Home or Overseas?
Donor Conception Outside the UK
For the past twelve or so years it has become increasingly common for people seeking egg, embryo or double donation to include going outside the UK in their thinking about where to have treatment. Over the last two years going abroad for sperm donation has become more popular, particularly but not exclusively, for single women and lesbian couples.
Egg, double and embryo donation
Egg donation overseas came about because of the perceived and actual shortage of egg donors in the UK in the early 2000s and the apparently endless availability of donors in countries such as Spain, Cyprus and the Czech Republic. Reports from those who went out to these countries were very positive. The first UK residents started going to Spain before the ending of anonymity for donors in this country in 2005. There didn’t seem to be much difference in having anonymous donation in either country, although there was far less information available about Spanish donors. But then anonymity for donors ended in the UK and going abroad became a very different prospect. However, egg donors remained scarce in the UK for a while thus providing a huge dilemma for those who by that time may have preferred an identifiable donor.
Sperm donation has traditionally taken place in the UK and it would appear that it is not necessarily a shortage of sperm that is driving people abroad. For some time now it has been possible to import sperm to the UK, from Denmark or the US, from donors prepared to be identifiable and thereby complying with UK law. This has probably masked a shortfall in UK donors, although it depends on who you talk to as to whether it is considered that the UK has a shortage of donors or not. However, there has been a recent trend for people to actually go abroad for sperm donation, single women and lesbians seeming to prefer midwife-led clinics in Denmark and heterosexual couples importing either identifiable or anonymous donor sperm from Denmark to clinics in the Czech Republic or Cyprus. Although some people may be seeking to avoid UK legislation, it would appear that most people making the decision to have sperm donation abroad are doing so for financial reasons.
The challenge of making a decision that is right for your child
When contemplating donor conception, the situation was and remains, how to give yourself the very best chance of having a family at all whilst at the same time doing the right thing by the child you are able to have.
For those for whom an identifiable donor is the preferred option, finding that one cycle of treatment in the UK costs almost the same as two in some other countries, presents potential recipients with tough choices. DCN knows that grappling with these issues is particularly hard at a time when people are often dealing with the emotional consequences of many unsuccessful treatments, the time pressure of age and the continued deep longing for a child.
Our organisation has many members who have gone abroad for all types of donation, facing and negotiating as they did so all the issues set out above and below. As an organisation we have very many years of experience of talking with donor conception families as children grow, change and express their own thoughts and needs. One of the keys to getting it right for the children is the confidence that parents have in the decisions they make at the beginning. And the key to that confidence is informed decision making.
It is important to take into account when contemplating going abroad that treatments that take place overseas and children conceived there will not appear on the HFEA register, even if UK clinics supported or organised the treatment and the children are born in the UK. The HFEA also offers guidance to people thinking of going abroad for treatment here http://www.hfea.gov.uk/fertility-clinics-treatment-abroad.html
DC Network’s position and role
In the interests of donor conceived people, DC Network has supported the ending of anonymity for donors and access to as much information as possible about donors and half-siblings. In many other countries where UK residents typically seek treatment donors are anonymous, either by law or in practice, information is sparse and connection with half-siblings so far unlikely (see section on DNA testing). DCN recognises that these facts make for very hard choices for those who would prefer their children to have the possibility of identifying their donor and/or half-siblings, but feel a time or financial pressure upon them. Our role is to support parents in making decisions they can feel confident about, with a clear view of the long-term implications for the whole family.
Egg Donation treatment in the UK
The good news is that many clinics in the UK are now in a position to offer both egg-share donors and donors not undertaking treatment of their own with either no waiting time at all, or under three months. With the improvement in freezing techniques, egg banks are also now being established.
Unfortunately some fertility doctors continue to give the impression that UK egg donation waiting lists are all around two years. While professionals can obviously give up to date information about the availability of donors at their own clinic they may be less familiar with the true position at other clinics or in the UK generally. In a competitive environment they may be reluctant to refer patients to a rival UK clinic; they may also have commercial links to clinics abroad and therefore an interest in referring patients there.
The National Gamete Donation Trust www.ngdt.co.uk may be able to give up to date information about recruiting clinics and waiting lists and sometimes DC Network can help as well. The HFEA will be including information about waiting times for egg and sperm donation on their new website, going live Winter 2016. There are also two egg donation agencies based in the UK.
