Artificial Insemination: Practice in the

United States: Summary of a 1987 Survey

August 1988

NTIS order #PB89-139903
Recommended Citation:

U.S. Congress, Office of Technology Assessment, Artificial Insemination: Practice in the

United States: Summary of a 1987 Survey—Background Paper, OTA-13P-BA-48 (Washington, DC: U.S. Government Printing Office, August 1988).

Library of Congress Catalog Card Number 88-600558

For sale by the Superintendent of Documents

U.S. Government Printing office, Washington, DC 20402-9325

(order form can be found in the back of this report)
Foreword

Artificial insemination is the oldest of the “new” reproductive technologies, yet

surprisingly little is known about its practice. This background paper presents the results

of a study of physician and sperm bank practice of artificial insemination in the United

States. It documents the number of women undergoing artificial insemination each

year, the annual cost, medical and social screening criteria for women seeking artificial

insemination and men who donate semen, the genealogical recordkeeping available to

the resulting children, and physician attitudes toward possible changes in artificial insemination practice.

This national survey was commissioned by OTA to complement its work on the

recently published assessment Infertility: Medical and Social Choices, a report requested

by the Senate Committee on Veterans’ Affairs and the Subcommittee on Human Resources and Governmental Relations of the House Committee on Government Operations. That report presents a technical, economic, ethical, and legal analysis of the latest

developments in infertility prevention and treatment, including use of new techniques

such as in vitro fertilization, gamete intrafallopian transfer, and surrogate motherhood.

Highlights from the artificial insemination survey were incorporated into the report.

This background paper presents the survey results in more depth.

In gathering information for the development of this survey, OTA staff made site

visits to 3 sperm banks and 10 in vitro fertilization clinics. OTA was assisted in the

preparation of the survey instrument and the background paper by a panel of 37 advisors and reviewers selected for their expertise in survey methodology, infertility research and treatment, artificial insemination services and protocols, civil rights, and

regulation of medical services.

OTA gratefully acknowledges the contribution of each of these individuals. As with

all OTA background papers, responsibility for the content is OTA’s alone.

u JOHN H. GIBBONS

Director

Ill
Artificial Insemination Practice in the United States

Summary of a 1987 Survey

OTA Project Staff

Roger C. Herdman, OTA Assistant Director

Health and Life Sciences Division

Gretchen S. Kolsrud, Biological Applications Program Manager

Gary B. Ellis, Project Director

R. Alta Charo, Study Director

E. Blair Wardenburg, Research Analyst

Contractors

Schulman, Ronca & Bucuvalas, Inc.

John M. Boyle, Principal Investigator

Jane Weinzimmer, Research Associate

Mark Morgan, Research Associate

Editor

Linda Starke, Washington, DC

Acknowledgments to Other OTA Staff

Robyn Y. Nishimi, Analyst

Kathi E. Hanna, Analyst

Gladys B. White, Analyst

Timothy P. Condon, Analyst

Franklin M. Zweig, Visiting Scholar

Sharon K. Oatman, Administrative Assistant

iv
Reviewers of Survey Design, Questionnaire, and Analysis

OTA is grateful for the valuable assistance and thoughtful critiques provided by the reviewers. The

views expressed in this OTA report, however, are the sole responsibility of the Office of Technology

Assessment.

Nancy J. Alexander

Jones Institute for Reproductive Medicine

Norfolk, VA

Lori B. Andrews

American Bar Foundation

Chicago, IL

Ricardo H. Asch

University of California

Irvine Medical Center

Orange, CA

Benjamin G. Brackett

University of Georgia

College of Veterinary Medicine

Athens, GA

William J. Bremner

University of Washington Medical School

Seattle, WA

Arthur L. Caplan

University of Minnesota

Institute for Biomedical Ethics

Minneapolis, MN

Grace Centola

Andrology Laboratory

University of Rochester

Rochester, NY

Daniel R. Curry

Abbott Laboratories

Abbott Park, IL

Ken Daniels

Department of Social Work

University of Canterbury

Christchurch, New Zealand

Alan H. DeCherney

Yale University School of Medicine

New Haven, CT

H. Tristram Engelhardt, Jr.

Center for Ethics, Medicine, and Public Issues

Baylor College of Medicine

Houston, TX

Mark Frankel

American Association for the Advancement

of Science

Washington, DC

Gary D. Hodgen

Jones Institute for Reproductive Medicine

Norfolk, VA

Neil A. Holtzman

Department of Pediatrics

Johns Hopkins University

Baltimore, MD

Janet Kennedy

Division of Reproductive Endocrinology

University of Maryland

Baltimore, MD

Patricia A. King

Georgetown University Law Center

Washington, DC

John H. Mather

Paralyzed Veterans of America

Washington, DC

Eileen McLaughlin

Bristol Maternity Hospital

Bristol, England

Virginia Michels

Mayo Clinic

Rochester, MN

Susan G. Mikesell

RESOLVE, Inc.

Washington, DC

Jon Miller

Public Opinion Laboratory

Northern Illinois University

DeKalb, IL

Father Albert S. Moraczewski

Pope John XXIII Center

Houston, TX

Barbara Raboy

Spermbank of Northern California

Oakland, CA

Barbara Katz Rothman

Baruch College

City University of New York

New York, NY

Cappy Miles Rothman

Century City Hospital IVF Center

Los Angeles, CA
Reviewers of Survey Design, Questionnaire, and Analysis

(Continued)

William Schlaff

Division of Reproductive Endocrinology

Johns Hopkins University

Baltimore, MD

Jerome Sherman

Department of Anatomy

University of Arkansas

Little Rock, AR

Sherman J. Silber

St. Luke’s Hospital-West

St. Louis, MO

Joe Leigh Simpson

University of Tennessee, Memphis

College of Medicine

Memphis, TN

Keith Snyder

Vietnam Veterans of America, Inc.

Washington, DC

Ronald Urry

Department of Urology

University of Utah

Salt Lake City, UT

Donna Vogel

National Institutes of Health

Bethesda, MD

Andy Walker

Midland Fertility Unit

West Midlands, England

John Ward

Centers for Disease Control

Atlanta, GA

James Weixel

Food and Drug Administration

Washington, DC

Thomas G. Wiggans

Serono Laboratories, Inc.

Randolph, MA

Norma Wilder

Department of Sociology

University of California-Santa Cruz

Santa Cruz, CA

OTA is also grateful for the assistance of the following organizations, which were visited in order to

prepare this survey.

California Cryobank

Los Angeles, CA

Cappy Miles Rothman

Charles Sims

Directors

Lesbian Rights Project

San Francisco, CA

Roberta Achtenburg

Attorney

Repository for Germinal Choice

Escondido, CA

Robert Klark Graham

Director

Sperm Bank of Northern California

Oakland, CA

Barbara Raboy

Director

vi
Contents

Page

Chapter l: Overview and Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Chapter 2: Survey Data: Physician Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Chapter 3: Survey Data: Sperm Bank Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Appendix A: Study Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Appendix B: Survey Instrument for Physician Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Appendix C: Survey Instrument for Sperm Bank Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

vii
Chapter 1

Overview and Summary
CONTENTS

Page

Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Cross-Sectional Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Fertility Society Sample. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Sampling Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Field Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

The Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Participation Rates.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Scope of the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Summary: Physician Practice of Artificial Insemination . . . . . . . . . . . . . . . . . . . . . 8

Recipient Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Donor Screening. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Characteristic Matching . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Fresh v. Frozen Semen Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Recordkeeping, Professional Standards, and Attitudes Toward

Artificial Insemination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Summary: Sperm Bank Practice of Artificial Insemination . . . . . . . . . . . . . . . . . . 11

Screening and Matching . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Recordkeeping, Professional Standards, and Attitudes Toward

Artificial Insemination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Boxes

l-A. Physician Practice of Artificial Insemination in 1977 . . . . . . . . . . . . . . . . . . 4

l-B. Physician Practice of Artificial Insemination by Donor in Ontario. . . . . . . 4

I-C. British Attitudes Toward Artificial Insemination by Donor ..., . . . . . . . 5

1-D, Artificial Insemination by Donor in New Zealand . . . . . . . . . . . . . . . . . . . . 6

1-E. Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Chapter 1

Overview and Summary

In May 1988, OTA released its assessment Infertility: Medical and Social Choices, delineating

options for congressional action with regard to

prevention, treatment, and research on infertility. The report considered the medical, ethical,

economic, and legal aspects of conventional drug

and surgical therapies, in vitro fertilization,

gamete intrafallopian transfer, surrogate motherhood, and artificial insemination. As part of

the assessment, OTA commissioned a national

survey of physician and sperm bank practice of

artificial insemination, the first such survey in a

decade. Two physician populations – a crosssectional sample of primary care and reproductive care specialties and a national probability

sample of members of medical fertility societies

— were surveyed by mail between June and

August 1987. A total of 1,558 questionnaires

were completed and returned by the sampled

physicians (a response rate of 61 percent), which

included 37 physicians in the cross-sectional

sample and 385 fertility society physicians regularly doing artificial insemination, i.e., seeing

four or more insemination patients per year. An

amended survey form was also sent to 30 U.S.

commercial sperm banks identified by the

American Association of Tissue Banks (MTB)

and the American Fertility Society (AFS), and 15

of those forms were returned.

The survey estimates that 172,000 women underwent artificial insemination in 1986-87, at an

average cost of $953, resulting in 35,000 births

from artificial insemination by husband (AIH),

and 30,000 births from artificial insemination by

donor (AID). The survey confirms certain findings first reported in 1979 concerning variability

in physicians’ donor screening practices and their

misuse of genetic histories (see box l-A). Sperm

banks were found to have more consistent donor

screening practices. The survey also documents

reluctance to offer artificial insemination to single women, variability in screening for infectious

diseases, and widespread refusal to release even

nonidentifying information about donors to their

offspring, findings similarly documented in surveys of artificial insemination practice in Canada

(see box l-B), England (see box l-C), and New

Zealand (see box l-D).

METHODS

Cross-Sectional Sample most likely to treat fertility problems. Hence, it

was decided to sample the four specialties disTo generate sample estimates that could be proportionately, to yield 1,600 cases for the

projected to the total population of U.S. physi- cross–sectional sample of physicians.

cians who conduct artificial insemination, a national cross-sectional sample was drawn from Fertility Society Sample

the universe of currently practicing physicians

likely to become involved in infertility therapy – Given the anticipated low physician involvethose in general practice and family practice or in ment in artificial insemination and fertility treatreproductive care specialties (gynecology, ob- ment, a second sampling frame was constructed

stetrics/gynecology, and urology). A propor- from the membership lists of two national protionate sampling of the population led to rela- fessional societies, the American Fertility Socitively small sample sizes for some specialties ety and the American Society of Andrology. The

3
4

Box l-A.-Physician practice of Artificial

Insemination in 1977

Interest in physician practice of artificial

insemination by donor increased dramatically with

the 1979 publication of a survey by a group of

researchers and clinicians at the University of Wisconsin. That survey was based largely on a group

of American Fertility Society physicians likely to

be doing artificial insemination. Four hundred

seventy-one questionnaires were completed, a

66-percent response rate, and 379 physicians were

identified who had offered artificial insemination

in the preceding year.

Most physicians reported that about 95 percent

of the requests they received were due to male infertility. A third, however, had received requests

due to Rh incompatibility or fear of passing on a

genetic disorder. Almost 10 percent had received

requests from single women. Less frequently reported reasons included impotence, paraplegia,

and exposure to mutagens.

Physicians reported that they generally selected

donors themselves, rather than purchasing specimens from a sperm bank or having women provide

their own donors. Sixty-two percent reported

using medical students or residents as donors, 11

percent used other university or hospital personnel, and 18 percent used both. Over 75 percent

matched for height and hair, skin, and eye color.

Over half would also match for blood type, religious or ethnic background, and educational level.

Only 5 percent reported that they did not make any

effort to match donors to recipients’ husbands or

specifications.

Donor screening for genetic diseases consisted

largely of oral family histories, as fewer than 30

percent performed any biochemical tests on

donors. Rejection patterns also did not always

match transmission patterns of the particular disorders. For example, nearly 75 percent reported

they would reject a donor with a family history of

hemophilia; this disorder is x-linked, and cannot

be transmitted unless the donor himself suffers

from the disease. Physicians were about as likely to

reject a donor with a family history of cystic fibrosis

or Huntington’s chorea as one with a family history of Tay-Sachs disease, although tests were

available at the time to identify Tay-Sachs carriers

but not those carrying cystic fibrosis or Huntington’s.

SOURCE: M. Curre-Cohen, L. Lutrrcll, and S. Shapuo, ‘“Current Pmcnce of

Arnficd Insermmmon b Donor m the United Su[~”’A”NE@n~

lcwmalofM&cme .3(Y3: 85-590, 1979. {

Box l-B.- Physician Practice of Artificial

Insemination by Donor in Ontario

In late 1983 and early 1984, a survey of physician practice of artificial insemination by donor

was carried out in Ontario, Canada, pursuant to a

request by the Ontario Law Reform Commission. By examining physician descriptions on the

registry of the Canadian Fertility and Andrology

Society, 16 physicians or practices were identified

that offered artificial insemination by donor. All

16 cooperated with the survey, yielding a sample

of 31 physicians. Their responses indicated that in

1983 approximately 500 women in the province

of Ontario underwent artificial insemination by

donor.

Recipient rejection was mostly strongly influenced by a woman’s sexual orientation (7),

impending divorce (6), or single state (5). Twelve

of the 31 physicians reported that they never (5)

or only occasionally treated (7) single women.

Eight physicians responded that they never (4) or

only occasionally (4) treated an unmarried couple. Nonetheless, all but one physician reported

that fewer than 5 percent of the women requesting artificial insemination were single.

For donor screening, physicians most commonly did semen analysis (12 physicians), syphilis

testing (12), and hepatitis testing (9). Fewer than

half did a complete blood count (7), semen culture (7), genetic history (6), or blood chemistry

(5). Two indicated that special genetic screening

was done.

Thirteen physicians maintained records allowing them to link donors to recipients, and a similar number followed recipients’ post-conception

and post partum. The physicians reported very

few cases of transmitted infectious disease or

congenital anomalies.

SOURCE: J. Jwrcll and R. Milner, “Artificial Inwminxron by Donor in

Ontio,” Annals RCPSC 19(2):1 15-118 (1986).

memberships of the two organizations are

currently estimated at ll,000 and 1,000,

respectively.

The total size of the sample of fertility specialists was 1,213. This included 1,000 from the

AFS sample and 213 from the Andrology

Society.
5

Box l-C.-British Attitudes Toward Artificial Insemination by Donor

In early 1985, a multicenter study of attitudes toward artificial insemination by donor among recipients,

their partners, physicians, counselors, nurses, and donors was carried out by sampling each individual attending or working in 1 of 10 clinics around England. Seventy-one percent of those solicited returned completed

questionnaires. The questionnaire focused on attitudes toward recipient screening, donor rights and duties,

recordkeeping, and governmental involvement.

Support for maintaining the anonymity of the donor was universal, although 43 percent favored supplying

recipients with information concerning physical appearance and 25 percent with information concerning social background. Fewer felt that the resulting child ought to get this information (6 to 9 percent ). Four to seven

percent felt that donors should get nonidentifying physical or social information about the intended recipient.

Two percent felt that donors ought to be able to choose to whom their semen would be given, and another 9

percent felt this ought to be up to the individual choice of the clinic or physician. (South Africa is the only

nation that has provision for such donor choice; see U.S. Congress, Office of Technology Assessment, Infertility: Medical and Social Choices (1988 ).)

Opinion was mixed concerning screening applicants for AID for their fitness for parenthood (as is done for

adoptions), with 57 percent saying that screening should not be done, and 28 percent saying that it should.

Homosexual women would be denied access to AID by a majority surveyed. Unmarried couples received a

more mixed response (single women were not distinguished from unmarried couples).

In response to the question “Should AID be provided for the following groups of people?” answers were as

follows:

Leave to

Individual Don’t Not

Yes No Choice Know Answered

unmarried couples . . . . . . . . . 43 30 18 7 2

homosexual women . . . . . . . . 19 54 12 14 1

women with medical

conditions making

pregnancy hazardous . . . . . 19 19 51 10 1

disabled people . . . . . . . . . . . . 45 8 37 9 1

those with a history of

psychiatric problems. . . . . . 6 45 23 24 2

Control of “artificial reproduction” by a national body was supported more broadly by clinic staff (39 percent) and donors (31 percent) than by recipients (15 percent). Little support was expressed by any of these

groups for a central registry of all children conceived by AID (3 percent of recipients, 16 to 19 percent of staff

and donors), or a registry of donors (12 to 30 percent). Patients and staff did favor limiting the number of

children born to a donor (37 to 58 percent), as well as limiting payment to expenses only (44 to 55 percent).

Twenty-two percent of donors favored these two suggestions.

SOURCE: A. Walker, S. Grcgson. and E. Mcl.mghhn. ‘6Atdtudcs Towards Donor Insemination - A Post-Wamock SuIVey,” Hutnon Repmdwnon 2: 745-7S0, 1987.

Sampling Method Field Procedures

For all samples, selection of sample within The field procedures used in this study were

stratum was by-simple random sample. Data are designed to produce an unbiased sample of phypresented here as weighted sample estimates. sicians from the two sampling frames. These proWeighting is by specialty and professional cedures included:

society.
6

Box I-D.-Artificial Insemination by

Donor in New Zealand

In 1983, a survey was done of 153 New Zealand

obstetricians and gynecologists concerning their

practice of artificial insemination by donor. Sixtyeight percent replied, of whom 20 physicians had

performed artificial insemination in the 12 months

prior to the survey, with a total of 68 conceptions in

the 159 women inseminated. Fifty-four percent of

those not offering artificial insemination had received requests for the service. Of those not offering artificial insemination, 5 percent cited moral

objections, and 29 percent cited other personal

reasons for preferring not to engage in the practice.

Eighty percent of those offering the service believed it is important to assess the psychological

suitability of the recipient and her partner before

proceeding with artificial insemination. Sixty-five

percent believed an assessment of the recipient’s

social circumstances is important as well. All practitioners reported discussing the options of childlessness and adoption with the recipient and her

partner, as well as the psychological, social, and legal implications of AID.

Sperm donors tended to be recruited from hospital staff and medical students. Sixty-five percent

of the physicians doing AID paid their donors, and

30 percent set no limit on the number of conceptions per donor. The remaining 70 percent set a

variety of limits, from five to one conception per

donor. Nearly half (45 percent) felt that children

conceived by AID should be told of their origins,

although 95 percent felt that there should be no

Health Department requirements on this point.

SOURCE: K.R. Damels. “llre Pmcbce of Artficnl Insemuranon of Donor

S rm m New Zealand,” k“ew Zealand Me&calJoumo198: 235-239.

1985.

● an advance letter sent to all sample respondents indicating that the questionnaire

would follow,

● a first mailing of the questionnaire with

cover letter,

• a followup letter to individuals whose replies

were not received within 4 weeks of the first

mailing,

● a second questionnaire mailing approximately 1 week after the followup letter, and

● a telephone followup of nonrespondents

among a predesignated 20-percent subset

of the sample to find out why the person had

not responded.

The Questionnaire

The survey used two questionnaires, one for

physicians and one for sperm banks. Physicians

seeing fewer than four insemination patients per

year were asked to answer a few questions concerning the demographics of their practice, as

well as to respond to a series of attitudinal questions concerning artificial insemination practice

as a whole. Physicians with four or more insemination patients per year (i.e., those “regularly doing artificial insemination”; see box l–E) were

asked to respond to a series of detailed questions

concerning their protocols and screening practices. To avoid doubling the size of the necessary

sample or of the survey instrument, separate

questionnaires were not used for AIH and AID

practice. Questions concerning the relative proportion of a physician’s practice devoted to AIH

and AID allow the data concerning screening

and protocol to be broken out according to

whether a physician does only AIH, some AID,

or predominantly AID.

Participation Rates

A total of 1,558 questionnaires were completed and returned by sampled physicians. The

overall response rate was 61 percent. Due to late

return of some questionnaires, analysis of the

survey data is based upon only 1,473 of the returned questionnaires, including 36 from physicians in the cross-section, 346 AFS members, and

21 andrologists regularly doing artificial insemination.

As the field period ended, all outstanding

cases from the predesignated 20-percent subset

were contacted in an attempt to learn why they

were not responding. Roughly 35 percent of the

contacted nonrespondents reported that they

had already completed the survey and just recently mailed it, that they intended to reply, or

that they were in the process of replying. Almost

25 percent of the nonresponse sample were on

vacation, not at home, or otherwise unreachable
i

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Box l-E.–Glossary

Cross-sectional sample: A national probability sample of physicians surveyed for this report whose primary

specialty is general practice, family practice, gynecology, obstetrics, obstetrics/gynecology, or urology,

drawn from the American Medical Association sampling frame.

Fertility society sample: In this report, a national probability sample of members of two professional societies that specialize in fertility treatment and research, the American Fertility Society and the American Society of Andrology.

