to donate gametes as my colleague suggest? Couldn’t one argue that this approach just shifts the paternalism to the mental health expert? Are the mental health experts better able to understand the mind of the donors than the donor themselves? Also, if the mental health professional receives patient referrals from the clinic, doesn’t that create a conflict of interest? The mental health professional who issues more “stop” rather than “go” assessments will likely risk being replaced as too cautious. So, call my attitude patronizing and “maternalistic” (as opposed to paternalistic) but I can’t quite convince myself that the current system really protects donors against future regret. And yes, I do (perhaps misguidedly) want to protect people from regret (and in worst cases, exploitation) when possible, especially when the consequences of their decisions affect other lives as well as their own. I would argue that if you really wanted to protect donors from exploitation, only donors with kids should donate gametes. This policy would actually have several advantages to recipients of gametes. First, all donors would be “proven donors’ in the sense that their gametes have been successful in producing a child. Secondly, a more complete medical history exists for older donors. For instance, severe genetic conditions may be revealed in an older donor that the 18 year old donor didn’t know about. You can read about one such example in which a rare cardiac genetic defect was passed on to many donor offspring for years until the donor had his own kids and the disease was diagnosed in himself and his children. Clearly, a more complete donor medical history would have been an advantage for these recipients. Having discussed advantages, one obvious disadvantage of having older donors is that older egg donors (say 25-35) would have less “fruitful” older eggs relative to the 18 year old donor which makes for a much less attractive donation for the older recipient. However, since under 35 years of age is still considered young in ART terms, most donors with kids would probably fall in this age group and still have adequate egg quality. I suspect the real non-starter for a policy of requiring donors to already have children would be the likely vast reduction in the number of gamete donors who are still interested in donating once they have a family. Why? Precisely because when they have real children in the world, I would predict, most potential donors (and their partners) are typically less enthusiastic about creating anonymous half-siblings for their children. Real children are much more compelling for inspiring caution than theoretical children. A crash in the number of available donors is something that would not benefit either recipients nor ART providers. In Great Britain, where the law was changed to simply require sperm donors to be known rather than anonymous, sperm donations plummeted dramatically and many Brits found they had to go outside Britain to find sperm donors. But I have to wonder, what does it say about our current framework of gamete donation if we can only readily find donors to donate who are both young and anonymous? Incidentally, the other major cultural “push back” against gamete donation increasingly comes from donor conceived children. Some of these children regret the nature of their conception because they feel deprived of that biological connection, even in cases where their intended parents truly made them their own children in every way. It may be time to rethink how gamete donation is currently provided and look beyond the immediate needs of conception to consider the long-term best interests of both donors and the children their donations produce.