Manhood: The Rise and Fall of the Penis (44 page)

vo l u n ta ry a n d i n vo l u n ta ry s t e r i l i t y icsi.

trast to ivf, icsi requires only one mobile sperm cell per ovum. In cases of azoospermia through obstruction, pesa is the most common technique: with obstruction the number of properly mobile sperm cells is highest in the head of the epididymis, with a production problem the chance of finding mobile sperm cells is greatest in the tail.

In pesa a needle is inserted into the epididymis under local anaesthetic and withdrawn as suction continues. The needle is connected to a syringe via a tube, which is then injected with growing medium so that the content can be assessed by an analyst for the number of mobile sperm cells. This procedure can be repeated several times in a session.

Usually one starts on the side of the larger testicle, and if the count is low one can try the other side.

In a tese treatment sperm cells are taken from the testicle itself, and subsequently sperm cells are extracted in a laboratory from the section of testicular tissue removed. This has the advantage that a section of testicular tissue can immediately be obtained for the Johnsen score.

The treatment of fertility problems is generally felt to be very onerous. There are many stressful events, including (for women) daily hormone injections, blood samples, and diagnostic procedures such as exploratory operations, and masturbating to order and ‘epididymal sperm aspiration’ in men. Intercourse tends to become reproduction-led, potentially placing the desire for sex under pressure. In addition there is the situation of being constantly tossed back and forth between hope and fear. It becomes particularly burdensome when one wants to keep treatments secret from family, friends and colleagues. Taking time off work without letting colleagues in on the secret necessarily involves some fibbing.

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Freezing sperm cells

Freezing sperm cells, cryopreservation, is important mainly to young men with testicular cancer who after removal of the affected testicle face a course of chemotherapy. Occasionally a man presents for sterilization, while expressing the wish that his sperm be stored in advance of the procedure. Such a wish cannot be met with the normal health service, though he can have sperm frozen by commercial institutions.

Anyone thinking that sperm banks are a twentieth-century human invention is wrong: for several million years the male springtail has been consistently distributing scores of sperm droplets in the form of a chain. When the female insect’s eggs are mature, she goes to the sperm depot and takes one.

Simple freezing of sperm cells leads to shrinkage of the cell, loss of fluid and sometimes cracks, resulting in loss of function. There was a great step forward after the discovery of glycerol, which could counter the above processes. In freezing for cryopreservation liquid nitrogen is used, cooled to –196 degrees Celsius. One sperm sample can be used to fill between five and fifteen ampoules containing 0.3 millilitres.

Depending on the situation between one and three batches of sperm will be frozen. After freezing, one ampoule is defrosted in order to assess the mobility of the spermatozoa: the percentage of mobile sperm that continues to move after freezing or defrosting respectively varies from 5 to 50 per cent. With a concentration of mobile sperm of at least one million per millilitre in the initial sample, there is a reasonable chance of mobile sperm after the defrosting of the whole amount. This is important information when icsi is being considered, since only mobile sperm can be used.

The ampoules of frozen sperm are distributed across two vats in order to reduce the chance of loss as far as possible. It is impossible to assign every individual a deep-freeze vat of their own, so that the sperm of several men is stored in a single deep-freeze vat. Occasionally tiny cracks in the ampoules appear during freezing, so that the contents may come into contact with the liquid nitrogen. In this way viruses and microbes can in theory be released and come into contact with the frozen seed of other men. Because of this risk the man is required by law to be tested in advance for infectious diseases such as aids and hepatitis.

Sperm donorship

The first recorded sperm donation that took place in a medical center was carried out with few of the ethical considerations that are mandated in clinics today: it was performed in 1884 at Philadelphia medical 232

vo l u n ta ry a n d i n vo l u n ta ry s t e r i l i t y school for an infertile couple. Instead of taking the sperm from the husband, the doctor chloroformed the woman, then let his medical students vote which of them was the ‘best looking’, with that elected one providing the sperm for the insemination. After talking to the husband, they decided it was best not to let the woman know.

Sperm donation can be a morally contentious issue. Couples in heterosexual relationships considering sperm donation as a solution to childlessness may view it as preserving the sexual integrity of their relationship. However, sperm donation does not maintain the reproductive integrity of a relationship in that the woman’s sexual partner is not the biological father of her child, and it is the sperm donor, not the partner, who has reproduced himself.

However, others point out that the process is essentially a sexual one: a woman’s innate sexuality may be the reason why a child is wanted, the donor has to be screened for sexually transmitted diseases which could be passed on through the use of his sperm, and the donor has to sexually stimulate himself in order to produce the sperm samples which are used for achieving pregnancies in women to whom he is not related. Some would argue that it is impossible to distinguish sexuality from reproduction, and that the reason for preserving sexual integrity is to preserve reproductive integrity.

The use of sperm donation is increasingly popular among unmarried women and single or coupled lesbians. Indeed, some sperm banks and fertility clinics, particularly in the us, Denmark and the uk have a predominance of women being treated with donor sperm who fall within these groups and their publicity is aimed at them. This produces many ethical issues around the ideals of conventional parenting and has wider issues for society as a whole, including the issues of the role of men as parents, the issue of family support for children, and the issue of financial support for women with children.

Some donor children grow up wishing to find out who their fathers were, but others may be wary of embarking on such a search since they fear they may find scores of half-siblings who have been produced from the same sperm donor. Even though local laws or rules may restrict the numbers of offspring from a single donor, there are no worldwide limitations or controls and most sperm banks will ‘onsell’ and export all their remaining stocks of vials of sperm when local maxima have been attained.

However, others would argue that sperm donation has liberated the way in which women can control their reproductive lives and that it has enabled many men as sperm donors to father children which they would not want or wish to support but which they know will fulfil a desperate biological and social need for the women who bear them.