Artificial insemination (AI): The introduction of semen in a woman’s vagina or uterus, other than by sexual

intercourse. Unless otherwise specified, AI includes artificial insemination with semen from the recipient’s

husband or partner (artificial insemination by husband or AIH) or from a donor (artificial insemination

by donor or AID). AID is sometimes referred to by professional societies as therapeutic insemination by

donor and by feminist groups as alternative insemination by donor.

Human immunodeficiency virus (HIV): The virus responsible for the autoimmune disease commonly

known as AIDS. HIV-infected refers to those infected with the virus, whether or not they yet exhibit symptoms of AIDS or of AIDS-related complex. Seropositive for HIV-antibodies refers to those who have been

shown by any available test to have developed antibodies to HIV. Seropositivity indicates that the person has

been exposed to HIV, and may be capable of transmitting it to others.

Practitioners: Physicians who perform artificial insemination.

Regularly doing artificial insemination: In this report, physicians who have accepted four or more patients

for artificial insemination in the past year.

Recipient: A woman seeking or undergoing artificial insemination, regardless of the source of the semen.

Also referred to as “patient” when describing interaction with her physician.

Recipient’s partner: The husband or nonmarital male partner of a recipient.

Donor: A man whose semen is used for inseminating someone other than his wife or partner. An anonymous donor is someone not known to the recipient. A recipient-selected donor is a man selected by the

recipient (other than her partner) to donate semen for artificial insemination.

Sperm bank: A facility that collects and stores semen for artificial insemination by husband, as well as

screening donors and storing semen for artificial insemination by donor. Also commonly known as a

“cryobank.” In this report, unless otherwise noted, all facilities are commercial sperm banks, i.e., operating

for a profit.

Infertility treatment: The range of medical and surgical treatments for infertility, including drugs, surgery,

in vitro fertilization, gamete intrafallopian transfer, and artificial insemination.

Membership in a fertility society: In this report, self-defined by the survey respondents who said that they

belong to a professional society that is a fertility society.

Proportion AIH: In t his report, proportion of artificial inseminations in the past year using husband/partner

semen. If all inseminations in the past year used husband’s or partner’s semen, then the practice is referred

to as exclusively AIH.

Exclusively AIH: In this report, physicians who in the previous year performed artificial inseminations using

only husband/partner semen. Also referred to as AIH-only practice. These physicians may have done artificial insemination by donor in previous years, and so may have answered questions about their lifetime experience in the practice of AID.

Predominantly AID: In this report, practices in which fewer than 25 percent of inseminations in the past

year used husband’s or partner’s semen.

Single: Unmarried and without a male or female partner. Maybe compared with unmarried, which refers to

heterosexual or homosexual couples not legally married.
8

at the time. Roughly 15 percent of the non- the survey, or a policy of refusal to participate in

response sample refused to participate for a vari- surveys.

ety of reasons, most of which involved the length Overall, the followup contact did not reveal

and/or complexity of the survey instrument or any underlying problem of sample bias among

the respondents’ actual time available to com- nonrespondents. Nonresponse bias testing was

plete the survey. A few physicians cited issues of not done for the 50 percent of the sperm banks

privacy, lack of incentive or benefit in completing failing to respond to the survey.

SCOPE OF THE SURVEY

The survey was designed primarily to serve as

a source of information on the extent of artificial

insemination in the United States, the patterns

of donor and recipient screening for genetic and

infectious diseases, and the economic or other

nonmedical obstacles to obtaining the service. It

was also designed to elicit information about

physician attitudes toward the practice, their use

of existing professional society guidelines for

practice, and their attitudes toward national

standards of practice, whether voluntary or mandatory. While data were gathered concerning the

detailed protocols of practice, and the success

rates for various methods of artificial insemination including sex selection techniques, this retrospective survey of physician experiences is not

intended as a substitute for controlled, prospective clinical studies on those topics. Information

on protocols and success rates gathered from the

survey is here used primarily to extrapolate to

the number of children conceived each year by

artificial insemination, and the total annual expenditures on the procedure.

SUMMARY: PHYSICIAN PRACTICE OF ARTIFICIAL INSEMINATION

The survey estimates that nearly 11,000 physicians provide – at least occasionally – artificial

insemination services to approximately 172,000

women. Live births are achieved in 37.7 percent

of cases, resulting in an estimate of 65,000 babies

born each year who had been conceived by artificial insemination. About half of those conceptions resulted from AIH, and half from AID.

Success rates vary considerably from case to

case, as do costs, depending on whether a woman

is seeking AIH or AID, and whether she has any

underlying infertility problem. AIH accounted

for approximately 54 percent of the artificial insemination done last year in the United States.

To achieve pregnancy, on average, a woman

spends $309 in initial consultations, examinations, and testing, and $92 for each of seven inseminations (done over the course of four to five

cycles), for a total average cost of $953, yielding a

national estimate of $164 million spent each year

for this procedure. Physicians report that 51 percent of these women have insurance coverage for

the procedure, and that on average the insurance

covers 48 percent of the total cost. At a national

level, this means that recipients pay three-quarters of the costs of artificial insemination out of

their own pockets.

Overall, those currently seeking and obtaining

artificial insemination, with a few exceptions,

identify themselves as married couples with a

male reproductive problem. Four out of five physicians (82 percent) routinely present other options to patients seeking artificial insemination.

The alternative most often presented is adoption

(54 percent). Eighty-five percent also routinely

present possible risks of artificial insemination,

generally infection or multiple births, as well as

the normal risks of birth defects or complications

associated with pregnancy. A relatively small

proportion of practitioners (and only those doing

at least some AID) present psychological complications for the recipient (3 percent), the husband
9

(1 percent), or the offspring (1 percent) as part of

the risks normally discussed.

Recipient Screening

Physicians regularly providing artificial insemination generally require the following before accepting a woman for insemination: a personal medical history (98 percent), a fertility

history (99 percent), a physical examination (96

percent), a family history (93 percent), and a personality assessment (52 percent). Young physicians (29 percent) and female physicians (39 percent) are less likely than older (60 percent) and

male physicians (53 percent) to require personality assessment prior to acceptance.

Twenty-eight percent of the physicians regularly doing artificial insemination indicate that a

family history of genetic disease would lead them

to require genetic screening of a potential insemination recipient. A majority (74 percent)

also require other diagnostic tests of patients

prior to accepting them for insemination. The

testing most often required by physicians doing

artificial insemination is that for infertility (47

percent). The most commonly reported tests for

infectious diseases were those for human immunodeficiency virus (HIV) (10 percent) and assorted sexually transmitted diseases (20 percent).

Four out of five patients who request artificial

insemination are accepted. The most common

reason that physicians have rejected requests is

that the patient is considered unsuitable for nonmedical reasons: she is unmarried (52 percent),

psychologically immature (22 percent), homosexual (15 percent), or welfare-dependent (15

percent). Other reasons include evidence of

child abuse (13 percent), drug abuse (11 percent), or alcohol abuse (10 percent). Sperm

banks rarely if ever have rejected men with these

characteristics who applied to store semen for future AIH use.

When asked if they would be “likely to reject”

an unmarried recipient with a partner, physicians

were evenly divided. If the unmarried recipient

does not have a partner, the proportion of physicians who had rejected or would be likely to reject the patient rises to 61 percent. If the recipient is homosexual, presumably in addition to

being unmarried and without a male partner, this

group increases to 63 percent.

Donor Screening

Forty-five percent of artificial inseminations

conducted in the past year used donor semen: 22

percent of all artificial inseminations used donor

semen from sperm banks and 21 percent from

physician-selected donors, with 2 percent from

other sources. Donor screening by physicians

prior to acceptance is quite varied. For AID

practices, half the physicians regularly doing artificial insemination require special prescreening

for genetic defects or diseases from some donors.

Two-thirds of the physicians regularly doing

artificial inseminations normally screen donor

sperm for motility, morphology, and other signs

of probable fertility, and an additional 10 percent

obtain their semen samples from sperm banks,

where such screening is routine. Fertility screening is done by 28 percent of those whose practice

is exclusively AIH, and by 74 percent of those

who use donors. A slim majority of physicians

regularly doing artificial insemination (56 percent) reported requiring other diagnostic tests of

donors. Seventy-eight percent of these practitioners reported testing for HIV.

Of the 24 characteristics examined by the survey, a history of serious genetic disorders was the

condition for which the greatest proportion of

practitioners (21 percent) had rejected a donor.

Physicians also reported having rejecting donors

due to drug abuse ( 14 percent), psychological immaturity (13 percent), alcohol abuse (11 percent), a criminal record (9 percent), less than average intelligence (8 percent), child abuse (6

percent), less than a high school education (6

percent), and less than average height (3 percent).

Forty-four percent of physicians providing artificial insemination on a regular basis require

special screening to detect genetic disorders for

which donors are at relatively high risk. However, the pattern of donor rejection is not always
10

consistent with the patterns of genetic transmission of the traits for which they are being rejected. In a number of cases, a majority of physicians would reject healthy donors with family

histories of sex-linked disorders that are not

transmissible unless the donor himself has the

condition, such as hemophilia (49 percent) or

Duchenne’s muscular dystrophy (61 percent).

The rate of rejection for having a family history

of Huntington’s chorea (63 percent) is similar to

that for those with a family history of Duchenne’s

muscular dystrophy, even though those with

Huntington’s are difficult to distinguish (due to

late onset of the disease and expense of seeking

genetic markers) yet may be capable of passing

on this serious disorder to their children even if

the other parent is free of the trait.

Characteristic Matching

Overall, 72 percent of physicians regularly doing artificial insemination are willing to match to

at least some recipient specifications, commonly

race (97 percent), eye color (94 percent), complexion (90 percent), height (90 percent), ethnic

or national origin (84 percent), body type (82

percent), and hair texture (81 percent). A majority also match specifications concerning the donor’s educational attainment (66 percent), age

(62 percent), intelligence quotient (57 percent),

and religion (56 percent), although a fairly substantial proportion of physicians who are generally willing to match at least some recipient specifications say that they would not try to match on

the basis of education (29 percent), age (31 percent), intelligence quotient (37 percent), or religion (39 percent). A majority of physicians refuse to match hobbies (56 percent) or income (72

percent). Nonetheless, 39 percent will match for

hobbies and 22 percent for income. Physicians

are more evenly split on whether they will (45

percent) or will not (50 percent) match for special abilities.

Fresh v. Frozen Semen Use

In 1987, at the time of this survey, approximately one-third of those regularly doing artificial insemination (whether AIH or AID) relied

exclusively on fresh semen, and about a quarter

relied entirely on frozen semen. Of those doing

AID, 22 percent used fresh semen exclusively.

Since 1985, the American Association of Tissue Banks has discouraged the use of fresh semen among its member sperm banks. Since this

survey was done, use of fresh donor semen was

also discouraged by AFS, the Food and Drug

Administration (FDA), and the Centers for Disease Control, because it is not possible to test donors for recent exposure to the HIV virus that

might render their semen infectious. Such testing

requires that the semen be frozen and quarantined, and the donor retested after 3 to 6 months.

Physician practice may have significantly

changed since the time of this survey as a result of

the new guidelines.

Most frozen semen is obtained from commercial vendors. Three-quarters of physicians who

use frozen semen report that either they or their

supplier have a quarantine period on the use of

the semen. The average period is 3.5 months, but

quarantine periods range up to 8 months. Six

months is the quarantine period recommended

by the FDA, and 3 months is what AATB advises.

Recordkeeping, Professional Standards, and

Attitudes Toward Artificial Insemination

About half of all physicians regularly doing artificial insemination (54 percent) keep records

that would permit them to identify the specific

donor for any specific pregnancy, although a majority will not give anyone access to them, under

any circumstances, even if all identifying information about the donor is removed.

The majority of fertility society members who

do artificial insemination on a regular basis (76

percent) report that they are aware of specific

professional guidelines for the selection of recipients or donors for artificial insemination.

Awareness of professional standards is important because it is virtually tantamount to adoption of at least some of those procedures.

Most physicians who practice artificial insemination favor establishing national standards (unspecified as voluntary or mandatory) for donor
11

screening by sperm banks (80 percent) or private cians split evenly on whether there is anything

practitioners (68 percent), for recipient screen- wrong with sperm banks that specialize in donors

ing (57 percent), and for recordkeeping (58 per- with particular artistic, athletic, or intellectual

cent), but strongly oppose releasing identifying gifts, and they tended to approve screening reinformation about sperm donors to the children cipients on such nonmedical grounds as marital

conceived with their sperm. As a group, physi- status and sexual orientation.

SUMMARY: SPERM BANK PRACTICE OF ARTIFICIAL INSEMINATION

For AID practice, 9 of the 15 facilities responding to the survey will sell samples only to doctors

and 5 will sell samples to both doctors and recipients (1 bank did not respond). No banks reported selling samples only to recipients.

Screening and Matching

Almost half of the sperm banks (7 of 15) reported that they would reject requests for specimens if the recipient, as reported by her physician or as seen by them, seemed unsuitable. Two

others said physicians do such screening for

them. The most likely reasons to reject a recipient were that she is seropositive to HIV-antibodies (6 of 9) or shows evidence of drug abuse, alcohol abuse, or child abuse (5 of 9). Psychological

immaturity and diseases such as hepatitis or

cytomegalovirus are also conditions that determine rejection for 4 of 9 facilities.

All 15 sperm banks in the survey reported that

they would allow recipients or their physicians to

provide specifications for particular donor traits.

Nearly all the banks (14 of 15) match physical

characteristics such as height, weight, eye color,

hair texture, and body type. Similarly, 14 facilities match recipients and donors by race, ethnic

group, or national origin. Twelve will match by

religion and 11 by educational attainment, special abilities, hobbies, or interests. Seven sperm

banks are willing to match by intelligence quotient. Income is the characteristic that sperm

banks are least willing to match (3 of 15). Another option available to recipients is sperm

separation for preconception sex selection.

Slightly more than half the banks (8 of 15) offer

this service.

Because sperm banks are most often located in

or near universities and hospitals, a majority of

sperm banks claim that their inventories contain

an overrepresentation of donor characteristics

such as “college or graduate degree holder” (12

of 15), “better than average IQ” (8 of 15), and

“better than average occupational status/

achievements” (7 of 15). There is, however, an

“about normal” representation of religious

groups or nationalities, as stated by 12 of 15

banks.

All the facilities reported that they require

some form of screening before accepting donors,

but the nature and extent of the tests vary. Thirteen sperm banks screen donors for genetic defects or diseases that tend to be of ethnic origin,

such as Tay-Sachs disease (in Jewish donors),

sickle cell anemia (in black donors), and thalassemia (in donors of Mediterranean origin).

All 15 sperm banks reported that they screen

donors for human immunodeficiency virus, regardless of whether their semen is intended for

use in AIH or AID. If a donor tests negative to

the presence of HIV antibodies, 13 banks quarantine the sample pending further donor testing,

which will occur, on average, every 1.9 months

but which may range anywhere from every 1 to 6

months. In the event that a donor tests positive

for HIV antibodies, every bank surveyed reported it would notify the donor of the test results. Sperm banks split on whether they would

inform the donor’s spouse or partner.

In general, the survey found that sperm banks

are reluctant to accept donors with a family history of genetic disorders, even those that are correctable, avoidable, or socially tolerated. In a

number of cases, a majority of sperm banks

would reject donors with family histories of disorders that are not widely recognized as predominately genetic.
12

In addition, like physicians although less

often, a number of sperm banks would reject

donors with family histories of hemophilia or

Duchenne’s muscular dystrophy but who were

themselves healthy, despite the fact that they

could not pass on these diseases. Sperm banks almost uniformly, however, screened out donors

with family histories of cystic fibrosis or Hunngton’s chorea.

Recordkeeping, Professional Standards, and

Attitudes Toward Artificial Insemination

At least 11 of the 15 sperm banks keep detailed records for each donor, which often includes information such as the number of women

inseminated, number of pregnancies achieved,

number of children born, the donor’s physical examination, the donor’s family genetic history,

and any followup examinations of the donor. The

majority of facilities will not allow offspring,

recipients, recipients’ partners, or the donors

themselves access to these records.

The sperm banks surveyed have generally

adopted professional guidelines and procedures

as part of their protocols for artificial insemination, with most using those set forth by AATB

or AFS. Members of AATB are bound by its

standards.

Establishing national standards (unspecified

as voluntary or mandatory) for donor insemination would be favored by most banks, with 14

supporting national standards for donor screening, 13 favoring standards for recordkeeping, and

11 favoring standards for recipient screening. Involvement by national medical societies and

Federal public health agencies to assure the

safety and quality of artificial insemination practice is more favored than involvement by peer

review organizations.

Those responding for the sperm banks generally disapproved of facilities that specialize in donors with intellectual, artistic, or athletic gifts,

despite the fact that their own donor pools and

screening processes tend to overrepresent educational attainment, and the fact that physicians

as a group split almost evenly on this question.

They did, however, split evenly on screening recipients for social characteristics, such as marital

status or sexual orientation, whereas physicians

tended to approve of recipient screening on such

nonmedical grounds.
Chapter 2

Survey Data:

Physician Practice

CONTENTS

Page Page

Prevalence and Distribution of Artificial

Insemination . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Artificial Insemination Practitioners . . . . . . . . . . 20

Fertility Services . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Reasons for Seeking Artificial Insemination . . . 23

Artificial Insemination by Husband v. Donor . . 24

Recipient Screening . . . . . . . . . . . . . . . . . . . . . . . . 24

General Screening Requirements . . . . . . . . 24

Personality Assessments . . . . . . . . . . . . . . . . 24

Genetic Screening . . . . . . . . . . . . . . . . . . . . . 26

Other Diagnostic Tests . . . . . . . . . . . . . . . . . 26

Correlation of Past Patient Rejection With

Patient Characteristics . . . . . . . . . . . . . . . . 27

Correlation of Likelihood of Rejection With

Patient Characteristics . . . . . . . . . . . . . . . . 28

Presentation of Risks and Options . . . . . . . . . . . 31

Donor Selection and Screening . . . . . . . . . . . . . . 33

Sources of Donor Semen . . . . . . . . . . . . . . . 33

General Screening Requirements . . . . . . . . 33

Genetic Screening . . .. . . . . . . . . . . . . . . . . . 33

Other Diagnostic Tests ., . . . . . . . . . . . . . . . 35

Fertility Screening . . . . . . . . . . . . . . . . . . . . . 35

Correlation of Past Donor Rejection With

Donor Characteristics . . . . . . . . . . . . . . . . 35

Correlation of Likelihood of Rejection With

Donor Characteristics . . . . . . . . . . . . . . . . .36

Inherited Conditions and Donor Screening .37

Characteristic Matching . . . . . . . . . . . . . . . . . . . . 40

Sex Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Fresh and Frozen Screen . . . . . . . . . . . . . . . . . . . 42

Use of Fresh Semen . . . . . . . . . . . . . . . . . . . 42

Sources of Fresh Semen . . . . . . . . . . . . . . . . 43

Use of Frozen Semen . . . . . . . . . . . . . . . . . . 43

Sources of Frozen Screen . . . . . . . . . . . . . . . 43

Quarantine Periods . . . . . . . . . . . . . . . . . . . . 43

Pregnancy Outcomes and Recordkeeping ... . 45

Tracking Pregnancy Outcomes , . . . . . . . . . 45

Birth Outcomes . . . . . . . . . . . . . . . . . . . . . . . 45

Recordkeeping . . . . . . . . . . . . . . . . . . . . . . . . 46

Access to Donor Records . . . . . . . . . . . . . . . 46

Costs of Artificial Insemination . . . . . . . . . . . . . 47

Preinsemination Costs . . . . . . . . . . . . . . . . . 47

Cost of Insemination . . . . . . . . . . . . . . . . . . . 48

Total Cost of Insemination . . . . . . . . . . . . . . 48
Page

Standards, Guidelines, and Regulation . . . . . . . .51

Adequacy of Professional Practices . .......53

Quality Assurance . . . . . . . . . . . . . . . .. ....53

National Standards . . . . . . . . . . . . . . . . . . . . .54

General Physician Attitudes . . . . . . . . . . .......57

Chapter 2 References . . . . . . . . . . . . . . . . . . . . ..60

Box

2-A.

Table

2-1.

2-2.

2-3.

2-4.

2-5.

2-6.

2-7.

2-8.

2-9.

2-10.

2-11.

2-12.

2-13.

2-14.

2-15.

2-16.

2-17.

2-18.

2-19.

2-20.

2-21.

2-22.

2-23.

2-24.