Counselling and preparation
Counselling is a valuable opportunity to talk through the implications of donor conception with someone not emotionally involved in the process. Taking up an offer of counselling or seeking it out does not mean you are weak or suffering from mental health problems. It just means you are recognising the ‘difference’ in using donated gametes for family creation and giving yourself the best chance of being a strong and healthy donor conception family by talking through the issues. Counselling can also be used very fruitfully to help people decide whether or not donor conception is actually right for them. DC Network’s Preparation for Donor Conception Parenthood workshops are an extended opportunity to think about what having a child with the help of a donor means for you and your future child. They are open to members and non-members of DCN and appropriate for everyone contemplating donor conception, regardless of donation type, relationship status, sexuality or whether you are having treatment abroad or in the UK.
Some UK NHS clinics do not allow access to their counselling service for patients who say they may go abroad for treatment. Counselling may need to be sought independently in the UK as it is rarely available in clinics in West or Eastern Europe. The British Infertility Counselling Association www.bica.net can help with this.
Recruitment of donors abroad
Whilst it is reasonable to assume that most donors will have mixed financial and altruistic reasons for donating, there have been reports that egg donors in some countries have been recruited in circumstances that suggest exploitation. The secrecy surrounding anonymous donation and the uneven pattern of regulation in other countries make it very difficult to know how much truth there is in these reports. The EU Tissues and Cells Directive says that EU donors should not be paid for donating but can be compensated for inconvenience. Clinics outside the EU are not bound by this directive, although the UK when it leaves the European Union, will remain highly regulated.
It is often difficult to get meaningful assurances about the circumstances in which overseas donors have been recruited. Some donor conceived adults have spoken of feeling demeaned by being the result of a commercial transaction. For others it seems to matter less or not at all. None of us can know how our children will feel in the future about this.
Donor information and selection
In the UK non-identifying information is given about both sperm and egg donors at the time of donor selection, although some clinics will withhold information beyond a basic physical description, age, nationality etc., until a woman has a confirmed pregnancy. The HFEA guidelines encourage clinics to show potential recipients, prior to selection, all the non-identifying information available, plus any pen portrait and ‘letter to the child’ that has been written by the donor, but some clinics still withhold the information until there is an established pregnancy. Most people will be able to make their own choice of donor, although choices may be limited in the case of some ethnic minorities and if people are wishing to match to specific features like red hair.
Outside the UK there is no standardisation of the non-identifying information about donors (including the reasons why the donor donated) that may be available. In some countries, such as the USA and to a slightly lesser extent Greece, South Africa, Ukraine and Russia, a large amount of information is obtainable about egg donors. There is also a lot of information available about Danish and US based sperm donors, including baby and sometimes adult photographs at extra cost. In most of the European countries where people from the UK go for egg donation there may be considerably less information given than in the UK. Most Spanish clinics claim that it is against their law to give more information than the age and blood group of a donor. Their law actually says that they can give all non-identifying information, although most choose not to do so. There is anecdotal evidence that some Spanish clinics are increasing the amount of information available because of demand from UK residents. You may want to consider using your power as a consumer to help change practice.
The UK is unique in having a central national register of donors and recipients. How records are kept and what might happen to them in the future (if, for instance, the clinic went out of business) may not be as clearly set out abroad as in the UK.
In most EU countries egg donors are selected by the clinic doctors and not by recipients. Requests can be made for specific hair, skin or eye colouring but parents have been known to be surprised, and sometimes unsettled, when their child has features that are typical of the country of origin of the donor, which may of course not be the country where treatment takes place. While unexpected features can crop up in any family, the focus on visual resemblances can become more laden with emotion in a donor family, particularly if the parents had anticipated not telling friends and other family members until the child was older. In a family where a positive decision to go abroad has been taken and parents plan on celebrating this connection, this is less likely to be a problem.
We also don’t know how children conceived with a sperm or egg donor from another country will feel about the half of their genetic heritage that comes from that country, particularly if their physical features make it obvious to themselves and to others. Feelings could range from pride in the special connection to discomfort at looking different and not ‘fitting in’ where they are growing up.