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Many donees do not tell the child that they were conceived as a result of sperm donation, or, when non-anonymous donor sperm has been used, they do not tell the child until it is old enough for the clinic to provide the contact information about the donor.

For children who find out after a long period of secrecy, their main grief is usually not the fact that they are not the genetic child of the couple who have raised them, but the fact that the parent or parents have kept information from them or lied to them, causing loss of trust.

Furthermore, the overturning of their knowledge of who their parents are may cause a lasting sense of imbalance and loss of control.

However, there are certain circumstances where the child very likely should be told: when many relatives know about the insemination, so that the child might find it out from somebody else; when the husband carries a significant genetic disease, relieving the child from fear of being a carrier; or where the child is found to suffer from a genetically transmitted disorder and it is necessary to take legal action which then identifies the donor.

Anonymous sperm donation is where the child and/or receiving couple will never get to know the identity of the donor, and non-anonymous when they will. A donor who makes a non-anonymous sperm donation is termed a known donor, open-identity or identity-release donor. Non-anonymous sperm donors are, to a substantially higher degree, driven by altruistic motives for their donations.

In any case, some information about the donor may be released to the woman/couple at the time of treatment. A limited donor information at most includes height, weight, eye, skin and hair colour. In Sweden, this is all the information a receiver gets. In the us, on the other hand, additional information may be given, such as a compre-hensive biography and sound/video samples.

For most sperm recipients, anonymity of the donor is not of major importance at the obtainment or tryer-stage. The main reason for anonymity is that recipients think it would be easiest if the donor was completely out of the picture. However, some recipients regret not having chosen a non-anonymous donor years later, for instance when the child desperately wants to know more about the donor anyway.

There is a risk of bias in the information given by clinics or sperm banks regarding anonymity, making anonymous sperm donation seem more favourable than it may actually be, resulting from the fact that anonymous sperm donations are easier for the clinic or sperm bank to handle in the long term, because anonymity doesn’t make them responsible for safely storing donor information for a long period of time. In addition, a majority of donors are anonymous, causing a relative deficit in non-anonymous sperm supply.

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vo l u n ta ry a n d i n vo l u n ta ry s t e r i l i t y The law usually protects sperm donors from being responsible for children produced from their donations, and the law also usually provides that sperm donors have no rights over the children which they produce. Several countries, e.g. Sweden, Norway, the Netherlands, Britain, Switzerland, Australia and New Zealand only allow non-anonymous sperm donation. The child may, when grown up (15–18

years old), get contact information from the sperm bank about his/her biological father. In Denmark, however, a sperm donor may choose to be either anonymous or non-anonymous. Nevertheless, the initial information which the receiving woman/couple will receive is the same.

In the United States, sperm banks are permitted to disclose the identity of a non-anonymous donor to any children brought to the world by that donor, once the child turns eighteen.

Where a sperm donor donates sperm through a sperm bank, the sperm bank will generally undertake a number of medical and scientific checks to ensure that the donor produces sperm of sufficient quantity and quality and that the donor is healthy and will not pass diseases through the use of his sperm. The donor’s sperm must also withstand the freezing and thawing process necessary to store and quarantine the sperm. The cost to the sperm bank for such tests is not inconsiderable.

This normally means that clinics may use the same donor to produce a number of pregnancies in a number of different women.

The number of children permitted to be born from a single donor varies according to law and practice. These laws are designed to protect the children produced by sperm donation from consanguinity in later life: they are not intended to protect the sperm donor himself and those donating sperm will be aware that their donations may give rise to numerous pregnancies in different jurisdictions. Such laws, where they exist, vary from state to state, and a sperm bank may also impose its own limits. The latter will be based on the reports of pregnancies which the sperm bank receives, although this relies upon the accuracy of the returns and the actual number of pregnancies may therefore be somewhat higher. Nevertheless, sperm banks frequently impose a lower limit on geographical numbers than some us states and may also limit the overall number of pregnancies which are permitted from a single donor. When calculating the numbers of children born from each donor, the number of siblings produced in any ‘family’ as a result of sperm donation from the same donor are almost always excluded (but see below for the provisions in various states). There is, of course, no limit to the number of offspring which may be produced from a single donor where he supplies his sperm privately.

Despite the laws limiting the number of offspring, some donors may produce substantial numbers of children, particularly where they 235

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donate through different clinics, where sperm is onsold or is exported to different jurisdictions, and where countries or states do not have a central register of donors.

Sperm agencies, in contrast to sperm banks, rarely impose or en-force limits on the numbers of children which may be produced by a particular donor partly because they are not empowered to demand a report of a pregnancy from recipients and they are rarely, if ever, able to guarantee that a woman may have a subsequent sibling by the donor who was the biological father of her first or earlier children.

Countries that have banned anonymous sperm donation have a substantial sperm shortage, because only a fraction of sperm donors want to continue their contributions if they know that the donor-conceived children may contact them one day. Banning of payment to donors has also caused shortages. This has prompted fertility tourism to other countries to get the treatment.

For instance, when Sweden banned anonymous sperm donation in 1980, the number of active sperm donors dropped from approximately 200 to 30. Sweden now has an eighteen-month-long waiting list for donor sperm. After the United Kingdom ended anonymous sperm donation in 2005, the numbers of sperm donors went up, reversing a three-year decline. However, there is still a shortage, and some doctors have suggested raising the limit of children per donor. Sperm exports from Britain are legal (subject to the eu Directive on Tissue Exports) and donors may remain anonymous in this context. Some uk clinics export sperm which may in turn be used in treatments for fertility tourists in other countries. uk clinics also import sperm from Scandinavia.