Box

Page

American Fertility Society Guidelines for

Physician Practice of Artificial

Insemination by Donor . . . . . . .......53

Tables

Page

Infertility Services As Part of Practice . . . 15

Patients Treated for Infertility . . . . . . . . . . 16

Population Estimates of Infertility

Treatment . . . . . . . . . . . . . . . . . . . . . . . . 16

Types of Infertility Treatment . . . . . . . . . . 17

Reasons for Not Accepting Patients for

Insemination . . . . . . . . . . . . . . . . . . . . . . 17

Requests for Artificial Insemination . . . . 18

Patients Accepted for Insemination . . . . . 19

Patients Accepted for Artificial

Insemination, by Physician Specialty . . 19

Population Estimate of Number of

Physicians Conducting Artificial

Insemination , . . . . . . . . . . . . . . . . . . . . .20

Profiles of the Samples . . . . . . . . . .......20

Patients Treated for Infertility . . . .......21

Inseminations During Past Year . .......21

Types of Infertility Treatment . . . .......22

Types of Patients . . . . . . . . . . . . . . . . . . . . 23

Reasons for Seeking Insemination .. ....24

Types of General Screening: Recipient ..25

Recipient Personality Assessment, by

Physician Characteristics . . . . . . . . . . . . 25

Circumstances Requiring Genetic

Screening: Recipient . . . . . . . . .......26

Diagnostic Tests: Recipients . . . . .......27

Reasons for Rejecting Recipients . . . . . . . 27

Types of Diagnostic Tests: Recipients .. .28

Criteria for Rejection: Recipients .. .....29

Acceptability of Recipient Characteristics,

by Age and Sex of Physicians . . .......30

Alternatives to Insemination . . . . .......31

Tables

2-25.

2-26.

2-27.

2-28.

2-29.

2-30.

2-31.

2-32.

2-33.

2-34.

2-35.

2-36.

2-37.

2-38.

2-39.

2-40.

2-41.

2-42.

2-43.

2-44.

2-45.

2-46.

2-47.

2-48.

2-49.

2-50. .

2-51.

2-52

2-53.

2-54.

2-55.

2-56.

2-57.

2-58.

2-59.

2-60.

2-61.

2-62.

2-63.

2-64.

Page

Presentation of Risks . . . . . . . . . . .......32

Risks of Insemination . . . . . . . . . .......32

Sources of Sperm ... , . . . . . . . . . .......33

General Screening: Donors . . . . . .......34

Genetic Screening: Donors . . . . . .......34

Circumstances Requiring Genetic

Screening: Donors , . . . . . . . . . . . . . . . . 35

Diagnostic Tests: Donors ... , . . .......36

Types of Diagnostic Tests: Donors .. ....37

Fertility Screening: Donors . . . . . .......38

Criteria for Rejection: Donors ., . . . .. ..39

Inherited Conditions and Donor

Rejection . . . ., . . . . . . . . . . . . . . . . .. ..40

Willingness To Select Donor

Characteristics , . . . . . . . . . . . . .......41

Specific Donor Characteristics . . . . . . . . .41

Fresh and Frozen Semen: User Profile ., 42

Use of Fresh Semen . . . . . . . . . . . . . . . .. .42

Number of Inseminations: Fresh Screen .43

Sources of Fresh Semen . . . . . . . . . . . . . . 43

Sources of Frozen Semen . . . . . . . . . . . . . 44

Use of Quarantine: Frozen Semen . . . . . . 44

Length of Quarantine Period: Frozen

Semen . . . . . . . . . . . . . . . . . . . . .......44

Awareness of Outcome . . . . . . . . . . . . . . . 45

Experience With Birth Defects . . .......40

Types of Records Kept . . . . . . . . .......47

Access to Records . . . . . . . . . . . . . . . . . . . 47

Preinsemination Costs: Total , ., .. .....48

Preinsemination Costs, by Physician

Characteristics . . . . . . . . . . . . . . . . . . . . 48

insemination Costs: Total . . . . . . .......49

Insemination Costs by Physician

Characteristic . . . . . . . . . . . . . . . . . . . . .49

Total Cost of Procedure . . . . . . . .......50

Awareness of Professional Guidclines . . . 51

Adoption of Professional Guidelines . . . . 52

Guidelines Used . . . . . . . . . . . . . . . . . . . . .54

Adequacy of Professiontal Practices . . . . . 55

Roles in Quality Assurance . . . . . . . . . . . . 55

National Standards for Artificial

Insemination . . . . . . . . . . . . . . . . . . . . . . 56

Regulation of Surrogate Motherhood .. .56

Recipient Acceptance Factors . . . . . . . . . . 57

Self Insemination . . . . . . . . . . . . . . . . . . . . 58

Offspring Rights . . . . . . . . . . . . . . . . . . . . .59

Favored Trait Specialization . . . . . . . . . . . 60
Chapter 2

Survey Data: Physician Practice

PREVALENCE AND DISTRIBUTION

Thirty-three percent of the cross-sectional

sample of physicians reported that they would

provide infertility services (table 2-l), with an

average of 32 patients treated in the last year (table 2-2), suggesting that approximately 1.2 million patients were treated by primary care and

reproductive care physicians last year for infertility problems (table 2-3). Of course, this estimate is somewhat imprecise, because it is physicians reporting on the number of patients they

have seen. As more than one physician might

treat the same individual, these figures may substantially overestimate the population seeking

treatment.

Table 2-1. –Infertility Services As Part of Practice’

(Question 1a):b As part of your practice, would you provide infertility services or treatment for infertility?

Base: Cross-sectional sample physicians responding to survey

Unweighed

basec Yes No

Tota l (827) % 33 67

Specialty

General practice (162) % 93

Family practice . . . .

OB/GYN d . . . . . . (196) % 79 21

Urology . . . . . . . . . . . . . . . . . . (199) % 76 22

Other . . . . ( 34) % 15 85

Practice

Office-based . . ... (715) % 33 67

Hospital-base d (108) % 31 69

Age

Under 3 5 (126) % 37 63

35 to 49 .., : : (344) % 43 57

50 or older . . . ... (342) % 23 77

Sex

Male .. . (759) % 33 67

Female . . . . . . . ( 66) % 36 64

a The sample iS the cross-sectional sample

b The code number of the question in the survey instrument (see app B)

c Percentages are presented as weighted sample estimates The unweighted sample

base is presented m parentheses so that the sampling variance for these estimates

can be calculated

d Obstetrics/gynecology

SOURCE: Office of Technology Assessment, 1988

OF ARTIFICIAL INSEMINATION

Among the cross-sectional sample physicians

who would provide infertility services as part of

their practice, most would provide fertility drug

therapy (90 percent) and surgical therapy (72

percent), but few would provide in vitro fertilization (3 percent) or gamete intrafallopian transfer

(3 percent), and fewer still surrogate mother

matching (2 percent) (table 2-4). Artificial insemination falls between these two extremes: 38

percent of physicians treating infertility problems would provide artificial insemination by

husband (AIH) and 24 percent, artificial insemination by donor (AID). Of those not offering artificial insemination, nearly half explained that

the procedure is not part of their practice (table

2-5). One in 10 cited fear of litigation or liability,

and one in 20 cited personal or ethical objections. Other physicians explained that lack of donors (3 percent) and facilities (3 percent) prevented the practice. Nearly one-third of those

not accepting patients failed to cite a reason.

However, four out of five physicians surveyed in

the cross-sectional sample said that they had received no requests for either AIH or AID in the

past 12 months, although 52 percent of the obstetrician/gynecologists had (table 2-6). Obstetrician/gynecologists also had larger artificial insemination practices than did other specialties

(table 2-7).

Overall, artificial insemination is a common

infertility treatment. The survey indicates that

during a 12-month period in 1986-87, approximately 172,000 women underwent at least one cycle of artificial insemination, 100,000 of them

under the supervision of physicians in primary

care or obstetrics/gynecology, and the rest under

the care of subspecialists, Overall, 9.3 percent of

the physicians in primary care or reproductive

care specialties have accepted a patient for artificial insemination in the past year, suggesting that

15
16

approximately 11,000 physicians in the United cial insemination (tables 2-8, 2-9).

States perform— at least occasionally—artifiTable 2-2.-Patients Treated for Infertility*

(Question lb): b In the past 12 months, approximately how many patients have you treated for infertility problems?

Base: Cross-sectional sample physicians responding to survey who would provide infertility services

Mean

Unweighed no. of

basec None 1-1o 11-20 21-50 >50 patients

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (356) % 8 36 22 21 12 32.1

Specialty

General practice . . . . . . . . . . . . . . . . . ( 11) % 27 73 0 0 0 3.9

Family practice . . . . . . . . . . . . . . . . . . ( 31) % 25 62 10 0 0 9.6

OB/GYN d. . . . . . . . . . . . . . . . . . . . . . . . (155) % 2 26 27 28 17 42.3

Urology . . . . . . . . . . . . . . . . . . . . . . . . (154) % 4 38 25 25 8 26.4

Other . . . . . . . . . . . . . . . . . . . . . . . . . . ( 5) % 20 20 20 20 20 31,2

Practice

Office-based . . . . . . . . . . . . . . . . . . . . (315) % 7 37 22 23 11 29.8

Hospital-based . . . . . . . . . . . . . . . . . . ( 43) % 18 32 25 11 18 53.0

a The sample is the cross-sectional sample

b

The code number of the question in the survey instrument (see app 8)

c Percentages are present as weighted sample estimates. The underweighted sample base is presented in parentheses so that the sampling variance for these estimates can be

calculated

d Obstetrics/gynecology

SOURCE: Office of Technology Assessment, 1988

Table 2-3. - Population Estimates of Infertility Treatment ●

Base: Cross-sectional sample physicians responding to survey

Unweighed base (827)b

Population Proportion Mean Total

Specialty size treating patients patients

General practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25,807 6.8 3.9 6,844

Family practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., . . . . . . . . . . 43,221 13.2 9.6 54,770

Obstetrics/gynecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28,511 79.2 42.3 955,164

Urology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8,944 76.5 26.4 180,633

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,197,411

a The sample is the cross-sectional sample

bProportions and means are presented as weighted sample estimates The unweighted sample base IS presented in parentheses so that the sampling variance for these estimate can

be calculated

SOURCE: Office of Technology Assessment, 1988
17

Table 24.-Types of Infertility Treatmenta

(Question 1c):b Which of the following types of infertility therapies would you perform as part of your practice?

Base: Cross-sectional sample physicians responding to survey who would provide infertility services

Total c d OB/GYN e f

Unweighed base: g

(356) (155)

%

h % % % %

Fertility drug therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 73 65 99 66

Surgical therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 20 10 64 94

Artificial insemination by husband . . . . . . . . . . . . . . . . . . . . . 38 27 20 52 10

Artificial insemination by donor . . . . . . . . . . . . . . . . . . . . . . . 24 20 15 34 4

In vitro fertilization/embryo transfer . . . . . . . . . . . . . . . . . . . . 3 0 0 4 0

Gamete intrafallopian transfer . . . . . . . . . . . . . . . . . . . . . . . . 3 0 0 4 0

Surrogate mother matching . . . . . . . . . . . . . . . . . . . . . . . . . . 2 0 2 2 0

a The sample is the cross-sectional sample.

b The code number of the question in the survey instrument (sea app. B)

c General practice

d Family practice

e Obstetrics/gynecology

f Urologyy

g Percentages are presented as weighted sample estimates. The unweighed sample base is presented in parentheses so that the sampling variance for these estimates can be

calculated

h Since multiple choices were permitted, percentages may add to more than 100%

SOURCE: Office of Technology Assessment, 1988

Table 2-5. - Reasons for Not Accepting Patients

for Insemination

(Question 2c):b What is the main reason you have not accepted

any requests for artificial insemination in the past year? (Verbatim)

Base: Cross-sectional sample physicians responding to survey

who received requests but did no inseminations

Unweighed base (71)C Total

%

Not my specialty/area of expertise . . . . . . . . . . . . . . . . . . 43

Legal risks/fear of litigation . . . . . . . . . . . . . . . . . . . . 10

Personal objection to artificial insemination . . . . . . . . . . . 5

Lack of qualified donors . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Lack of facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Recipient changed mind . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Husband did not agree . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Not medically indicated . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Risk of HIV (AIDS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

All other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

NO reason reported . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

a The sample is the cross-sectional sample

bThe code number of the question m the survey instrument (see app. B)

c Percentages are presented as weighted sample estimates The unweighted sample

base is presented in parentheses so that the sampling variance for these estimates

can be calculated

SOURCE: Office of Technology Assessment, 1988
18

Table 2-6.-Requests for Artificial Insemination

(Question 2a):b In the past 12 months, approximately how many requests have you received for artificial insemination, including requests

for insemination with either husband or donor sperm?

Base: Cross-sectional sample physicians responding to survey

Mean

Unweighed no. of

base c None 1-3 4-1o >11 requests

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (827) % 82 10 5 2

0

<0.5

8

2

3

1.6

Specialty

General practice . . . . . . . . . . . . . . . . . . . . . . . . .

Family practice . . . . . . . . . . . . . . . . . . . . . . . . .

Obstetrics/gynecology . . . . . . . . . . . . . . . . . . . .

Urology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(162)

(236)

(196)

(199)

( 34)

99

92

48

85

88

%

%

%

%

%

1

6

27

7

3

0

1

17

4

6

0

0.2

4.4

5.1

0.9

Practice

office-based . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hospital-based . . . . . . . . . . . . . . . . . . . . . . . . . .

(715)

(108)

82

87

10

6

5

3

2

4

1.5

2.7

1.1

1.9

1.5

%

%

Age

Under 35 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35 to 49 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

50 or older . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(126)

(344)

(342)

80

75

89

5

8

3

%

%

%

11

14

6

1

3

2

sex

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(759)

( 66)

%

%

84

70

9

20

5

7

2

4

1.5

2.7

a The sample is the cross-sectional sample.

bThe code number of the question in the survey instrument (see app. B).

c Percentages are presented as weighted sample estimates. The unweighted sample base represented in parentheses so that the sampling variance for these estimates can be

calculated. Unweighted sample base does not add to 827 where physicians failed to respond to particular question concerning demographic characteristic

SOURCE: Office of Technology Assessment, 1988
19

Table 2-7. - Patients Accepted for Inseminationa

(Question 2b):b How many patients have you accepted for artificial insemination, with either husband or donor sperm, in the past 12

months?

Base: Cross-sectional sample physicians responding to survey who received requests in last 12 months

Unweighed Mean no.

basec None 1-3 4-1o >11 accepted

Total . . . . . . . (154) % 43 31 16 8 5.0

Specialty

General practice . . . . .

Family practice . . . . . . .

Obstetrics/gynecolog y

Urolog y

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

( 2)

( 19)

(101)

( 28)

( 4)

%

%

%

%

%

100

72

32

70

50

16

36

20

25

0

21

0

25

4

11

0

0

1.0

6 5

1.4

2.5

Practice

office-base d

Hospital-base d

17

0

7

33

(136)

( 16)

%

%

44

42

31

25

4 0

17.8

Age

Under 35

35 to 49

50 or olde r

( 26)

( 82)

( 43)

46

43

45

31

36

25

15

15

18

3 4

5 8

4,6

%

%

%

4

8

12

sex

Mal e

Femal e

(132)

( 21)

44

39

30

39

16

13

8

9

4.7

6.8

%

%

a The sample is the cross-sectional sample

b The code number of the question in the survey instrument (see app. B)

c Percentages are presented as weighted sample estimates. The unweighted sample base IS presented in parentheses so that the sampling variance for these estimates can be

calculated

SOURCE Office of Technology Assessment, 1988

Table 2-8.– Patients Accepted for Artificial insemination, by Physician specialty”

(Question 2b):b How many patients have you accepted for artificial insemination, with either husband or donor sperm, in the past 12

months?

Base: Cross-sectional sample physicians responding to survey

Unweighed

basec None 1-3 4-10 >11

Total (827) % 90.1 5.4 2.8 14

General practice . (162) % 100,0 0 0 0

Family practice (236) % 98.0 13 0 3

Obstetrics/gynecology . (196) % 648 188 10.9 5 4

Urology (199) % 95.6 2.9 0 0

Other ., ( 34) % 94,1 2.9 2 9 0

a The sample is the cross-sectional sample

bThe code number of the question in the survey instrument (see app. B)

c percentages are presented as weighted sample estimates. The unweighted sample base is presented in parentheses so that the sampling Variance for these estimates can be

calculated

SOURCE: Office of Technology Assessment, 1988
20

Table 2-9. -Population Estimate of Number of Physicians Conducting Artificlal Inseminatlona

Percentage Estimated number of

having accepted practitioners offering

Population a patient for artificial artificial

Specialty size insemination insemination

General practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25,807 0 0

Family practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43,221 1.64 709

Obstetrics/gynecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28,511 35.15 10,022

Urology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8,944 2.94

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10,994

aThe sample is the cross-sectional sample

SOURCE: Office of Technology Assessment, 1988

ARTIFICIAL INSEMINATION PRACTITIONERS

The cross-sectional survey found that 4l percent of all physicians who conduct artificial insemination report that they belong to a national

fertility society, and nearly all physicians who

perform more than 10 inseminations a year (92

percent) belong to such a professional organization. This population of fertility society members

treat the majority (75 percent) of the 172,000 recipients of artificial insemination. Furthermore,

the incidence of artificial insemination practice

among practitioners surveyed in the general

cross-sectional sample was too low to generate

enough respondents with large artificial insemination practices for useful data. Therefore, a

national probability sample of members of a fertility society who are likely to do a great deal of

artificial insemination was developed (see

app. A).

In 1985-86, the American Fertility Society

(AFS) surveyed its members to identify those

who offer artificial insemination, even on an occasional basis, although it did not distinguish between AIH and AID. The AFS members responding that they offer artificial insemination,

plus the entire membership list of the American

Andrology Society, provided the sampling frame

here called the “fertility society sample” (table

2-10). Within this sample, a number of physicians reported that they have accepted four or

more women for artificial insemination in the

Table 2-10. - Profiles of the Samples

Fertility

society

samplea

Unweighed base:c(646)

Crosssectional

sample b

(827)

%

Specialty

General practice . . . . . . . . . . . . . . . . . . . 0

Family practice . . . . . . . . . . . . . . . . . . . . <0.5

Obstetrician/gynecologist . . . . . . . . . . . 80

Urology . . . . . . . . . . . . . . . . . . . . . . . . . . 6

other . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Practice

Office-based . . . . . . . . . . . . . . . . . . . . . . 82

Hospital-based , . . . . . . . . . . . . . . . . . . . 17

Age

Under 35. . . . . . . . . . . . . . . . . . . . . . . . . 6

35 to 49. ...., ., . . . . . . . . . . . . . . ., . . 57

50 or older . . . . . . . . . . . . . . . . . . . . . . . 36

Sex

Male , ... , . . . . . . . . . . . . . . . . . . . . . . . 92

Female . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Currently member of a

fertility society

Yes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

No . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

%

27

37

24

8

4

68

11

16

37

45

90

9

11

65

a The fertility society sample is drawn from the total membership of the American Society of Andrology and from a subset of the membership of the American Fertility

Society who had responded to a previous survey that they do offer artificial insemination services.

b The cross-sectional sample is drawn from American Medical Association lists of

Physicians identifying themselves as in general practice, family practice, obstetrics/

gynecology, and urology

c Percentages are presented as weighted sample estimates The unweighted sample

base is presented in parentheses so that the sampling variance for these estimates

can be calculated

SOURCE: Office of Technology Assessment, 1988

past year. These physicians are referred to as

“regularly doing artificial insemination.”
21

Ninety-five percent of the physicians in the

fertility society sample report that they provide

infertility services as part of their practice and

have accepted patients in the last year (table

2-11). The remaining 5 percent tend to be researchers. On average, these physicians treat approximately 168 patients per year for infertility.

There is relatively little difference in the average

number of infertility patients seen per year by

obstetrician/gynecologists (145) and urologists

(162). Hospital-based physicians with infertility

practices see more patients about infertility

problems per year (262) than do office-based

physicians (151).

Specialists in reproductive endocrinology and

infertility, who constitute the “other” category in

table 2-11, however, see about twice as many patients for infertility problems per year (335).

These specialists also handle a relatively large

proportion of inseminations - on average annually 107 (table 2-12) - and represent nearly 36

percent of the total number of artificial inseminations conducted each year by fertility society

members.

Table 2-11 .- Patients Treated for Infertility’

(Question 1b):b In the past 12 months, approximately how many patients have you treated for infertility problems?

Base: Would provide infertility services

Unweighed Mean no.

basec None 1-10 11-20 21-50 >50 treated

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . (620) % 5 5 11 26 53 167,7

Specialty

Obstetrics/gynecology . . . . . . . . . . . . (520) % 5 4 11 30 50 144,6

Urology . . . . . . . . . . . . . . . . . . . . . . . . ( 31) % 3 9 21 12 53 161.6

Other . . . . . . . . . . . . . . . . . . . . . . . . . . ( 69) % 4 7 4 8 73 335,2

Practice

Office-based . . . . . . . . . . . . . . . . . . . . (522) % 5 4 12 29 50 151.0

Hospital-based . . . . . . . . . . . , . . . . . . ( 92) % 2 8 6 11 71 262.2

a The sample is the fertility society sample

bThe code number of the question in the survey instrument (sea app. B)

c Percentages are presented as weighted sample estimates. The unweighted sample base is presented in parentheses so that the sampling Variance for these estimates can be

calculated. Unweighted sample base does not add to 620 where physicians failed to respond to particular question concerning demographic characteristic

SOURCE: Office of Technology Assessment, 1988

Table 2-12. - Inseminations During Past Year ●

(Question 2b):b How many patients have you accepted for artificial insemination, with either husband or donor sperm, in the past twelve

months?