Anonymous or identifiable donors
In most countries outside the UK all donation is anonymous and this is a most difficult issue for some people who would prefer an identifiable donor. They are aware that a child might grow up wanting identifying information about his or her donor, and the choice to have treatment with an anonymous donor rather than an identifiable UK one, may have to be explained to the child later. If, on the other hand, an overseas donor (such as may be found in the US or Denmark) is to be identifiable when the child reaches 18, the systems for recording and eventually accessing the donor’s details may not be as robust as in the UK where information is held centrally by the HFEA. There are of course no guarantees that donors recruited inside or outside the UK will actually be traceable, or alive, or willing to have the sort of contact some donor offspring might be hoping for when they turn 18. This is a question that can be talked about with children and young people as they grow up.
We know that if children are conceived via sperm donation abroad then there may be very many half-siblings world-wide. If sperm is imported from the US or Denmark, then there may be up to ten families created from the same donor in the UK but an unspecified number of half-siblings around the world. Some donor conceived adults have said they feel very uncomfortable about the idea of there being the possibility of so many half-sibs. As egg donors usually donate far fewer times than sperm donors, the number of half-siblings is unlikely to pose the same issues for offspring.
Some heterosexual and lesbian couples and many single women are keen to explore the possibility of half-sibling contact to provide genetic links for their child. They need to be aware that conceiving a child by anonymous donation abroad may mean that this is less likely to be an option for their child, although independent donor sibling registries outside the US and UK are beginning to be set up and DNA testing may prove to be a game-changer in the future. Sometimes single women, and others, choose sperm donors from American banks so that they have the opportunity to link with half-siblings and potentially the donor via the privately run Donor Sibling Registry in the US.
Additional issues to consider with embryo donation
Embryos are only rarely donated to other families for fertility treatment in the UK. One reason for this is the ending of anonymity for donors in 2005. This brought to the forefront for a donating couple the issue of resulting children making contact with them and with their own children when those born from embryo donation reach 18. They would be full genetic parents to those children who would also be full brothers or sisters to their own children.
Because counselling is virtually mandatory for people donating or receiving embryos in the UK, potential donors and recipients have to think through the range of feelings that children conceived in this way may have, knowing that they would have full genetic parents and brothers or sisters in another family. While for children conceived by donated sperm or eggs, there is a possibility of half siblings in other donor families or indeed in the family of the donor, for embryo donation children the existence of siblings is a near certainty, and they will be in the family of the donating couple and possibly another family as well.
Embryos that are donated in the UK come from couples or individuals who have completed their family by IVF and have remaining embryos in storage. However, at many clinics in West and Eastern Europe and the USA, embryos may be created with eggs and sperm from separate anonymous donors. Where two or more embryos are transferred, DNA testing of twins is beginning to reveal that sometimes the eggs and sperm used may not be from the same donor, although this fact is unlikely to have been told to the recipient(s) who will have one, rather than two donor descriptions. This situation could of course also happen in egg donation. If you are contemplating donor conception outside the UK and more than one embryo is being transferred, you may want to seek assurances that the gametes being used are from the same donor(s).
Conceiving with anonymously donated embryos means that not only will a child have no genetic connection to the recipient parent or parents, and virtually no information about the donors, but also there will be little or no possibility of future contact with the donors, whether they are a couple or individuals, and perhaps more importantly no chance of tracing siblings. DNA testing may change this situation significantly in the future but it may be sometime before this sort of testing becomes commonplace everywhere and databases in all countries are as large as they currently are in the USA and Scandinavia and starting to be in the UK.
Treatments abroad not available in the UK or EU
Some clinics outside the UK and European Union carry out procedures and treatments that are not allowed by the HFEA and are banned by the European Tissues and Cells Directive. These include gender selection and the transfer of large numbers of embryos potentially resulting in a dangerous multiple pregnancy and sometimes selective termination of some of the foetuses. ‘Tandem cycles’ are also available in some clinics. This is where embryos are created with both donor eggs and the woman’s own eggs and then nurtured to maturity. Where embryos of both types are transferred, only subsequent DNA testing could prove which embryo had produced a pregnancy/resulting child.
These procedures are not allowed in the UK and the EU for ethical reasons. With regard to the transfer of more than two embryos the OneAt ATime website shows that putting back more embryos does NOT improve your chances of a healthy live birth. We would recommend reading the information on their website before agreeing to multiple embryo transfers.