Base: Have received requests in past twelve months

Unweighed Mean no.

basec None 1-3 4-1o 11-50 >50 accepted

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (550) % 11 22 21 31 15 34.0

Specialty

OB/GYNd . . . . . . . . . . . . . . . . . . . . . . . . (470) % 9 26 23 30 12 25.2

Urology . . . . . . . . . . . . . . . . . . . . . . . . . ( 18) % 63 – 5 32 - 7.9

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 62) % 10 3 10 33 43 106.7

Practice

Office-based . . . . . . . . . . . . . . . . . . . . . (463) % 11 25 22 30 13 30.8

Hospital-based . . . . . . . . . . . . . . . . . . . ( 16) % 11 7 14 37 31 52.9

a The sample is the fertility society sample

bThe code number of the question in the survey instrument (sea app. B) C Percentages and means are presented as weighted sample estimates. The unweighted sample base iS presented in parentheses so that the sampling variance for these estimates

can be calculated

d Obstetncs/gynecology

SOURCE: Office of Technology Assessment, 1988
22

FERTILITY SERVICES

The physicians from the fertility society sample who treat infertility problems would normally

offer fertility drug therapy (97 percent) and surgical therapy (90 percent) (table 2-13). They differ from the cross-sectional fertility practitioners

in that 85 percent have received requests for artificial insemination, and most would offer the

service: 85 percent would perform AIH and 62

percent would perform AID. (This is a product of

the sample selection, as the sampling frame was

based in large part on AFS members who reportedly perform artificial insemination.)

A number of these fertility society members

also offer less common forms of infertility treatment, such as in vitro fertilization (19 percent) or

gamete intrafallopian transfer (20 percent).

These treatments are found more commonly

among endocrinologists and those reporting

themselves as “infertility specialists” than in the

general population of urologists and obstetrician/gynecologists.

Although these forms of infertility treatment

are comparatively rare, even among specialists,

the survey suggests that based upon an estimated

population of 10,994 members of fertility societies (96 percent of whom provide infertility services or treatment), on the order of 2,111 physicians would perform gamete intrafallopian

transfer, 2,005 would perform in vitro fertilization or embryo transfer, and 528 would arrange

surrogate mother matches.

Table 2-13. -Types of Infertility Treatment*

(Question 1c):bWhich of the following types of infertility therapies would you perform as part of your practice?

Base: Would provide infertility servicesc

Specialty Sample

American

Obstetrics/ fertility Andrology

Total gynecology Urology Other society society

Unweighed base:d(620) (520) (31) (69) (561) (59)

% % % % % %

Fertility drug therapy . . . . . . . . . . . . . . . . . . . . 97 98 91 93 98 88

Surgical therapy . . . . . . . . . . . . . . . . . . . . . . . 90 95 91 55 93 65

Artificial insemination by husband . . . . . . . . . 85 90 24 82 90 47

Artificial insemination by donor . . . . . . . . . . . 62 65 15 68 66 38

In vitro fertilization/embryo transfer . . . . . . . . 19 16 3 44 19 17

Gamete intrafallopian transfer . . . . . . . . . . . . 20 18 3 38 20 15

Surrogate mother matching . . . . . . . . . . . . . . 5 6 0 6 6 2

a The sample is thw fertility society sample.

b The code number of the question in the survey instrument (see app. B)

c Since multiple choices were permitted, percentages may add to more than 100%. d Percentages are presented as weighted sample estimates. The unweighted sample base is presented in parentheses so that the sampling variance for these estimates can be

calculated

SOURCE: Office of Technology Assessment, 1988
23

REASONS FOR SEEKING ARTIFICIAL INSEMINATION

Nearly all women who request artificial insemination report to their physicians that they

are married (92 percent) or living as a couple

with a man (2 percent) (table 2–14). Even practices in which at least 75 percent of the inseminations use donor semen report that 92.5 percent of

the women present themselves as married or living with a man.

Requests also come from women identifying

themselves as without partners (3 percent) or as

part of a lesbian couple (1 percent), which translates into approximately 4,000 requests from single women and 1,000 requests from lesbian couples being received during a 12-month period in

1986-87.

For patients seeking AIH or AID, male partner infertility is the primary reason for the request (table 2-15). Physicians doing mostly AIH

as well as those primarily doing AID report that

about 8 out of 10 requests for treatment are due

to male infertility.

Other problems with the male partner that led

to artificial insemination in the past year include:

impotence (3 percent); genetic disorders (3 percent); exposure to mutagens (0.4 percent); Rh incompatibility (0.2 percent); and sexually transmitted disease (0.2 percent).

Fewer than 4 percent of the women accepted

for artificial insemination in the past year stated

that they sought insemination because of the lack

of a male partner. Even among physicians whose

practice is primarily (75 percent or more) AID,

fewer than 5 percent of the women stated that

they sought insemination because of the lack of a

male partner. None of the physicians reported

accepting cases in the past year when patients

requested artificial insemination to obtain children with desired characteristics. Overall, those

currently seeking and obtaining artificial insemination, with a few exceptions, identify

themselves as married couples with a male reproductive problem, primarily male infertility.

Table 2-14. -Types of Patientsa

(Question 4a):b What proportion of the patients who have requested artificial insemination in the past year were:

Base: Have accepted 4 or more patients for artificial insemination in the past year

Proportion AIH c

Total 100% 99-75% 74-25% 24-0%

Unweighed base:d

(367) (61) (70) (144) (91)

% % % % %

Married couples . . . . . . . . . . 92.2 97.8 94.1 90.7 90,7

Women without a partner . . ... . . . . 2.9 0.4 2.3 3.2 4.6

Unmarried couples (heterosexual) . . . . . ., . . . . 2.2 1.9 2.7 2.2 1.8

Unmarried couples (lesbian) . . . . . . . . . . . 0.7 0.2 0.8 1.0 0.6

Don’t know marital status . . . . . . . . . . . ., . . 0.7 0 0.6 1.2 0.4

a The sample IS the fertility society sample.

b The code number of the question m the survey instrument (see app. B)

c "Proportion AIH” means the proportion of the physician’s artificial insemination practice in the past 12 months in which husband or partner sperm (rather than donor sperm) was

used d percentages are presented as weighted sample estimates. The unweighted sample base is presented in parentheses so that the sampling variance for these estimates can be

calculated

SOURCE. Office of Technology Assessment, 1988
24

Table 2-15. - Reasons for Seeklng Inseminatlona

(Question 4b):b What proportion of the patients whom you accepted for artificial insemination in the past year sought artificial insemination

because of:

Base: Have accepted 4 or more patients for artificial insemination in the past year

Proportion AIH c

Total 100% 99-75% 74-25% 24-0%-

Unweighted base: d(367) (61) (70) (144) (91)

%

Infertility of male partner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81.4

No male partner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.7

Impotence of male partner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3

Genetic disorder of male partner . . . . . . . . . . . . . . . . . . . . . . . . . 3.1

Exposure of male partner to mutagens . . . . . . . . . . . . . . . . . . . . 0.4

Rh incompatibility of male partner . . . . . . . . . . . . . . . . . . . . . . . . 0.2

Male partner has sexually transmitted disease . . . . . . . . . . . . . . 0.2

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.8

%

78.0

0.1

3.6

1.5

0

0

0

17.2

%

84.1

3.3

2.6

1.7

0.3

0.5

0.2

7.7

%

80.5

4.7

3.9

2.9

0.3

0.1

0 3

5.8

%

83.7

4.9

2.7

5.4

0.8

0.4

0.3

0.9

a The sample IS the fertility society sample.

b The code number of the question in the survey instrument (see app. B).

c “Proportion AlH” means the proportion of the physician’s artificial insemination practice in the past 12 months in which husband or partner sperm (rather than donor sperm) was

calculated

SOURCE: Office of Technology Assessment, 1988

ARTIFICIAL INSEMINATION BY HUSBAND V. DONOR

Artificial insemination by husband (or partner) currently represents about half of all inseminations being done in the United States, although relatively few practitioners offer only this

procedure. Among those regularly doing artificial insemination (i.e., four or more patients per

year), 15 percent restricted themselves to AIH.

The remaining 85 percent conduct a mixed practice, doing both AIH and AID.

Practitioners who do only AIH tend to have

smaller practices. Sixty percent of the physicians

who do inseminations only with husbands’ or

partners’ semen have treated 4 to 10 insemination patients in the past year. Nearly all of the remaining 40 percent did 50 or fewer inseminations in the past year.

RECIPIENT SCREENING

General Screening Requirements

Prior to accepting a woman for insemination,

the majority of physicians who regularly provide

artificial insemination (i.e., accept four or more

patients per year) will screen for indications of

infertility (99 percent), obtain a medical history

(98 percent), perform a physical examination

(96 percent), test for disease that might affect a

developing fetus (74 percent), and do a personality assessment (52 percent). Forty-four percent

will also do some special screening for genetic

defects, and 6 percent will do a karyotype (table

2-16).

Personality Assessments

The likelihood of requiring a personality assessment increases with the size of a physician’s

artificial insemination practice, changing from 48

percent of those seeing 4 to 10 insemination pa-
25

Table 2-16.-Types of General Screening: Recipient.

(Question 5):b Prior to accepting a patient for artificial insemination, do you normally require that the patient undergo/provide:

Base: Have accepted 4 or more patients for artificial insemination in the past year

Unweighed base (367) cInappropriate

Yes No response

Fertility history ... ... . . . . . . . . . . . . . . . . . . % 99 1 1

Personal medical history ... . . . . . . . . . . . . . . . . . . % 98 1 1

Physical examination ... ., ., . . . . . . . . . . . . . . . . . . % 96 1 3

Family medical and genetic history . . . . . . . . . . . . . . . . % 93 5 2

Personality assessment . . . . . . . . % 52 43 5

Karyotyping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . % 6 87 7

Screening for genetic disease (high risk groups) . . % 44 53 2

Diagnostic tests for selected diseases . . . . . . . . . . . . % 74 22 4

a The sample is the fertility society sample.

b The code number of the question in the survey instrument (see app. B).

c Percentages are presented as weighted sample estimates. The unweighted sample base IS presented in parentheses so that the sampling variance for these estimates can be

calculated

SOURCE: Office of Technology Assessment, 1988

tients per year, to approximately 53 percent of

those with 11 to 50 insemination patients per

year, to 61 percent of those with 100 or more. By

contrast, there is relatively little variation by size

of practice for most of the other general screening procedures (medical history, family history,

fertility history, and physical examination). The

survey instrument did not specify the type of personality assessment used. The nature of the “personality assessments” may vary from an interview and individual physician assessment to use

of standardized psychological examinations.

Further, the assessments could be used to detect

diagnosable mental illness or to address more

general considerations of fitness for pregnancy

and motherhood (Mikesell, 1988).

Physicians with office-based practices are

roughly as likely as those with hospital-based

practices to require such an assessment (table

2-17). Personality assessments are somewhat

less common, although still widely used, among

physicians who perform only AIH (38 percent)

compared with those performing mainly AID

(54-59 percent). Young physicians (29 percent)

and female physicians (39 percent) are less

likely than older (60 percent) and male physicians (53 percent) to require personality assessment prior to acceptance (table 2-17). However,

the sample size of physicians who are female or

Table 2-17.– Recipient Personality Assessment,

by Physician Characteristics”

(Question 5): b Prior to accepting a patient for artificial insemination, do you normally require that the patient undergo/provide:

Base: Have accepted 4ormore patients for artificial insemination

in the past year

Unweighed Not

basec Yes No applicable

Total (367)

Age

Under 35 . ( 21)

35 to 49 (221)

50 or over (121)

sex

Male (339)

Female ( 28)

Practice

Office ., (296)

Hospital ( 66)

Proportion AIHd

100% ( 61)

75-99% ( 70)

25-74% (144)

O-24% ( 91)

%

%

%

%

%

%

%

%

%

%

%

%

52 43

29 71

51 46

60 32

53 42

39 54

53 41

51 48

38 50

55 44

54 44

59 38

5

0

3

8

5

7

6

. —

13

3

2

4

a The sample is the fertility society sample.

b The code number of the question in the survey Instrument (see app. B).

c Percentages are presented as weighted sample estimates The unweighted sample

base is presented in parentheses so that the sampling variance for these estimates

can be calculated. Unweighted sample base does not add to 367 where physicians

failed to respond to particular question concerning demographic characteristic

d "Proportion AIH" means the proportion of the physician’s artificial insemination

practice in the past 12 months in which husband or partner sperm (rather than donor

sperm) was used

SOURCE: Office of Technology Assessment, 1988
26

under 35 on which this figure is based is quite

low.

Genetic Screening

Twenty-eight percent of the physicians regularly doing artificial insemination indicate that

a family history of genetic disease would lead

them to require genetic screening of a potential

insemination recipient, and 7 percent would require screening of a patient whose reproductive

history was consistent with an underlying genetic

problem. As noted, 6 percent required karyotyping prior to accepting a recipient. Hence, genetic

testing is far from routine for insemination patients, even those in higher than average risk

groups (table 2-18).

Special screening for genetic diseases is more

common among hospital-based practitioners (53

percent) than among office-based ones (42 percent), and the likelihood increases with the size

Table 2-18. –Circumstances Requiring Genetic

Screening: Recipient

(Question 6b):b Under what circumstances do you require special screening for genetic defects or diseases? (verbatim)

Base: Have accepted 4 or more patients for artificial insemination

in the past year

All physicians Physicians

doing doing some

inseminations screening

Unweighed base:C

(367) (162)

Family history of genetic

diseases or defects

Membership in high risk . . . . . . .

ethnic group

Personal medical history . .

(no reference to fertility)

Fertility history/reproductive

problems (menstrual

problems/spontaneous

abortions/stillbirths)

Infectious diseases . . . . . . . . .

Age . . . . . . . . . . . . . . . . . . . .

Other . . . . . . . . . . . . . .

13

9

7

3

1

2

%

63

29

20

17

8

3

6

a The sample is the fertility society sample.

bThe code number of the question in the survey instrument (see app. B).

c Percentages are presented as weighted sample estimates. The unweighted sample

base IS presented in parentheses so that the sampling variance for these estimates

can be calculated

d Since multiple choices were permitted, percentages may add to more than 100%

SOURCE: Office of Technology Assessment, 1988

of the practice, from 34 percent of those with 4 to

10 patients per year to 63 percent of those seeing

more than 50 a year. Few tests are available for

genetic screening at this time, and special screening beyond oral family histories may be largely

restricted to karyotyping for chromosomal defects and testing for a select group of disorders

such as Tay-Sachs disease, sickle cell anemia,

thalassemia, and so on.

Physicians who do AIH only are less likely (32

percent) than are those who also do AID (46-48

percent) to screen recipients for genetic diseases,

although there is no difference in the risk of genetic disease. As with personality assessments,

younger doctors (43 percent) are less likely than

older ones (52 percent) to use genetic screening,

and female physicians (39 percent) less likely

than male physicians (45 percent), although the

differences are not as striking.

Other Diagnostic Tests

A majority of physicians regularly doing artificial insemination (74 percent) require other diagnostic tests of recipients prior to accepting

them for insemination, with hospital-based physicians again more likely (80 percent) than office-based physicians (73 percent) to require

tests. The likelihood also increases with the size

of the physician’s artificial insemination practice,

from 69 percent for those accepting 4 to 10 patients per year to 76 to 78 percent for those accepting more than 10. There is no real difference

in the use of diagnostic tests between physicians

doing AID (70 percent) and those exclusively doing AIH (72 percent) (table 2-19).

The diagnostic screening most often required

by physicians doing artificial insemination is that

for infertility (47 percent), by taking a fertility

history or doing one of the many tests required

for an infertility workup (U.S. Congress, 1988).

The most commonly reported tests for infectious

diseases were those for human immunodeficiency virus (HIV) antibodies (10 percent),

chlamydia (9 percent), rubella (9 percent), gonorrhea (7 percent), syphilis (6 percent), hepatitis

(4 percent), cytomegalovirus (3 percent), and

herpes (1 percent) (table 2-21). In addition, 5

percent of physicians who conduct artificial insemination report testing for unspecified sexu-
2 7

ally transmitted diseases and 1 percent for other

infectious diseases.

Table 2-19.-Diagnostic Tests: Recipients.

(Question 6c):b Do you require any other diagnostic tests

of potential recipients, prior to accepting them for artificial

insemination?

Base: Have accepted 4 or more patients for atificiai insemination

in the past year

Unweighed Not

basec Yes No applicable

Total . . . (367)

Al patients/past year

4-10 . . . . . . (115)

11-50 .., . . (169)

51-100 ( 47)

>100 . ( 36)

Proportion AIH d

100% . . . . . . ( 61)

75-9996 . . . . ( 70)

25-74% (144)

O-24% ( 91)

Practice

Office . . . (296)

Hospital .,. ( 66)

%

%

%

%

%

%

%

%

%

%

%

74 22

69 27

76 22

78 15

78 14

72 28

77 22

77 18

70 23

73 23

80 17

4

4

2

9

8

2

2

5

7

4

3

a The sample is the fertility society sample.

b The code number of the question is the survey instrument (see app. B).

c Percentage are presented as weighted sample estimates. The unweighted sample

base is presented in parentheses so that the sampling variance for these estimates

can be calculated. Unweighted sample base does not add to 367 where physicians

failed to respond to particular question concerning demographic characteristic d "Proportion AIH" means the propostion of the physician's artificial insemination

practice in the past 12 months in which husband or partner sperm (rather than donor

sperm) was used

SOURCE: Office of Technology Assessment, 1988

Correlation of Past Patient Rejection

With Patient Characteristics

Four out of five patients who request artificial

insemination are accepted. The remaining 20

percent are rejected for a variety of medical and

nonmedical reasons (table 2–20). The most common reason that requests have been rejected are

that the patient is unsuitable for nonmedical

reasons: she is unmarried (52 percent), psychologically immature (22 percent), homosexual (15

percent), or welfare-dependent (15 percent) (table 2-22). Other reasons include evidence of

child abuse (13 percent), drug abuse (11 percent), or alcohol abuse (10 percent). About 1 in

20 practitioners report rejecting applicants because of a prior criminal record. These rates are

similar for physicians doing AIH only and those

doing mostly AID.

Table 2-20.-Reasons for Rejecting Recipients.

(Question 3b): b Could you describe the main reason(s) that you

did not accept certain requests for artificial insemination? (verbatim)

Base: Accepted 4 or more patients for artificial insemination in the

past year and rejected a request for artificial insemination

Number of

Total recipients rejected

1-4

Unweighed base: c

(190) (68)

Inappropriate recipient (NET) . . . . .

Too old/over 40 . . . . . . . . . . . . . .

Single. . . . . . . . . . . . . . . . . . . . . .

Unmarried . . . . . . . . . . . . . . . . . .

Lesbian/homosexual . . . . . . . . . .

Emotionally unstable. . . . . . . . .

Inappropriate unspec. . . . . . . . . .

Not medically indicated (NET) . . .

No male factor problem . . . . . . .

Fernal factor problem . . . . . . . .

Male sperm too poor for AIH . .

Not indicated unspec.) . .

Will only do AIHd 

. . . . . . . . . . . . .

Inappropriate couple (NET) . . . .

Unstable marriage . .

Financial/economic . . . . . .

Not suitable parent s

Not ready . . . . . . . . . . .

Lack of qualified donors

Inappropriate donor (NET)

Too closely relate d

Semen not suitable . .

Donor emotionally unstable . . .

Other donor characteristics

Medical risks (NET) . . . . . . . . . .

Risk of HIV infectio n

Risk of venereal disease . . . . .

Medical risks (unspec.)

Inadequate recipient understand.

Recipient changed mind

Husband did not agre e

Recipient refused counseling

Lack of facilities .

Not area of expertise ., .

Personal objection to artificial

inseminatio n

Fear of litigation .,

Other . . . . . . . . . . . . . . . . . . . . . ...

Not reported . . . . . . . . . . . .

%d

42

5

20

13

7

5

4

31

3

6

8

16

16

10

5

2

2

1

7

7

4

1

1

2

6

4

2

1

5

3

2

2

2

1

1

> 0 5

4

7

%

49

4

21

16

9

8

3

16

2

3

3

9

16

10

6

2

2

2

9

3

3

0

0

0

4

3

2

2

10

2

0

3

2

3

3

0

2

4

%

38

5

20

12

6

3

5

38

4

8

10

19

15

9

5

2

2

1

6

8

4

2

2

4

7

5

2

1

2

4

4

2

2

0

0

1

5

8

a

The sample si the fertility society sample

b The code number of the question in the survey instrument (sea app. B)

cPercentage are presented as weighiad sample estimates. The unweighted sample

base iS presented in parentheses so that the sampling variance for these estimates can

d be calculated

Since multiple choices were permltted, percentages may add 10 more than 100%

SOURCE: Office of Technology Assessment, 1988

Nearly one-third of physicians who have

rejected a request gave a medical justification:

femnale infertility (6 percent), husband/partner
28

Table 2-21 .–Types of Diagnostic Tests: Recipients’

(Questions 6d, 6e):b Which diagnostic tests do you require? (verbatim)

Base: Have accepted 4 or more patients for artificial insemination in the past year

All physicians Physicians doing

doing inseminations diagnostic testing

In all In some In all In some

cases cases cases cases

Unweighed base: c

(367) (367) (271) (271)

%

d

% % %

Infertility tests (NET) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 38 63 52

Blood type/rh factor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 3 23 4

AIDS (HIV) testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 4 13 6

Urethral culture for chlamydia . . . . . . . . . . . . . . . . . . . . . . . . . . 9 2 12 3

Rubella antibody . . . . . . . . . . . . . . . . . . . . . . . 9 <0,5 12 < 0 5

GC culture . . . . . . . 7 2 10 3

Syphilis testing (VDRI/RPR) . . . .. 6 1 8 1

Pap smear . . . . . . . . . . . . 6 < 0 5 8 <0,5

Sexually transmitted diseases . . . . . . . . . . . . . . . . . . . . 5 1 7 2

Routine blood screen analysis . . . . . . . . . . . . . . . . 5 1 7 2

Hepatitis serum. . . . . . . . . . . . . . . . . . . . . . 4 1 6 2

NGU/Ureaplasma/Mycoplasma test . . . . . . . . . . . . . . . . . . . . . . . 4 1 5 2

Cytomegalovirus . . . . . . . 3 1 4 1

Physical exam and history . . . . . . . 2 1 3 2

Semen mucus interaction . . . . . . . . . . . . . 2 3 3 4

Herpes culture . . . . . . . . . . . . 1 1 2 1

Urinalysis . . . . . . . . . . . . . 1 0 1 0

Thyroid panel . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 1 2

Other infectious disease . . . . . . . . . . 1 1 1 1

Karyotyping . . . . . . . . . . . . . . . . . . . . . . 1 2 1 3

Inheritable disease . . . . . . . . . . . . . . . . . . 1 2 1 3

Genetic screening.. . . 0 1 0 2

Inappropriate response . . . . . . . . 13 4 18 6

No answer . . . . . . . . . . . . . . . . . . . . . . . . . 6 22 8 30

a

The sample is the fertilty society sample

The code number of The question in the survey instrument (see app. B).

c Percentages are presented as weighted sample estimates The unweighted sample bases presented parentheses so that the sampling vatiance for these estimates can be

calculated.

dSince multiple choices were permitted, percentages may add to more than 100%

SOURCE. Office of Technology Assessment, 1988

semen too poor for AIH (8 percent), or in general finding that the procedure was not medically

indicated (16 percent).

Physicians have also rejected potential recipients becausc they evidenced HIV antibodies (7

percent), syphilis (6 percent), gonorrhea (4 percent), genital herpes (3 percent), cytomegalovirus (2 percent), hepatitis (2 percent), and

chlamydia (1 percent). Ten percent have rejected patients because of histories of serious

genetic disorders.Eight percent have done so because of medical risks from pregnancy, and percent because the applicant was over 40.

Correlation of Likelihood of Rejection

With Patient Characteristics

The incidence of past rejection ofpatientswith

certain types of characteristics may be misleading because some physicians may never have had

contact with a potential recipient with such characteristics. Therefore, the physicians were asked

for which recipient characteristics they “had rejected’’ or "would be likely to reject”a request

for artificial insemination (table 2-22)

Fewer than half the physicians regularly doing

artificial insemination have rejected or would be

likely to reject a patient despite evidence of an
29

Table 2-22.-Criteria for Rejection: Recipients.

(Question 7):b Have you ever rejected or would you be Iikely to reject a request for artificial insemination from a potential recipient because

she was/has:

Base: Have accepted 4 or more patients for artificial insemination in the past year

Unweighed base (367) c Would be Not

Have likely to likely to Not

rejected reject reject applicable

Unmarried without a partner ., ., . . . . . . . . . . . . . . . . . % 32 29 37 2

Psychologically immature . . . . . . . . . . . . . . . . . . . . . . . . % 22 63 12 3

Unmarried with a partner . . . . . . . . . . . . . . . . . . . . . . . % 20 29 49 2

Homosexual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . % 15 48 33 4

Welfare dependent : ., . . . . . . . . . . . . . . . . . . . . . . . % 15 39 41 5

Evidence of child abuse . . . . . . . . . . . . . . . . . % 13 82 3 2

Evidence of drug abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . % 11 79 8 2

Evidence of alcohol abuse . . . . . . . . . . . . . . . . % 10 79 9 2

History of serious genetic disorders . . . % 10 69 17 5

Over 40 years old . . . . . . . . . . . . . . . . . . % 9 26 62 3

Medical risks from pregnancy . . . . . . . . . . . . . % 8 46 41 5

HIV (HTLV) positive . . . . . % 7 88 2 2

Syphilis % 6 46 44 4

Less than 18 years old .: . ::: : “::’:::::::::: % 6 64 27 3

Gonorrhea % 4 34 59 3

Criminal record . ::.: : :::..:: ::,::::’: % 4 49 40 7

Genital herpes . . . . . . . % 3 15 78 3

Less than average intelligence . . . . . . . . . . . . . . . . . . . . . . % 3 29 62 6

Hepatitis . . . . . . % 2 36 58 4

Cytomegalovirus : ..... % 2 28 65 5

Chlamydia . . . . . . . % 1 16 78 4

Less than high school degree . . . . . . . . . . . % 1 8 87 4

Other living children % < 0 5

Prior miscarriage

3 94 2

. . . . . . . . . . . . . . . % < 0 5 3 94 3

a The sample IS the fertility society sample

b The code number of the question in the survey instrument (see app. B).

c Percentages are presented as weighied sample estimates. The unweighted sample base IS presented m parentheses so that the sampling variance for these estimates can be

calculated

SOURCE Offce of Technology Assessment, 1988

infectious disease, including genital herpes (18

percent), chlamydia (17 percent), cytomegalovirus (30 percent), gonorrhea (38 percent), or

hepatitis (38 percent). Fifty-two percent have rejected or would be likely to reject a patient with

syphilis. It should be noted that the physicians responding to this question frequently qualified

their answers on the basis of the state of the disease.

Physicians were evenly divided on whether

they would (49 percent) or would not (49 percent) he likely to reject an unmarried recipient

with a partner. If the unmarried recipient does

not have a partner, the proportion of physicians

who have rejected or would be likely to reject the

patient rises to 61 percent. If the patient is homosexual, presumably in addition to being unmarried and without a male partner, the number increases to 63 percent of the surveyed fertility

society physicians regularly doing artificial insemination.

Other recipients whom more than half the

physicians have rejected or would be likely to reject include those with a criminal record (53 percent) or welfare dependence (54 percent). Those

with AIH-only practices stated less frequently

(52 percent) than those with predominantly AID

practices (30 percent) that they have or likely

would reject a recipient with a criminal record.

Sperm banks report rarely, if ever, rejecting a

man who requests semen storage for future AIH

use, despite a history of these characteristics

(see ch. 3).

Seventy-nine percent of the physicians are

likely to reject or have already rejected a recipient because she has a history of serious genetic
30

disorders that might affect the resulting child. In

contrast, 54 percent have rejected or would be

likely to reject an applicant because of medical

risks to herself associated with being pregnant.

Most of those who conduct artificial insemination on a regular basis have already rejected or

would be likely to reject a patient who is a minor

(70 percent), psychologically immature (85 percent), or evidenced alcohol abuse (89 percent),

drug abuse (90 percent), child abuse (95 percent), or HIV antibodies (95 percent).

The age and sex of the physician are correlated

with some aspects of recipient rejection (table

2-23). For example, physicians over age 50 are

more likely than those under age 35 to have rejected or to state they would reject an unmarried,

homosexual, or welfare-dependent recipient.

They are also more likely to reject a recipient

with a sexually transmitted disease, a history of

serious genetic disorders, a criminal record, or

infection with HIV. In general, physicians over

the age of 50 are more likely than those under

the age of 35 to have rejected or state they would

reject an applicant for artificial insemination,

whether on medical or nonmedical grounds. This

does not appear to be an artifact of the physician

population, in which there are relatively more

young physicians who are female and older physicians who are male, as with the exception of recipient homosexuality and infection with certain

sexually transmitted diseases, male physicians

are less likely than female physicians to have reTable 2-23.-Acceptabiiity of Recipient Characteristics, by Age and Sex of Physicians.

(Question 7):b Have you ever rejected or would you be likely to reject a request for artificial insemination from a potential recipient because

she was/has:

Base: Have accepted 4 or more patients for artificial insemination in the past year

Not Iikely to reject

Age sex

Under 35 35 to 49 Male Female

Unweighed base:c(21) (221) (339) (28)

%

Less than 18 years old . . . . . . . . . . . . . . . . . . 19

Welfare dependent . . . . . . . . . . . . . 57

Psychologically immature . . . . . . . . . . . . 19

Unmarried with a partner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Unmarried without a partner . . . . . . . . . . . . . . . . . . . . . . 43

Less than high school degree . . . . . . . . . . . . . 100

Less than average intelligence . . . . . . . . . . . . . . . 81

Criminal record . . . . . . . . . . . . . . . . . . . . 52

Homosexual ... . 52

Other living children . . . . . . . . . . . . . . 100

Evidence of alcohol abuse . . . 0

Evidence of child abuse . . . . . . . . . . . . . . . . . . . . . . 5

Over 40 years old . . . . . . . . . . . . . . . . . . . . 71

Prior miscarriage . . . . . . . . . 100

Medical risks from pregnancy . . . . . . . . . 52

History of serious genetic disorders . 33

Syphilis . . . . . . . . 62

Gonorrhea . . . . . . 71

Genital herpes . . . . 90

Cytomegalovirus . . . . . . . . . . . . . . 71

Chlamydia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

Hepatitis . . . . . . . . 67

HIV(HTLV) positive . . . . . . . . . . . . . . . . . . 5

%

30

41

14

51

36

88

69

41

33

94

10

3

68

95

44

16

46

59

78

66

76

56

3

%

22

38

8

41

35

83

48

37

30

93

7

2

50

92

36

15

39

59

77

62

80

58

2

%

28

42

12

50

38

87

62

41

32

94

9

3

61

94

42

16

42

58

78

64

77

57

3

%

14

29

14

32

21

86

64

25

39

93

7

0

75

100

39

25

71

75

79

71

86

61

0

a The sample is the fertility society sample.

b The code number of the question in the survey instrument (see app B).

c percentages are presented as wieghted sample estimates. The unweighted sample base is presented in parentheses so that the sampling variance for these estimates can be

calculated. Unweighted sample base does not add to 367 where physicians failed to respond to particular question concerning demographic characteristic

d Items are in order as they appeared on survey Instrument

SOURCE: Office of Technology Assessment, 1988
31

jected or state they would reject applicants for

artificial insemination, either on medical or

nonmedical grounds. This finding must be qualified, however, by noting that there were only 28

PRESENTATION OF

Four out of five physicians (82 percent) routinely present other options to patients seeking

artificial insemination, even though some patients may have come specifically seeking artificial insemination after having considered other

options presented by previous physicians. The alternative most often brought up is adoption (54

percent) (table 2-24). A fourth of artificial insemination practitioners normally present the

option of in vitro fertilization (26 percent). A

smaller proportion discuss gamete intrafallopian

transfer (11 percent), embryo transfer (2 percent), and surrogate motherhood (less than 1

percent). Other options presented include furpractitioners in the sample of female physicians

regularly doing artificial insemination (i.e., four

or more insemination patients per year).

RISKS AND

ther testing

OPTIONS

for male infertility (11 percent),

other forms of correction of male infertility (7

percent), and remaining childless (2 percent).

Options presented by physicians whose practices use only husband or partner semen differ

from those presented by physicians also offering

AID (table 2-24). Adoption is presented routinely in 43 percent of the AIH-only practices,

compared with 57 percent of the predominantly

AID practices. By contrast, in vitro fertilization is

routinely presented in 34 percent of the AIHonly practices, compared with 23 percent of the

predominantly AID practices. The option of

Table 2-24.-Alternatives to lnseminationa

(Question 16):b Which other options do you normally present? (verbatim)

Base: Have accepted 4 or more patients for artificial insemination in the past year

Proportion AIH c

Total 100% 99-75% 74 25% 24-0%

Unweighed base:d

(367) (61) (70) (144) (91)

%

e % % % %

Adoption . . . . . . . . . . . . . . . 54 43 51 59 57

In vitro fertilizatio n 26 34 29 25 23

Further testing for male infertilit y 11 7 9 14 12

Gamete intrafallopian transfer . . . . . . . . . . . . . . . . . . . . . . . . . . 11 22 13 11 3

Other correction for male infertility ., ., . . . . . 7 7 4 6 9

Intrauterine insemination . . . . . . . . . . ., 3 2 3 4 4

Artificial insemination by donor . . . . . . . . . 3 5 6 2 1

Artificial insemination by husand . . . . . . . . . . . . . . . . . . . . . . . . 3 0 4 5 1

Further testing (unspec.) . . . . . . . . . . . 3 7 3 2 3

Remain childless . . . . . . . . . . . . . 2 0 2 2 4

Embryo transfer . . . . . . . . . . . . . . 2 0 2 2 1

Self insemination . . . . . . . . . . . . . . . . . . . . . . 1 0 4 0 1

Further testing for female infertility . . . . . . . . . . . . . . . . . . . . 1 2 2 1 1

Surrogate motherhood . . . . . . . . . . . . . . . . . . . . <0.5 0 0 1 0

All other . . . . . . . . . . . . . . . . . 5 7 6 6 3

It depends . . . . . . . . . . . . . . . . . . . . . 4 2 9 3 4

Not sure . . . . . . . . . . . . . . . . . . . 3 0 3 5 2

a The sample IS the fertility society sample.

b The code number of the question in the survey instrument (see app. B).

c "Proportion AIH” means the proportion of the physician’s artificial insemination practice in the past 12 months in which husband or partner sperm (rather than donor sperm) was

used

d percentage are presented as weighted sampl estimates. The unweighted sample base IS presented in parentheses so that the sampling variance for these estimates can be

calculated.

e Since multiple choices were permitted, percentages may add to more than 100%

SOURCE Office of Technology Assessment, 1988
32

Table 2-25.– Presentation of Risks’

(Question 17a):b Do you routinely present possible risks of artificial insemination to patients who request artificial insemination?

Base: Have accepted 4 or more patients for artificial insemination

in the past year

Unweighed Not

basec Yes No applicable

Total . . (367) % 85 11

Insemination patients/past year

4-10 . (115) % 81 14 1

11-50 . . . . . (169) % 84 11 4

51-100 . . . . ( 47) % 96 6 0

>100 ( 36) % 94 6 0

Proportion AIH d

100 % ( 61) % 62 27 2

75-9996 . . . . ( 70) % 90 4 4

25 74 % (144) % 92 8 1

O-24% ( 91) % 87 11 2

Practice

Office (296) % 86 11 1

Hospital ( 66) % 85 11 3

Age

Under 35 ( 21) % 95 5 0

35 to 49 (221) % 88 2

a The sample IS the fertility society sample

b The code number of the question in the survey instrument (see app. B).

c Percentages are presented as weighted sample estimates. The unweighted sample

base is presented in parentheses so that the sampling variance for these estimates

can be calculated. Unweighted sample base does not add to 367 where physicians

failed to respond to particular question concerning demographic characteristic

d "Proportion AIH” means the proportion of the physician’s artficial insemination

practice in the past 12 months in which husband or partner sperm (rather than donor

sperm) was used

SOURCE Office of Technology Assessment, 1988

gamete intrafallopian transfer follows a similar

pattern. AID is presented as a treatment option

in few of the AIH-only practices (5 percent).

Eighty-five percent of physicians regularly

doing artificial insemination routinely present

its possible risks (table 2-25) – most commonly

infection and normal risks of birth defects, although the likelihood of presenting risks declines

with the physician’s age, from 95 percent of those

under 35 to 79 percent of those 50 or older. Likelihood of presenting risks is also affected by the

size of practice, increasing from 81 percent

among practitioners with 4 to 10 patients per

year to 94 to 96 percent among practitioners with

more than 50 patients per year. Those doing AIH

only are considerably less likely (62 percent) than

those who also do AID (87-92 percent) to disclose risks.

Forty-five percent of the physicians mention

the normal risks of birth defects, 40 percent mention infectious diseases, and 26 percent specifically mention sexually transmitted diseases when

discussing risks, Eight percent routinely mention

the risk of HIV transmission (table 2-26). Risks

discussed also include other normal risks of pregnancy (13 percent), as well as specific risks of

miscarriage (12 percent) and ectopic pregnancy

(4 percent). Multiple pregnancies are presented

as a risk by a few practitioners (2 percent). Far

more, however, present the failure to conceive

(17 percent) as a possible outcome. A relatively

Table 2-26. – Risks of Insemination.

(Question 17b):b Which risks do you normally present?

(verbatim)

Base: Have accepted 4 or more patients for artificial insemination

in the past year

Proportion AIH c

Total 100% 99 75%74-25% 24-O%

Unweighed base:d (367) (61) (70) (144) (91)

%“

Birth defects . . 45

Infection 40

Sexually transmitted

disease ., ., ., ..26

Failure to conceive . . . . 17

Normal risks of pregnancy 13

Miscarriage ., . . . . 12

HIV transmission 8

Ectopic pregnancy 4

Psychological (recipient) 3

Legal complications 3

Allergic reactions 3

Cramps/spasms 2

Hepatitis 2

Multiple pregnancies 2

cost 2

Psychological (husband) 1

Psychological (child) ., 1

Bleeding . . . . . . . . . . . 1

Other . . . ..10

None reported ., . . . . 3

% %

12 54

364 0

15 28

16 22

8 12

5 10

2 10

5 6

0 5

2 2

3 6

2 2

0 2

2 0

0 5

0 2

0 0

0 3

8 7

5 3

%

53

34

31

14

14

15

11

4

4

4

0

2

4

2

1

0

2

1

5

5

%

51

41

28

17

12

15

7

4

7

3

3

3

0

3

1

3

1

0

11

3

a The sample IS the fertility society sample

b The code number of the question in the survey Instrument (see app B)

c “Proportion AIH” means the proportion of the physician’s artificial insemination

practice in the pest 12 months in which husband or partner sperm (rather than donor

d sperm) was used

Percentages are presented as weighted sample estimates. The unweighted sample

e base is presented in parentheses so that the sampling variance for these estimates

can be calculated

Since multiple choices were permitted, percentages may add to more than 100%

SOURCE: Office of Technology Assessment, 1988
33

small proportion of practitioners present psychological complications for the recipient (3 percent), the husband ( 1 percent), or the offspring

(1 percent) as part of the risks normally discussed, and then only in practices doing artificial

insemination by donor.

DONOR SELECTION AND SCREENING

Sources of Donor Semen

Forty-five percent of artificial inseminations

conducted in the preceding year used donor semen; 22 percent of all artificial inseminations

used donor semen from sperm banks and 21 percent used physician-selected donors. AIH, using

husband or partner semen donors, accounted for

almost all the remaining inseminations (54 percent), as AID using semen from recipient-selected donors represented only 1 percent of all

artificial inseminations in the preceding year and

other sources (such as the physician himself)

were reportedly even less common (table 2-27).

General Screening Requirements

Since relatively few physicians who accept four

or more insemination patients a year are engaged exclusively in either AIH (16 percent) or

AID (7 percent), practitioners were asked which

screening procedures they normally required

from donors selected by the recipient (such as

husbands and partners), which they required

from other donors, and which they required from

neither.

Physicians doing artificial insemination by

donor appear to require far less screening for a

donor selected by a recipient than they do for the

recipient herself. Ninety-eight percent of the

practitioners who regularly provide artificial insemination will require a personal medical history of a potential recipient, compared with 43

percent who require it of a recipien--selccted donor (table 2-28). Similarly, fertility screening,

family medical and genetic history, and personality assessments are less frequently required for

recipient-selected donors than they are for the

recipients themselves. Karyotyping, on the other

hand, is more frequently done for these donors

than for the recipients.