The reference to DNA testing in the section on embryo donation shows just one way in which this technology, now available in kits sent to your home, is changing the donor conception world. Donors can no longer be considered anonymous, whether they started as identifiable or anonymous. Donor conceived adults are using DNA tests to find genetic relatives, who sometimes need only to have a very remote cousin on the same data-base, for them to be found. In other cases further detective work, not necessarily DNA-based, is necessary. Parents are testing their children and people seeking health information and with no prior knowledge about being donor conceived, are finding that the people they assumed they were biologically linked to, actually are not. It is a revolution that cannot be ignored. Being open with children about their beginnings has to be the way to avoid tragic future family confrontations as well as being in the children’s best interest to know from a young age.
What we know and what we don’t know…
Due to the history of secrecy, there is no long-term research on donor conceived families, and little reliable knowledge. A number of individual sperm-donor-conceived adults have spoken up about their situation, with a variety of views, and there is now some research on their experiences and feelings. Most of those researched were told about their beginnings when they were teenagers or adults and often in very unsatisfactory circumstances. There is beginning to be research with some children who have ‘known’ since they were little but it is early days with this. So far there are only a few anecdotal accounts of how teenagers and adults conceived by egg or embryo donation feel. No research has been carried out into how the feelings and needs of adults conceived with egg, double (egg and sperm) or embryo donation may differ from those conceived by sperm donation. It is possible that those who have no genetic connection to their parent(s) may have stronger feelings about their origins, but this remains unknown, as does any child or adult’s perspective on being conceived abroad.
Since identifiable donors are available in the UK, the best we can do is try to imagine our children’s feelings and reactions, and consider how we might explain our choices and decisions to them, and support them as they grow up.
What we do know is that psychologists and social workers experienced in this field say very clearly that openness between parents and children about donor conception (whether the donor is anonymous or identifiable) is supportive of warm family relationships, and parental confidence about choices made may be a key factor here. Many Network members have conceived abroad and are adopting different strategies about how to integrate the foreign connection into the story they tell their children. Some are encouraging their children to take an interest in the culture of the country by learning the language, deliberately taking holidays there or supporting that country’s team in international sporting events. Some see it as simply a fact to be shared and focus more on the ‘nurture’ side of cultural identity.
Some Dos and Don’ts
So, if after weighing up all the options and taking all the factors into consideration, you think that having treatment abroad is the course you will take, do make this a decision that you can feel confident about in years to come. There may be very positive reasons to go abroad –you or your partner may have a connection with that country, or you may want a greater range of donors to choose from with more information about them than is available in the UK. Get as much information as you can about the clinic and the country as possible. Do try to contact other families who have been there –the Network may be able to help with this. And do think about how you will tell your child the reasons for your decision, how much you will want them to feel a link with the country, and how you might become comfortable encouraging a connection of this sort.
Don’t accept that going abroad is the only option because UK clinics have told you about a shortage of donors in the UK. Both egg and sperm donors are available in the UK now, but the choice remains yours. Finances are not a trivial part of the decision making process, but they are not the only thing to consider. Whatever decision you make, or have made in the past, identify the positive aspects, record the thoughts that went into the decision and how you saw the options available to you at the time. This will help you develop a confidence that you made the best choice possible in the circumstances.
For couples or individuals needing donor conception, these are uniquely complex decisions that our friends who have glided into unassisted parenthood cannot begin to comprehend. And parental confidence and pride, gained in advance or retrospectively, is the key to children being able to manage the range of feelings they may have about their beginnings.
DC Network’s support for and promotion of openness about donor conception is based on research that started with adopted people – who now have the right to know about their birth parents – and has continued with adult donor conceived people who almost universally believe that it is their right to be told of their origins and as early in life as possible. The research included those people who didn’t consider the information to carry any deep meaning for them at that time.
Donor-conceived people’s views and experiences of their genetic origins: A critical analysis of the research evidence
Eric Blyth, Marilyn Crawshaw, Lucy Frith and Caroline Jones
(2012) 19 JLM 769
Modern Families: Parents and Children in New Family Forms
Cambridge University Press 2015
You might also want to read this document
The following document was produced following an international forum on cross-border reproductive care that took place in Canada in January 2009
Cross-Border Patient Prompter (PDF)