Genetic Screening

Approximately half of all physicians engaged

in artificial insemination on a regular basis require special screening for genetic defects or diseases from some donors prior to accepting them

(table 2-29). Even though available biochemical

Table 2-27. – Sources of Sperma

(Question 4d):b In what proportion of artificial insemination was the sperm from:

Base: Have accepted 4 or more patients for artificial insemination in the past year

Proportion AIH c

Total 100% 75 99% 25 74% O-24%

Unweighed base:d

(367) (61) (70) (144) (91)

Mean proportion from:

Husband/partner ., . . . . . . . . . . . . . . . 54.0 100.0 840 489 8 8

Sperm bank ., ... . . . . . . . 22.3 0 9 3 235 455

Donor selected by you (physician) . . . . . . . . . 21.3 0 6 7 258 398

Donor provided by recipient . . . . . . . . . 1.0 0 0 5 10 19

Other e 

. . . . . . . . . . 0.4 0 0 0 8 0 5

a The sample is the fertility society sample.

b The code number of the question in the survey instrument (see app B).

c “Proportion AIH" means the proportion of the physician’s artificial insemination practice in the past 12 months in which husband or partner sperm (rather than donor sperm) was

used

d Means are presented as weighted sample estimates. The unweighted sample base IS presented in parentheses so that the sampling variance for these estimates can be calculated

e Includes from physician himself, from donor supplied by another source other than a sperm bank, or other unspecified sources

SOURCE. Office of Technology Assessment, 1988
34

Table 2-28.-General Screening: Donorsa

(Question 35):b Prior to acceptance as a donor, which of the following do you normally require from donors selected by the recipient

(e.g., husbands, partners), which do you require from other donors, and which do you require from neither?

Base: Have accepted 4 or more patients for artificial insemination in the past year.

Unweighted base (367) c Practice only

Recipient- Only Done by artificial

selected other Don’t sperm insemination

donor donors require bank by husband

Personal medical history . . . . . . . . . . . . . . % 43 57 4 9 11

Family medical and genetic history . . . . . . % 42 58 4 9 11

Fertility history . . . . . . . . . . . . . . . . . . . . . . . % 43 55 4 9 11

Physical examination . . . . . . . . . . . . . . . . . % 25 42 20 9 11

Personality assessment . . . . . . . . . . . . . . . % 18 34 29 9 11

Karyotyping . . . . . . . . . . . . . . . . . . . . . . . . . % 4 13 48 9 11

aThe sample is the fertility society sample.

b The code number of the question in the survey instrument (see app. B)

c Percentage are presented as weighted sample estimates. The unweighted sample base is presented in parentheses so that the sampling variance for these estimates can be

calculated

SOURCE: Office of Technology Assessment, 1988

Table 2-29.–Genetic Screening: Donorsa

(Question 36a):b Do you ever require special screening for genetic defects or diseases from any donors, prior to accepting them for artificial

insemination?

Base: Have accepted 4 or more patients for artificial insemination in the past year

Practice only

artificial Sperm

Unweighed insemination bank Not

base c Yes No by husband only applicable

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (367) % 48 33 10 7 2

Insemination patients/past year

4-10 . . . . . . . . . . . . . . . . . . . . . . . . . . (1 15) % 32 41 20 7 2

11-50 . . . . . . . . . . . . . . . . . . . . . . . . . (169) % 47 34 8 10 2

51-100 . . . . . . . . . . . . . . . . . . . . . . . . . ( 47) % 76 17 2 6 0

>10 0 ( 36) % 78 22 0 0 0

Proportion AIH d

100% . .., . . . . . . . . . ( 61) % 20 22 55 0 3

75-99% . . . . . ( 70) % 64 29 3 4 1

25-74% . : : : : : : : : : : : : : (144) % 54 36 0 10 1

O-24% . . . . . . . . . . . ( 91) % 49 39 0 11 2

Practice

Office . . . . . . . . . . . . . (296) % 47 34 11 8 2

Hospital . . . . . . . . . . ( 66) % 59 30 6 4 0

a The sample IS the fertility society sample.

b The code number of the question in the survey instrument (sea app. B)

c Percentages are presented es weighted sample estimates The unweighted sample base is presented in parentheses so that the sampling variance for these estimates can be

calculated. Unweighted sample base does not add to 367 where physicians failed to respond to particular question concerning demographic characteristic

d "Proportion AIH" meanS the proportion of the physician’s artificial insemination practice in the past 12 months in which husband or partner sperm (rather than donor sperm) was

used

SOURCE: Office of Technology Assessment, 1988.

tests for screening are few, such donor screening based physicians are somewhat more likely (59

becomes more likely with increased practice size, percent) than office-based physicians (47 perrising from 32 percent of those with 4 to 10 pa- cent) to sometimes require special genetic

tients per year to 76 to 78 percent among those screening of donors.

with more than 50 patients a year. Hospital-
35

Twenty Percent of the physicians regularly doing artificial insemination indicate that a family

history of genetic disease would lead them to require genetic screening of a potential donor (table 2-30). Eighteen percent would require it of a

potential donor from an ethnic group at high risk

to a genetic disease. Hence, genetic testing is not

routine for donors, including those in higher than

average risk groups.

Table 2-30.-Circumstances Requiring Genetic

Screening: Donors”

(Question 38b): b Under what circumstances do you require special screening of donors for genetic defects or diseases?

(verbatim)

Base: Have accepted 4 or more patients for artificial insemination

in the past year

Physicians All physicians

doing some doing

screening inseminations

Unweighted basec(177) (387)

%d

Family history of genetic 42

diseases or defects

Membership in high-risk 38

ethnic group

Personal medical history 9

(no reference to fertility)

Fertility history/reproductive 4

problems

Infectious disease s 9

Age . , 0

Othe r 5

Require for everyon e 5

Sperm bank does screening 7

Not reporte d 4

%

20

18

4

2

4

0

2

2

4

2

a The sample IS the fertility society sample

b The code number of the question in the survey Instrument (see app B)

C percentages are presented as weighted sample estimates. The unweighted sample

base in presented in parentheses so that the sampling variance for these estimates

can be calculated

d Since multiple choices were permitted, percentages may add to more than 100%

SOURCE Office of Technology Assessment, 1988

Other Diagnostic Tests

Fifty-six percent of physicians regularly providing artificial insemination require other diagnostic tests of donors prior to accepting them

for insemination (table 2-31). Once again, hospital-based practitioners are more likely (76 percent) than are office-based practitioners (52 percent) to require diagnostic tests of donors.

Similarly, the requirement of diagnostic tests of

donors increases directly with practice size, from

30 percent of those with 4 to 10 patients per year

to 97 percent of those with 100 or more patients

per year.

For those doing both AIH and AID, the rate of

diagnostic testing of donors varies from 62 percent to 68 percent. As another 10 to 11 percent of

these practitioners report that all testing is done

by a sperm bank, rather than themselves, the rate

of diagnostic testing maybe as high as 79 percent

among these practices.

Physicians most commonly test for infectious

diseases (table 2-32). Forty-four percent do

tests for evidence of HIV infection, 28 percent

for syphilis, 27 percent for gonorrhea, 26 percent

for hepatitis, 23 percent for chlamydia, 12 percent for cytomegalovirus, 6 percent for herpes,

and 11 percent for unspecified sexually transmitted diseases.

Fertility Screening

Seventy-two percent of the fertility society

physicians predominantly doing artificial insemination by donor on a regular basis will

screen donor semen for probable fertility (table

2-33), and an additional 10 percent obtain their

semen samples from sperm banks, where such

screening is routine. Sixteen percent of those

predominantly doing AID, however, do not require such screening. For those doing fertility

screening, over 90 percent use sperm count, motility, and morphology as criteria. A majority also

examine semen for white blood cell count (76

percent) and viscosity (59 percent), and, if using

frozen semen, for post-thaw motility (52 percent). Fertility testing increases with the size of

practice, from 51 percent of those with 4 to 10 patients to 94 percent of those with more than 100

patients.

Correlation of Past Donor Rejection With

Donor Characteristics

Among the 24 characteristics examined by the

survey, a history of serious genetic disorders was

the condition for which the greatest proportion

of practitioners (21 percent) had rejected a donor

(table 2-34). Practitioners also have rejected do-
36

Table 2-31.- Diagnostlc Tests: Donorsa

(Question 36c):b Do you ever require any other diagnostic tests for donors prior to initial acceptance, not counting analysis of sperm?

Base: Have accepted 4 or more patients for artificial insemination in the past year

Practice only

artificial sperm

Unweighed insemination bank Not

basec Yes No by husband only applicable

Total . . . . . . . . . . . . . . . . . . . . (367) % 56 24 10 8 2

Insemination patients/past year

4-10 . . . . . . . . . . . . . . (1 15) % 30 42 19 8 3

11-50 . . . . . . . . . . . . . . (169) % 60 18 9 11 2

51-100 . . . . . . . . . . . . . . . . . . . . . . ( 47) % 76 15 2 9 0

>100 . ( 36) % 97 3 0 0 0

Proportion AIH d

100% . , ( 61) % 8 35 57 0 2

75 99% : : : : : : : : ( 70) % 65 20 4 10 1

2574 % (144) % 66 21 0 11 1

024 % ( 91) % 62 26 0 10 3

Practice

Office . . . . . . . . . . . (296) % 52 26 12 9 2

Hospital . . . . . . ( 66) % 76 14 4 6 1

a The sample IS the fertility society sample

b The code number of the question in the survey Instrument (see app.B).

c Percentages are presented as weighted sample estimates. The unweighted sample base IS presented in parentheses so that the sampling variance for these estimates can be

calculated. Unweighted sample base does not add to 367 where physicians failed to respond to particular question concerning demographic characteristic

d "Proportion AIH" means the proportion of the physician’s artificial insemination practice inn the past 12 months in which husband or partner sperm (rather than donor sperm) was

used

SOURCE. Office of Technology Assessment, 1988

nors with evidence of being seropositive to HIV

antibodies (13 percent), or having hepatitis (13

percent), genital herpes (13 percent), syphilis (12

percent), gonorrhea (11 percent), chlamydia (11

percent), and cytornegalovirus (10 percent). Rejections for reasons other than overt genetic or

infectious disease were most commonly related

to the risk of undetected HIV infection. Physicians have rejected donors due to homosexual

contacts (16 percent), intravenous drug use (13

percent), multiple heterosexual partners (12 percent), sexual contacts with HIV-infected persons

(“AIDS cases”) (10 percent), and residence in

areas with a high incidence of HIV infection

(6 percent).

Physicians also reported rejecting donors due

to drug abuse (14 percent), psychological immaturity (13 percent), alcohol abuse (11 percent), a

criminal record (9 percent), less than average

intelligence (8 percent), child abuse (6 percent),

less than a high school education (6 percent),

and less than average height (3 percent).

Correlation of Likelihood of Rejection

With Donor Characteristics

As with potential recipients, physicians may

have never rejected certain types of donors because they have not encountered someone with

these particular characteristics. Therefore, they

were asked if they “have ever rejected” or

“would be likely to reject” donors with particular

traits. Eight percent replied that they obtained

semen only from sperm banks, and a further 10

percent answered that they did AIH only, implying that they did no screening (table 2-34).

Beyond this 18 percent who apparently do not

screen, a minority of practitioners regularly

doing artificial insemination have rejected or

would reject a donor of less than average height

(16 percent) or less than high school education

(39 percent).

The donor characteristic that generates the

most widespread concern among practitioners is

exposure or risk of exposure to HIV. Eighty percent of the practitioners have rejected or would
37

Table 2-32.-Types of Diagnostic Tests: Donors’

(Question 36d,e):b Which diagnostic tests do you require: (verbatim)

Base: Have accepted 4 or more patients for artificial insemination in the past year

All physicians doing Physicians doing

inseminations diagnostic tests

In all In some In all In some

cases cases cases cases

Unweighed base:c(367) (367) (205) (205)

%

d

% % %

HIV testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 1 78 2

Syphilis testing (VDRl/RPR) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 1 50 1

GC culture (gonorrhea) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 2 49 3

Hepatitis serum ........ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 2 47 3

Urethral culture for chlamydia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 2 41 3

Blood type/rh factor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 1 36 2

Cytomegalovirus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 1 21 1

Sexually transmitted diseases (not specified) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1 19 2

Herpes culture .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 2 10 3

Routine blood screen analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4 1 8 1

NGU/ureaplasma/mycoplasma test (nongonococcal urethritis) . . . . . . . . . . . . . . . . . . . 4 1 8 2

Semen analysis (unspec.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 0 7 0

infertility tests (NET) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 2 11 3

Other infectious disease . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1 5 2

Karyotyping. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 3 3 6

Urinalysis .,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 <0.5 3 <0,5

Rubella antibody..,.,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 0 2 0

Physical exam and history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 <0,5 2 <0.5

Semen mucous interaction . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 2 2

Inheritable disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 6 2 11

Genetic screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 1 4

Blood count with differentiation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 0 1 0

Thyroid panel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <05 1 <0.5 2

Other inappropriate response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 0 1 0

Other . . . . . . . . . . . . . . . . . . . . . . 3 <0.5 5 <0,5

No answer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 36 2 65

aThe sample is the fertility society sample.

b The code number of the question in the survey instrument (see app. B).

cPercentages are presented as weighted sample estimates. The unweighted sample base is presented in parentheses so that the sampling variance for these estimates can be

calculated

dSince multiple choices were permitted, percentages may add to more than 100%

SOURCE: Officeof Technology Assessment 1988

be likely to reject a donor who is seropositive for

HIV antibodies. Similarly, they would rejector

already have rejected an intravenous drug user

(81 percent), someone who has had sexual contact with an HIV-infected person (79 percent),

someone who has had homosexual contacts (78

percent) or multiple heterosexual partners (65

percent) or someone who resides in an area with

a relatively high rate of HIV infection (54 percent). (Again, a further 18 percent in all these

cases replied that they did AIH only, or exclusively used semen from sperm banks.)

Infectious diseases also caused concern for

most physicians, as most have rejected or would

reject donors with genital herpes (67 percent),

cytomegalovirus (68 percent] gonorrhea (69

percent] syphilis (73 Percent> or hepatitis (75

percent). They also reported that they would rejector have rejected donors with a criminal record (65 percent) or a history of child abuse (74

percent), alcohol abuse (77 percent), or drug

abuse (79 percent).

Inherited Conditions and Donor Screening

A donor with a history of serious genetic disorders would reaccepted by only l percent of the

surveyed physicians. To determine which heritable characteristics would disqualify a donor, the
38

Table 2-33.-Fertility Screening: Donors.

(Question 37):b Do you normally require screening of the semen of donors for fertility or not?

Base: Have accepted 4 or more patients for artificial insemination in the past year

Practice only

artificial

Unweighed Don’t insemination sperm Not

basec

Require require by husband bank applicable

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (367) % 66 12 10 10 2

Insemination patients/past year

4-10 . . . . . . . . . . . . . . . . . . . . . . . . . . . (1 15)

11-50 . . . . . . . . . . . . . . . . . . . . . . . . . . . . (169)

51-100 . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 47)

>100 . . . . . . . . . . . . . . . . . ( 36)

51

66

78

94

%

%

%

%

20

10

11

3

12

12

11

16

18

10

2

0

9

13

11

0

4

2

.

3

Proportion AIH d

100% . . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 61)

75-9996 . . . . . . . . . . . . . . . . . . . . . . . . . . ( 70)

25-74% . . . . . . . . . . . . . . . . . . . . . . . . . . (144)

0 24% . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 91)

%

%

%

%

28

74

74

72

58

3

0

0

2

12

13

10

2

1

3

3

Practice

Office . . . . . . . . . . . . . . . . . . . . . . . . . . . . (296)

Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . ( 66)

%

%

64

76

12

9

11

6

10

8

2

2

a

The sample is the fertility society sample

b The code number of the question in the survey instument (see app. B).

cPercentages are presanted as weighted sample estimates. The unweighted sample base is presented in parentheses so that the sampling variance for these estimates can be

calculated. Unweighted sample base does not add to 367 where physicians failed to respond to particular question concerning demographic characteristic

d “Proportion AIH" means the proportion of the physician’s artificail insemination practice in the past 12 months in which husband or Partner sperm (rather than donor sperm) was

used

SOURCE: Office of Technology Assessment, 1988

inherit the same gene from their mother as well.

The donor himself w-ill not suffer from the disease because although he has one chromosome

with the disease gene, his matching chromosome

has the normal gene. Carrier status for these particular disorders can be identified with laboratory tests, and physicians could choose to run

such tests on potential donors rather than screen

men out of the pool entirely on the basis of a family history. In the alternative, physicians could

screen recipients and donors to assure that those

with family histories of these disorders are not

matched to one another.

Some autosomal recessive disorders, such as

cystic fibrosis, have no reliable carrier test, and

the 33 percent of physicians who do not reject a

donor with a family history of this most common

of genetic disorders among American caucasian

children may be failing to screen out some

donors who are carriers.

Some of the conditions that lead the majority

of physicians to reject apparently healthy donors

are autosomal dominant disorders, i.e., having

survey asked physicians to report whether they

would accept a donor with a particular disorder,

reject a donor who has it, or reject a donor whose

family history includes someone with the disorder. In general, the survey found that physicians

are reluctant to accept donors with so much as a

family history of genetic disorders, even those

whose genetic transmission patterns are poorly

understood or that pose no danger if the recipient is not a carrier of the disorder. In a number of

cases, a majority of physicians would reject

healthy donors with family histories of x-linked

disorders that are not transmissible unless the

donor himself has the condition, for example,

hemophilia (49 percent) or Duchenne’s muscular dystrophy (61 percent) (table 2-35).

Physicians also frequently screen out healthy

donors with family histories of Tay-Sachs disease (50 percent), sickle cell anemia (46 percent), or thalassemia (47 percent). These are

autosomal recessive disorders– i.e., a healthy

donor may carry the trait and pass it on to his

children, who will suffer from the disease if they
39

Table 2-34.-Criteria for Rejection: Donorsa

(Question 40):b Have you ever rejected or would you be likely to reject a donor because he was/has:

Base: Have accepted 4 or more patients for artificial insemination in the past year

Unweighed base (367)’ Practice only

would artificial Semen

Have Would not insemination bank

rejected reject reject by husband only

History of serious genetic disorders . . . . . . . . . . . . . . . . . . . .

Homosexual contacts

Evidence of drug abuse . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .

Psychologically Immature .

Genital herpes . . . . . . . . . . . . .

Hepatitis . . . . . . .

HIV (HTLV) positive .

Intravenous drug user ., ... . . . .

Multiple heterosexual partners ... . ,

Syphilis

Evidence of alcohol abuse

Chlamydia . . . .

Gonorrhea .

Cytomegalovirus

Sexual contact with AIDS cases . .. . . .

Less than 18 years old .

Over 40 years old .

Criminal record .. . . . .

Less than average intelligence . . . . . . . . . .

Residence in high HIV area . . . . . . . . . . . . . . .

Less than high school degree . . . . . . . . .. . . . . . .

Evidence of child abuse . .

Less than average height . . . . .

Married ,,

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

21

16

14

13

13

13

13

13

12

12

11

11

11

10

10

9

9

9

8

6

6

6

3

>0.5

59

62

65

46

54

62

67

68

53

61

66

57

58

58

69

45

31

56

53

48

33

67

13

2

1

3

2

22

14

6

1

1

15

8

4

12

12

12

1

26

40

13

18

25

39

7

62

76

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

8

8

8

8

8

8

8

8

8

8

8

8

8

8

8

8

8

8

8

8

8

8

8

8

a The sample is the fertility society sample

b The code number of the question in the survey Instrument (see app.B)

c Percentages are presented as weighted sample estimates. The unweighted sample base IS presented m parentheses so that the sampling variance for these estimates can be

calculated

SOURCE Office of Technology Assessment, 1988

even one deleterious gene would cause the donor

to express the symptoms of the disease. Therefore, a healthy donor can be presumed to be free

of the trait. For example, 53 percent would

screen out someone with a family history of

neurofibrornatosis; diagnosis of those with the

disorder is possible from the characteristic cafe

au lait spots on their bodies (although this could

be missed in some donors suffering from very

few visible symptoms).

With other diseases, such as Huntington’s chorea, it is very difficult to test for carrier status,

and its onset late in life makes it impossible to

determine clinically if a donor has the deleterious gene. One available test requires extensive

testing among related family members, is very

time-consuming, and has an approximately

2-percent error rate. A newer test reduces the

error rate, but is not widely available. Given the

severity of the disease, and the difficulty of determining if a person has the gene, it is surprising

that the rate of rejection for apparently healthy

donors having a family history of Huntington’s

(63 percent) is similar to that for those with a

family history of Duchenne’s muscular dystrophy or hemophilia, as apparently healthy donors

could pass on Huntington’s to their offspring,

but not the other two diseases.

The variation among practitioners concerning

rejection of donors with family histories of depression, Alzheimer’s disease, malignant melanoma, and astigmatism reflect the current lack of

definitive information on the role genetic predisposition plays in the etiology of these disorders.

The only condition on a list of 17 that a plurality of practitioners do not feel to be a basis for
4 0

Table 2-35.-inherited Conditions and Donor Rejectiona

(Question 41):b For each of the following conditions, would you be likely to reject a donor only if he had the condition, if anyone in the

donor’s immediate family had the condition, or would you not reject a donor even if he had the condition?

Base: Have accepted 4 or more Patients for artificial insemination in the past year

Unweighed base (367) c

Practice only

Reject if Reject Not reject artificial Semen

any family only if even if insemination bank

history donor has donor has by husband only

Huntington’s chorea . . . . . . . . . . . . . . . %

Duchennes muscular dystrophy . . . . . . %

Cystic fibrosis . . . . . . . . . . . . . . . . . . . . . . . %

Neurofibromatosis . . . . . %

Tay-Sachs %

Hemophilia ~ ~ ~ %

Mental retardation . . . . . . %

Thalassemia ... . . . %

Sickle cell anemia %

Alzheimer’s disease %

Hypercholesterolemic heart disease %

Diabetes . . . . . %

Malignant melanoma . . . %

Depression %

Asthma %

Severe astigmatism %

Obesity ., %

63

61

55

53

50

49

48

47

46

40

36

31

27

24

16

16

13

25

27

29

29

33

32

38

33

35

34

32

38

38

36

29

27

24

1

1

4

4

2

4

2

5

4

10

15

14

18

20

34

36

42

9

9

9

9

9

9

9

9

9

9

9

9

9

9

9

9

9

8

8

8

8

8

8

8

8

8

8

8

8

8

8

8

8

8

a The sample IS the fertility society sample

b The code number of the question in the survey Instrument (see app. B).

c Percentages are presented as weighted sample estimates The unweighted sample base is presented in parentheses so that the sampling variance for these estimates can be

calculated

SOURCE Office of Technology Assessment, 1988

rejecting a donor is obesity. Although 13 percent has the condition. Obesity is now thought to have

of practitioners would reject a donor with a fam- some genetic component, but the predisposition

ily history of obesity, and 24 percent would reject interacts with a number of strong environmental

a donor who is obese, 42 percent of practitioners factors in most cases.

reported that they would not reject a donor who

CHARACTERISTIC MATCHING

On average, about two-thirds of the requests

for artificial insemination are accompanied by a

request from the recipient to use a donor who

meets certain criteria. Among physicians offering AID, 78 to 88 percent stated they are “willing” to select donor characteristics to recipient

specifications. Overall, 72 percent of all physicians offering artificial insemination are willing

to match at least some recipient specifications

(table 2-36), commonly race (97 percent), eye

color (94 percent), complexion (90 percent),

height (90 percent), ethnic or national origin (84

percent), weight (83 percent), body type (82 percent), and hair texture (81 percent) (table 2-37).

A majority also match specifications concerning

the donor's educational attainment (66 percent),

age (62 percent), intelligence quotient (57 percent), and religion (56 percent), although a fairly

substantial proportion of physicians who are generally willing to match at least some recipient

specifications say that they would not try to

match on the basis of education (29 percent), age

(31 percent), intelligence quotient (37 percent),

or religion (39 percent). A majority of physicians

refuse to match hobbies (56 percent) or income

(72 percent). Nonetheless, 39 percent will match

for hobbies, and 22 percent for income. Physicians are more evenly split on whether they will

(45 percent) or will not (50 percent) match for

special abilities.
41

Table 2-36.– Willingness To Select Donor

Characteristica

(Question 10):b Are you generally willing to select donor characteristics to recipient specifications?

Base: Have accepted 4 or more patients for artificial insemination

in the past year

Practice only

artificial Not

Unweighed insemination applicbase c Yes No by husband able

Total ... ., (367)

Al patients/past year

4-10 . . . . . (1 15)

11-50. (169)

51-10 0 ( 47)

>10 0 ( 36)

Proportion AIH d

100 % ( 61)

75-99 % ( 70)

25-74% (144)

O 24 % ( 91)

Practice

Offic e (296)

Hospital ( 66)

Age

Under 3 5 ( 21)

35 to 4 9 (221)

50 or ove r (121)

Sex

Mal e (339)

Female ( 28)

% 72

% 5 5

% 7 7

% 87

% 8 9

% 15

% 78

% 82

% 8 8

% 71

% 77

% 67

% 73

% 73

% 71

% 79

20

31

17

9

11

45

16

16

12

21

17

29

20

17

20

14

7

13

5

0

0

40

1

0

0

8

2

0

6

9

7

4

1

1

0

4

0

0

3

1

0

0

3

0

<0.5

1

1

4

Table 2-37. –Specific Donor Characteristics.

(Question 11):b Which of the following donor characteristics are

you normally willing to try to match, if requested?

Base: Have accepted 4 or more patients for artificial insemination

in the past year and willing to match donor characteristics to recipient characteristics

Unweighted base (264)c Not Not

Willing willing sure

Race . . . . . . . . . . . . . . . . . % 97

Eye color . . . . . . . . . . . . . . . . . % 94

Complexion . . . . . . . . . . . . . . . % 90

Height . . . . . . . . . . . . . . . . . % 90

Ethnic/national origin % 84

Weight . . . . . . . . . . . . . . . . . . % 83

Body type . . . . . . . . . . . . . . . . % 82

Hair texture . . . . . . . . . . . . . % 81

Educational attainment . . . . . . % 66

Age . . . . . . . . . . . . . . . . . . % 62

I.Q. . ... . % 57

Religion . . . . . . . . . . . . . . . . % 56

Special abilities . . . . . . . . . % 45

Hobbies or interests . % 39

Income . . . . . . . . . . . . . . . % 22

2

4

7

7

14

13

14

16

29

31

37

39

50

56

72

2

2

3

3

3

4

4

3

5

6

6

5

6

6

6

a The sample is the fertility society sample

bThe code number of the question in the survey Instrument (see app. B).

c Percentages are presented as weighted sample estimates. The unweighted sample

base IS presented in parentheses so that the sampling variance for these estimates

can be calculated

SOURCE: Office of Technology Assessment, 1966

a The sample IS the fertility society sample

b The code number of the question in the survey Instrument (see app. B).

c Percentage s are presented as weighted sample estimates. The unweighted sample

base is presented in parentheses so that the sampling variance for these estimates

d can be calculated. Unweighted sample base does not add to 367 where physicians

failed to respond to Particular question concerning demographic characteristic

"Proportion AIH” means the proportion of the physician's artificial insemination practice in the past 12 months in which husband or partner sperm (rather than donor

sperm) was used

SOURCE: Office of Technology Assessment, 1986

SEX SELECTION

Fourteen percent of practitioners regularly

doing artificial insemination say that they offer

sperm separation for preconception sex selection. Willingness to provide this appears to be

wholly a function of practice size, rising from 5

percent of those with 4 to 10 patients per year to

31 percent of those with more than 100 patients

per year. Practitioners with small practices most

often cite a lack of facilities as the reason for not

offering the service, with ethical concerns expressed by one in six physicians. The survey instrument’s questions could not substitute for a

prospective clinical trial of the efficacy of sperm

separation techniques, but the survey results did

indicate that physicians do not generally perceive

the technique as effective.
42

FRESH AND FROZEN SEMEN

Use of Fresh Semen Table 2-39.-Use of Fresh Semena

Nearly one third of those regularly doing artificial inseminations rely exclusively on fresh semen (28 percent). Four percent did not respond

to the question, stating that they do only AIH (4

percent), thus implying that they feel questions

concerning usage of frozen semen do not apply to

them (table 2-38). About a quarter rely entirely

on frozen semen. Practitioners who do only AIH

use fresh semen almost exclusively. More than

one-fifth (22 percent) of those who do artificial

insemination by donor, however, use fresh semen exclusively (table 2-38).

Seventy-two percent of those regularly doing

artificial insemination used fresh semen in the

past year (table 2-39). The uniform frequency of

Table 2-38.-Fresh and Frozen Semen: User Profile.

(Question 32a):b Have you performed any artificial insemination

in the past year in which fresh sperm was used?

(Question 43a):b Have you performed any artificial insemination

in the past year in which frozen sperm were used?

Base: Have accepted 4 or more patients for artificial insemination

in the past year and repotted type of semen

Fresh

Unweighed Fresh and Frozen Not

basec only frozen only applicable

Total . (363) % 28 40 23 9

Insemination patients/past year

4-10 . . . . . (1 13) % 39 20 25 17

11-50 . . . . (167) % 26 46 21 7

51-100 . . . ( 46) % 11 50 35 4

>100 (37) % 16 68 11 5

Proportion AIH e

100% . . . . ( 60) % 55 2 2 42

75-99% (69) % 22 52 23 3

25-74% . . (142) % 22 49 25 4

O-24% (90) % 22 42 34 1

Practice

Office (292) % 28 40 21 11

Hospital . . (66) % 24 39 30 6

a The sample is the fertility society sample.

b The code number of the question is the survey instrument (see app. B).

c lncludes 4% reporting “AIH Only”

d Percentages are presented as weighted sample estimates. The unweighted sample

base is presented in parentheses so that the sampling variance for these estimates

can be calculated. Unweighted sample base does not add to 363 where physicians

failed to respond to particular question concerning demographic characteristic e "Proportion AIH" means the proportion of the physician'artificial insemination

practice in the past 12 months in which husband or partner sperm (rather than donor

sperm) was used

SOURCE: Office of Technology Assessment, 1988

(Question 32a):b Have you Performed any artificial insemination

in the past year in which fresh sperm was used?

Base: Have accepted 4 or more patients for artificial insemination

in the past year

Unweighed Not

basec Yes No applicable

Total . . . . . . . , . . . (367) % 72 25

Insemination patients/past year

4-10 . . . . . . . . . (115) % 69 28

11-50 . . . . . . . . (169) % 74 23

51-100 . . . . . . . (47) % 65 37

>100 . . . . . (36) % 89 11

Proportion AIHd

100% . . . . . . . .

75-99% . . . . . . . ( 70) % 23

25-74% . . . . . . . (144) % 72 25

0-24% . . . . . . . . (91) % 67 34

Practice

Office . . . . . . . . (296) % 74 24

Hospital . . . . . . (66) % 65 35

2

4

2

0

0

7

1

2

0

2

—

a The sample is the fertility society sample

b The code number of the question in the survey instrument (see app. B).

c Percentages are presented as weighted sample estimates. The unweighted sample

base IS presented in parentheses so that the sampling variance for these estimates

can be calculated Unweighed sample base does not add to 367 where physicians

failed to respond to particular question concerning demographic characteristic

d "Proportion AIH" means the proportion of the physician’s artificial Insemination

practice in the past 12 months in which husband or partner sperm (rather than donor

sperm) was used

SOURCE: Office of Technology Assessment, 1988

fresh semen use among physicians whose practices vary from O to 99 percent AID indicates that

fresh semen is used for such inseminations even

by physicians who have access to and use frozen

semen for part of their practice (table 2-40).

These data were collected in 1987. As of February 1988, the American Fertility Society, the

Centers for Disease Control, and the Food and

Drug Administration have all recommended that

only frozen semen be used, in conjunction with a

minimum 6-month quarantine period and periodic donor retesting for evidence of antibodies.

to HIV. Physician practice may have substantially changed with respect to the use of fresh and

frozen semen as a result of the 1988 recommendations. However, it should be noted that the

American Association of Tissue Banks has been

publishing standards since 1985 directing its

member sperm banks to use of frozen semen,
43

Table 2-40.-Number of Inseminations: Fresh Semena

(Question 32b):b Approximately how many inseminations have

you performed in the past year, using fresh sperm?

Base: Accepted 4 or more patients forartificial insemination in the

past year and has used fresh semen

Unweighed

basec Mean Not sure

Total . . . . . . . . . . . . . . . . (266) 106.5 2%

Insemination patients/past year

4-10 . . . . . . . . . . . . . . . . . . . . ( 79) 20.0 1

11 -50 . . . . . . . . . . . . . . . . . . . (125) 76.2 1

51-100 . . . . . . . . . . . . . . . . . ( 30) 166.1 3

>100 ., ., (32) 374.4 6

Proportion AIH d

100% . . . . . . . . . . . . . . ( 48) 40.4 0

75-9996 . . . . . . . . ( 53) 129.9 0

25-74% . . . . . . . . . . . . . . . . . (104) 109.0 3

O-24% . ( 60) 129.1 2

Practice

Office (220) 102.5 2

Hospital . . . (43) 131.2 0

a The sample is the fertility society sample.

b The code number of the question in the survey instrument (see app B)

C Percentage and means are presented as weighted samples estimates. The unweighted sample base IS presented Iin parentheses so that the sampling variance

for these estimates can be calculated. Unweighted sample base does not add to

266 where physicians failed to respond to particular question concerning demographic characteristic

d "Proportion AIH" means the proportion of the physician’s artificial Insemination

practice in the past 12 months in which husband or partner sperm (rather than donor

sperm) was used

SOURCE Office of Technology Assessment, 1966

with a 2-month quarantine and periodic donor

rescreening.

Sources of Fresh Semen

The most common source of fresh semen is the

recipient’s husband or partner: 94 percent of

practitioners who have used fresh semen report

having done AIH (table 2-41). Medical students

are the next most common source, used for AID

by 44 percent of the physicians regularly doing

artificial insemination, with graduate students

(34 percent), hospital personnel (23 percent),

and other physicians (20 percent) also having

been used by at least one out of five physicians.

Few practitioners reported having used their

own semen (2 percent).

Use of Frozen Semen

Six out often physicians who regularly provide

artificial insemination have used frozen semen in

the past year. Its use is uncommon among those

doing only AIH (5 percent), but for all others, regardless of the proportion of their practices devoted to AIH, approximately three-quarters

have used frozen semen in the past year.

Sources of Frozen Semen

Most practitioners who use frozen semen report that they obtain it from commercial sperm

banks (74 percent); hospital supplies are used

by no more than U percent of these physicians

(table 2-42). Use of commercial sperm banks,

however, is a function of practice size, declining

from 88 percent of those with 4 to 10 patients per

year to 55 percent of those with more than 100

patients per year. In fact, 62 percent of those with

more than 100 patients per year do at least some

of their inseminations with semen they have frozen and stored themselves, although this is generally restricted to physicians with a hospitalbased practice.

Quarantine Periods

Seventy-five percent of the practitioners who

use frozen semen report that they or their supplier quarantine the semen prior to use (table

2-43), although quarantining is less common

Table 2-41.-Sources of Fresh Semena

(Question 33): b Do you use the sperm of husbands or partners?

(Question 34):b Which of the other following sources have you

used to obtain fresh sperm in the past yeaf?

Base: Have accepted 4 or more patients for artificial insemination

in the past year and has used fresh semen

Insemination patients/past year

Total 4-10 11-50 51-100 >100

Unweighted base:c (266) (79) (125) (30) (32)

%

d

Husbands/partners 94

Medical students 44

Graduate students 34

Nonhospital personnel 24

Hospital personnel 23

Other doctors 20

Andrology laboratories 18

Self . . . . . 2

%%% %

94 93 93 97

26 46 70 59

12 37 60 50

14 26 33 31

10 27 37 25

9 26 30 19

12 21 20 19

1 2 0 3

a The sample IS the fertilty society Sample

b The code number of the question in the survey Instrument (see app B)

c percentage are presented aS weighted sample estimates The unweightad sample

base is presented in parentheses so that the sampling variance for these estimates

can be calculated

d Since multiple choices were permitted, percentages may add to more than 100%

SOURCE: Office of Technology Assessment, 1988
44

Table 242.-Sources of Frozen Semena Table 243.-Use of Quarantine: Frozen Semena

(Question 44):b Which of the following sources have you used in

the past year to obtain frozen sperm?

Base: Accepted 4 or more patientsfor artificial insemination int he

past year and has used frozen semen

(Question 46):b Do you or your supplier have a quarantine period

prior to use of frozen sperm?

Base: Accepted 4 or more patients for artificial insemination in the

past year and has used frozen semen

Unweighed Own Hospital Commercial

base c

supplies supplies vendor Other

Total . . . . . (232) % 26 7 74 4

Al patients/past year

4-10 . . . . ( 51) % 88 10

11-50 . . . 78 2

51-100. . ( 39) % 46 3 59 0

>100 . . . ( 29) % 62 3 55 3

Proportion AIHd

100% . . . ( 3) % o 0 100 0

75-9996 . ( 52) % 12 12 86 2

25-74% . (107) % 32 5 68 5

O-24% . . ( 69) % 28 7 72 3

Practice

office . . . (184) % 19 6 80 4

Hospital ( 47) % 51 11 51 0

Unweighed

base c Yes No Not sure

Total . . . . . . . . . . . (232) % 75 20 5

Insemination patients/past year

4-10 . . . . . . . . . . (51) % 66 34 2

11-50 . . . . . . . . . (113) % 70 22 8

51-100 . . . . . . . . ( 39) % 90 5

>100 . . . . . . . . .

Proportion AIHd

100% . . . . . . . . . ( 3) % 100 0

75-9996 . . . . . . .

25-74% . . . . . . . (107) % 76 6

Practice

office . . . . . . . . . (184) % 72 22 6

Hospital . . . . . . . ( 47) % 85 15 0

a The sample is the fertility society sample

b The code number of the question in the survey instrument (see app. B).

c Percentages are presented as weighted sample estimates. The unweighted sampe

base is presented in parentheses so that the sampling variance for these estimates

can he calculated Unweightad sample base does not add to 232 where physicians

failed to respond to particular question concerning demographic characteristic

d "Proportion AIH" means the proportion of the physician’s artificial insemination

practice m the past 12 months in which husband or partner sperm (rather than donor

sperm) was used

SOURCE: Office of Technology Assessment, 1988

among those with 4 to 50 patients a year (66 to 70

percent) than by those with larger practices (90

percent). Hospital-based practices are also more

likely (85 percent) than office-based practices

(72 percent) to have a quarantine period (85 percent). Quarantine periods average 3.6 months,

although a quarter of the physicians report a

longer period, usaually 6 months (table 2-44).

a The sample is the fertility society sample

b The code number of the question in the survey instrument (see app. B).

c Percentages are presented as weighted sample estimates. The unweighted sample

base is presented in parentheses so that the sampling variance for these estimates

can be calculated Unweighed sample base does not add to 232 where physicians

failed to respond to particular question concerning demographic characteristic

d "Proportion AIH" means the proportion of the physician’s artificial insemination

practice in the past 12 months in which husband or partner sperm (rather than donor

sperm) was used

SOURCE: Office of Technology Assessment, 1988

Table 2-44.-Length of Quarantine Period:

Frozen Semena

(Question 47):b How long is that quarantine period?

Base: Have accepted 4 or more patients for artificial insemination

in the past year, has used frozen semen with a quarantine period

Unweighted base (173) c Total

%

One month . . . . . . . . . . . . . . . . . . . . 1

Two months . . . . . . . . . . . . . . . . . . . . . 5

Three month . . . . . . . . . . . . . . . . 59

Four months . . . . . . . . . . . . . . . . . 6

Five months . . . . . . . . . . . . . . . . . . . . . . . . 1

Six months . . . . . . . . . . . . . . . . . . . 17

Seven months . . . . . . . . . . . . . . 1

Eight months. . . . . . . . . . . . . . . . 1

Nine months or more ., ... . . . . . . . . . . . . . . . 0

Not sure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Mean . . . . . . . . . . ... . . . . . . . 3.6 months

a The sample is the fertility society sample

bThe code number of the question in the survey instrument (see app.B)

cPercentages and means are presented as weighted sample estimates. The unweighted sample base is presented in parentheses so that the sampling variance for

these estimates can be calculated

SOURCE: Office of Technology Assessment, 1988
45

PREGNANCY OUTCOMES AND RECORDKEEPING

Tracking Pregnancy Outcomes

Seventy-seven percent of the fertility society

members who are regularly doing artificial insemination report that they know whether their

patients become pregnant (table 2-45). These

physicians report that nearly half of all the

women they see (i.e., those seeking AIH and

AID) do become pregnant, on average after

seven inseminations over a period of 4.4 cycles.

Of course, these recollections by physicians cannot substitute for prospective clinical trials of the

efficacy of artificial insemination protocols. Further, figures on the number of inseminations and

cycles vary greatly, according to the reason for

seeking artificial insemination, whether the

semen is washed or otherwise treated, and on the

precise placement of the semen during insemination.

Table 2-45. –Awareness of Outcomea

(Question 24):b In what percentage of cases that you have treated

by artificial insemination do you know whether pregnancy is

achieved as a result or not?

Base: Have accepted 4 or more patients for artificial insemination

in the past year

Unweighed Mean

basecpercentage

Total . . . . . . .. .. . . . . . . . . . (367) 77.1

Al patients/past year

4-1 o (1 15) 67.4

11-5 0 . . . . . . . . . . . . (169) 79.0

51-100. : : ( 47) 86.3

>10 0 . . . . . . ( 36) 88.0

Proportion AIH d

100 % ( 61) 54.4

75-99% . . . ( 70) 82.4

25-74 % (144) 81.0

O-24% . . . . . . . . . . . . . . ( 91) 82.4

Practice

Office . . . . . (296) 76.5

Hospita l ( 66) 84.8

a The sample is the fertility society sample

b The code number of the question in the survey Instrument (see app. B).

c Means are presented as weighted sample estimates The unweighted sample base

IS presented in parentheses so that the sampling variance for these estimates can

be calculated Unweighted sample base does not add to 367 where physicians

failed to respond to particular question concerning demographic characteristic

d "Proportion AIH" means the proportion of the physician’s artificial insemination

practice in the past 12 months in which husband or partner sperm (rather than donor

sperm) was used

SOURCE” Office of Technology Assessment, 1988

Physicians do not necessarily follow the entire

course of the pregnancy, as the patient’s obstetrician normally would; nearly half report that they

do not. By combining the estimated proportion

of patients who eventually become pregnant as a

result of artificial insemination with the proportion of pregnancies from artificial insemination

that yield live births, the survey suggests that live

births are achieved in 37.7 percent of cases involving artificial insemination.

The likelihood of following the full course of a

patient’s pregnancy varies with a physician’s

practice size, from 74 percent of those with 4 to

10 patients a year to 24 to 28 percent of those

with more than 50 patients a year.

Birth Outcomes

Physicians may know outcomes without actually following a woman’s pregnancy by, for example, having women send back postcards with

news of a birth or miscarriage (Raboy, 1986).

Some 64 percent of physicians regularly practicing artificial insemination know whether pregnancy was achieved, a higher number than those

following the pregnancies.

The majority of physicians who follow the

births of their artificial insemination recipients

(73 percent) report that they have never encountered a case of birth defects (table 2-46). Another 20 percent report one or two cases of birth

defects in their experience. Four percent report

three or more cases of birth defects among the

offspring of their inseminations. While the survey data do not permit a direct comparison of the

rate of birth defects among the offspring of artificial insemination with the offspring of natural insemination (the rvumey collected information on

the number of patients accepted for insemination in the past year and the physician’s lifetime

experience of birth defects), they do not suggest

that children conceived by artificial insemination

are suffering from an incidence of birth defects

in excess of the general population.

Although most practitioners follow the outcomes of the live births of patients whom they

have inseminated, far fewer (16 percent) report
4 6

Table 2-46. - Experience With Birth Defectsa

(Question 30b): b How many cases of birth defects have you encountered?

Base: Accepted 4 or more patients for artificial insemination in the past year and follows outcomes of live births

More Mean

Unweighed than Not no. of

basec None One Two Three four sure cases

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (233) % 73 11 9 2 2 2 0.5

Insemination patients/past year

4-10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 74) % 93 7 0 0 0 0 0.1

11-50 . . . . . . . . . . . . . . . . . . . . . . . . . . . (103) % 79 9 7 2 1 2 0.3

51-100 . . . . . . . . . . . . . . . . . . . . . . . . . . ( 30) % 40 20 27 7 7 0 1,4

>100 . . . . . . (26) % 31 23 23 4 12 8 1.4

Proportion AIH d

100 % ( 36) % 94 3 3 0 0 0 .1

75-9996 . . . . . . . . ( 44) % 70 9 14 2 2 5 .6

25-74% . ...........:.::.::: “: :::: ( 90) % 70 15 9 3 2 1 5

O-24 % ( 63) % 70 13 10 2 5 2 7

Practice

Office . . . . . . . . . . . . (189) % 79 8 8 2 2 1 .4

Hospital . . . . . . (43) % 46 26 14 5 5 5 1.0

a The sample is the fertility society sample.

b The code number of the question in the survey instrument (see app. B).

c Percentages and means are presented as weighted sample estimates. The unweighted sample base is presented in parentheses so that the sampling variance for these estimates

can be calculated. Unweighted sample base does not add to 233 where physicians failed to respond to particular question concerning demographic characteristic.

d "Proportion AIH" means the proportion of the physician’s artificial insemination practice in the past 12 months in which husband or partner sperm (rather than donor sperm) was

used

SOURCE: Office of Technology Assessment, 1988

that they follow the health and development of

children from these inseminations subsequent to

birth. Consequently, developmental problems

and certain forms of genetic disorders that do

not manifest themselves at birth would not normally be tracked by these practitioners.

Recordkeeping

Fifty-four percent of those regularly doing artificial insemination keep records permitting

them to match donors to the pregnancies resulting from use of the donor’s semen. For those using semen from a sperm bank, such records could

match the donor code used by the sperm bank to

the pregnancy that resulted. Nine percent report

that such records are unnecessary, as they do

only AIH. Nearly one-third (32 percent) do not

keep such records. Such recordkeeping is more

likely with increased practice size, from 35 percent of those with 4 to 10 patients a year to 78 to

80 percent of those with more than 50 patients a

year. Similarly, hospital-based practices are

more likely (74 percent) than office-based practices (51 percent) to keep such records.

The information maintained in the donor records, beyond matching the donor to inseminations, varies according to the size of the practice.

On average, 71 percent of the physicians maintaining such records will also know how many

pregnancies have been achieved with the semen

of each donor (table 2-47). Such information is

less frequently kept by those with 4 to 10 patients

(50 percent) than those with more than 100 patients (100 percent). Similarly, most practitioners

who keep donor records also note family genetic

history (71 percent), number of women inseminated (68 percent), number of children born (65

percent), physical examinations (59 percent),

and followup examinations (52 percent). However, these details are more often kept by those

with large practices than those with small or office-based practices.

Access to Donor Records

A majority of physicians regularly doing artificial insemination who keep donor records will

not give anyone access to them, under any circumstances, even if all identifing information
4 7

Table 247.-Types of Records Kepta

(Question 49):b Do you keep records for each donor of:

Base: Accepted 4 or more patients for artificial insemination in the past year and keeps donor records

Insemination patients in past year

Total 4-1o 11-50 51-100 >100

Unweighed base: c(199) (41) (93) (37) (28)

%

d % % % %

Family genetic history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 52 72 81 89

Number of pregnancies achieved . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 50 70 76 100

Number of women inseminated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 58 66 70 89

Number of children born . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 52 63 65 93

Physical examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 38 60 65 82

Follow-up examinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 28 51 65 75

a The sample is the fertility society sample.

b The code number of the question in the survey instrument (see app B).

c Percentages are presented as weighted sample estimates. The unweighted sample base is presented in parentheses so that the sampling variance for these estimates can be

calculated

d Since multiple choices were permitted, percentages may add to more than 100%

SOURCE: Office of Technology Assessment, 1988

about the donor is removed. Approximately

three-quarters of practitioners with donor records say that they would not permit access to the

donors themselves (76 percent), to recipients (72

percent), to the partners of recipients (73 percent), or to the resulting children (77 percent)

(table 2-48). Nor would they allow access, even

without the donors’ names, to public health departments (67 percent) or research scientists (60

percent). Even judicial requests would be

refused by a majority of these physicians (52

percent).

Table 2-48.-Access to Recordsa

(Question 50): b Would you permit access to donor records,

including the name of the donor, only excluding the name of the

donor, or not at all, to:

Base: Accepted 4 or more patients for artificial insemination in the

past year and keeps donor records

Unweighed base (199)C

Access Access

with without No Not

name name access sure

Donor . . . . . . . . . . . . . %d 8 9 76 6

Recipient . . . . . . . . . . . . % 2 20 72 5

Recipient partner ., . . . . . % 2 19 73 5

Offspring of insemination % 1 16 77 5

Public health department % 2 25 67 4

Research scientists . . . . . . % <0.5 33 6 0 5

Judicial requests % 10 30 52 6

a The sample IS the fertility society sample

b The code number of the question in the survey instrument (see app. B).

c Percentage are presented as weighted sample estimates. The unweighted sample

base IS presented m parentheses so that the sampling variance for these estimates

can be calculated

d Items are in order as they appear on survey Instrument

SOURCE: Office of Technology Assessment, 1988

COSTS OF ARTIFICIAL INSEMINATION

Preinsemination Costs and testing prior to the first actual insemination

The cost of screening, testing, and consultative

is under $100 (table 2-49), although 9 percent estimate the cost of preinsemination services at

activities varies among practitioners. Approxi- more than $1,000.

mately 4 out of 10 who do artificial insemination

on a regular basis report that the average cost to The average cost of preinsemination services

their patient for the consultations, examinations, across all practitioners is $309. Physicians who
4 8

Table 2-49.-Preinsemination Costs: Totala

(Question 59): b What do you estimate the average cost is to your

patient (or her insurance earner) for the consultations, examinations and testing prior to the first actual insemination?

Base: Have accepted 4 or more patients for artificial insemination

in the east year

Unweighted base (367) c

Total

%

Under $100 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

$100 -199 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

$200-299 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

$300-499 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

$500-999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

$1,000 and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Not sure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Mean cost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $309

a The sample is the fertility society sample.

bThe code number of the question in the survey instrument (see app. B).

c Percentages and means are presented as weighted sample estimates. The unweighted sample base is presented in parentheses so that the sampling variance for

these estimates can be calculated

SOURCE: Office of Technology Assessment 1988

do inseminations only with husband or partner

semen charge $145, on average, for these services

(table 2-50), approximately half the rate ($300 to

$372) charged by physicians who do AID as well.

This is consistent with earlier findings that physicians doing only AIH tend to require fewer tests.

Hospital-based practices charge more ($376), on

average, than do office-based practices ($298)

for initial consultations, and practices with 100

patients or fewer charge less ($265 to $31 1) than

those with more than 100 patients ($521).

Cost of Insemination

The average cost to the patient for each insemination also varies considerably among practitioners. Approximately a third report an average cost per insemination of less than $50 (table

2-51). A similar proportion of practitioners (38

percent) report an average per insemination cost

of between $50 and $150. A quarter of practitioners estimate that the average is $150 or more.

For all fertility society members regularly doing artificial insemination, the average cost to a

patient for each subsequent insemination is $92

(table 2-52), with variation largely due to the

source of the semen. In cases of AIH, where

there is no charge for the semen, the only costs

are medical costs. The survey found that the average cost per additional insemination is $30 in

Table 2-50. - Preinsemination Costs, by

Physician Characteristicsa

(Question 59): b What do you estimate the average cost is to your

patient (or her insurance carrier) for the consultations, examinations and testing prior to the first actual insemination?

Base: Have accepted 4 or more patients for artificial insemination

in the past year

Unweighed Mean

baseccost

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . (367) $309

Insemination patients/past year

4-10 ..., , . . . . . . . . . . . . . . . . . . . . . . (1 15) 311

11-50 . . . . . . . . . . . . . . . . . . . . . . . . . . (169) 275

51-100 . . . . . . . . . . . . . . . . . . . . . . . . . ( 47)

>100 , . . . . . . . . . . . . . . . . . . . . . . . . . ( 36) 521

Proportion AIHd

100% . . . . . . . . . . . . . . . . . . . . . . . . . . ( 61) 145

75-99% . . . . . . . . . . . . . . . . . . . . ... ( 70) 372

25-74% . . . . . . . . . . . . . . . . . . . . . . . . (144) 357

O-24% . . . . . . . . ... . . . . . . . . . . . . ( 91)

Type of semen

Fresh ., . . . . . . . . . . . . . . . . . . . . . . . . (100)

Fresh/frozen . . . . . . . . . . . . . . . . . . . . (146) 324

Frozen . . . . . . . . . . . . . . . . . . . . . . . . . ( 84) 394

Practice

Office . . . . . . . . . . . . . . . . . . . . . . . . . (296) 298

Hospital . . . . . . . . . . . . . . . . . . . . . . . . ( 66) 376

Specialty

OB/GYNe . . . . . . . . . . . . . . . . . . . . . . . (307) 303

Other ., . . . . . . . . . . . . . . . . . . . . . . . . ( 53) 371

a 

The sample is the fertility society sample

b The code number of the question in the survey Instrument (see app. B).

c Means are presented as weighted sample estimates. The unweighted sample base

is presented in parentheses so that the sampling variance for these estimates can

be calculated. Unweighted sample base does not add to 367 where physicians

failed to respond to particular question concerning demographic characteristic d "Proportion AIH" means the proportion of the physician's artificial insemination

practice in the past 12 months in which husband or partner sperm (rather than donor

sperm) was used

e Obstetrics/gynecology

SOURCE: Office of Technology Assessment, 1988

practices doing only AIH. By contrast, the average cost in practices doing AID varies from $97

to $115.

Total Cost of Insemination

To achieve pregnancy, physicians regularly

doing artificial insemination reported that on

average a woman spends $309 in initial consultations, examinations, and testing, and $92 for

each of seven inseminations (used during an average of 4.4 cycles), for a total cost of $953. However, practices doing only artificial insemination by husband report an average cost per

patient of one-quarter ($316) that charged by

other types of practice ($1,017 to $1,248) (table
4 9

Table 2-51.– Insemination Costs: Totala

(Question 60):b What do you estimate the average cost is to

your patient (or her insurance carrier) for each subsequent

insemination?

Base: Have accepted 4 or more patients for artificial insemination

in the past year

Unweighted base (367) c Total

%

Under $50 . . . . . . . . . . . . . . . . . . . . . 36

$50-99 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

$100 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

$101 -149 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

$150 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

$151-199 . . . . . . . . . . . . . . . . . . . . . . . . 4

$200 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Over $200 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Not sure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Mean cost . . . . . . . . . . . . . . . . . . . . . . . . . $92

aThe sample is the fertility society sample.

bThe code number of the question in the survey instrument (see app. B).

cPercentages and means are presented as weighted sample estimates. The unweighted sample base is presented in parentheses so that the sampling variance for

these estimates can be calculatad

SOURCE: Office of Technology Assessment, 1988

2-53). There is relatively little variation in the total patient cost between practices with 4 to l0 patients a year ($822), 11 to 50 patients ($889), and

51 to 100 patients ($945). Practices with more

than 100 patients report a per-patient cost

($1,718) nearly twice that of smaller practices

The full average cost per recipient for artificial insemination by donor or by husband, $953,

yields unestimated expenditure on the order of

$164 million spent by 172,000 women each year

for this procedure. This figure may overestimate

the cost if women undergo the inseminations

over more than a 12-month period.

Physicians report that 51 percent of these

women have insurance coverage for the procedure, and that on average the insurance covers 48

percent of the total cost. At a national level, this

means that recipients pay three-quarters of the

costs of artificial insemination out of their own

pockets.

Table2-52.-lnseminatlon Costs by

Physician Characteristica

(Question 60): b What do you estimate the average cost is to

your patient (or her insurance earner) for each subsequent

insemination?

Base: Have accepted 4 or more patients for artificial insemination

in the past year

Unweighed Mean

base c

cost

Total . . . . . . . . . . . . . . . . . . . . . (367) $92

Insemination patients/past year

4-10 . . . . . . . . . . . . . . . . . . . . . . . . . . . (1 15) 74

11-50 .., ., . . . . . . . . . . . . . . . . . . . . . (169) 93

51-100 . . . . . . . . . . . . . . . . . . . . . . . . ( 47) 100

>100 . . . . . . , . ( 36) 133

Proportion AIHd

100% . . . . . . . . . . . . . . . . . . ... . . ( 61) 30

75-99% . . . . . . ., ( 70) 103

25-74% . . . . . . . . . . . . . . . . . . . . (144) 97

O-24% . . . . . . . . . . . . . . . . . . . . . . ( 91) 115

Type of semen

Fresh ... . . . . . . . . . . . . . . . . . . . (loo) 77

Fresh/frozen . . . . . . . . . . . . . . . . . . . . (146) 106

Frozen . . . . . . . . . . . . . . . . . . . . . . . . ( 84) 112

Practice

Office . . . . . . . . . . . . . . . . . . . . . . . . . . (296) 88

Hospital . . . . . . . . . . . . . . . . . . . . . . . . ( 66) 113

Specialty

OB/GYN e . . . . . . . . . . . . . . . . . . . (307) 89

Other . . . . . . . . . . . . . . . . . . . . . . . . . . ( 53) 106

a The sample is the fertility society sample

b The code number of the question in the survey instrument (see app. B).

c Means are presented as weighted sample estimates. The unweighted sample base

is presented in parentheses so that the sampling variance for these estimates can

be calculated. Unweighed sample base does not add to 367 where physicians

failed to respond to particular question concerning demographic characteristic

d "Proportion AIH" means the proportion of the physician’s artificial insemination

practice in the past 12 months in which husband or partner sperm (rather than donor

sperm) was used

e Obstetrics/gynecology

SOURCE: Office of Technology Assessment, 1988.
5 0

Table 2-53. -Total Coat of Procedurea

(Question 59):b What do you estimate the average cost is to your patient (or her insurance carrier) for the consultations, examinations and

testing prior to the first actual insemination?

(Question 25):b Based on your experience, what is the average number of inseminations needed to achieve pregnancy?

(Question 60):b What do you estimate the average cost is to your patient (or her insurance carrier) for each subsequent insemination?

Base: Have accepted 4 or more patients for artificial insemination in the past year

Unweighed Initial Subsequent inseminations Total

bas e

c Number Cost per Total cost

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Insemination patients/past year

4-10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11-50, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

51-100 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

>100 . . . . . . . . . . . . . .

Proportion AIH d

100% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75-99% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-74% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

O-24% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Type of semen

Fresh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Fresh/frozen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Frozen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Practice

Office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(367) 7.0 $92 $953

(115)

(169)

( 47)

(36)

311

275

521

6.9

6.6

6.8

9.0

74

93

100

133

511

614

1197

822

889

945

1718

(61)

( 70)

(144)

(91)

145

372

357

5.7

8.5

6.8

7.0

30

103

97

115

171

876

316

1248

1017

1105

(100)

(146)

(84)

324

394

5.9

6.9

8.4

77

106

112

454

731

941

747

1055

1335

(296)

( 66) 376

7.2

6.2

88

113 701

932

1077

a The sample is the fertility society sample

b The code number of the question in the survey instrument (see app. B).

c Means are presented as weighted sample estimates. The unweighted sample based is presented in parentheses so that the sampIing variance for these estimates can be calculated

Unweighted sample base does not add to 367 where physicians failed to respond to particular question concerning demographic characteristic

d "Proportion AIH" means the proportion of the physician's artificial’s insemination practice in the past 12 months in which husband or partner sperm (rather than donor sperm) was

used

SOURCE: Office of Technology Assessment, 1988
51

STANDARDS, GUIDELINES, AND REGULATION

The majority of fertility society members who guidelines, but this sample is too small for confido artificial insemination on a regular basis re- dence in the estimate. Even this figure may overport that they are aware of specific professional estimate awareness in the total population of

guidelines for the selection of recipients or do- physicians doing artificial insemination, as those

nors for artificial insemination (76 percent). with only one to three patients a year were not

These findings, however, overstate general asked whether they are aware of professional

awareness of professional standards because the guidelines. There is a correlation between the

sample was drawn from the membership of two number of inseminations done per year and

national fertility organizations, one of which has awareness of standards (table 2-54), and physiissued guidelines and published them in the jour- cians with only one to three may be among

nal that all members automatically receive. By the least knowledgeable about professional

contrast, 44 percent of the cross-sectional sam- standards.

ple of physicians who have four or more insemination patients a year arc aware of professional

Table 2-54. -Awareness of Professional Guidelines ●

(Question 51):b Are you aware of any specific professional guidelines or suggested procedures for the selection of recipients or donors for

artificial insemination?

Base: Have accepted 4 or more patients for artificial insemination in the past year

Practice

only artificial sperm

Unweighed insemination bank No

basec Yes No by husband only response

Total (367) % 76

65

75

94

94

42

80

84

86

74

91

81

78

73

75

89

44

15 5 1 3

Insemination patients/past year

4-10

11- 50

51-10 0

> 10 0

0

1

0

0

(1 15)

(169)

( 47)

( 36)

%

%

%

%

20

17

6

3

12

4

0

0

4

3

2

3

Proportion AIH d

100%

75 99%

25 74 %

0 24%

( 61)

( 70)

(144)

( 91)

%

%

%

%

23

17

13

12

32

0

0

0

2

0

1

0

3

4

3

3

Practice

Office

Hospital

(269)

( 66)

%

%

17

6

6

3

1

0

3

0

Age

Under 3 5

35 to 4 9

50 or olde r

( 21)

(221)

(121)

%

%

%

14

16

14

5

5

7

0

1

0

0

<0.5

7

Sex

Mal e

Female ~

(339)

( 28)

( 36)

%

%

%

16

4

5

7

6

1

0

0

4

0

Cross-sectional Sample 39 11 e . . .

a Except as noted otherwise in last line, the sample is the fertility society sample.

b The code number of the question in the survey instrument (see app. B).

c Percentages are presented as weighted sample estimates. The unweighted sample base is presented in parentheses so that the sampling varience for these estimates can be

calculated. Unweighted sample base does not add to 367 where physicians failed to respond to particular question concerning demographic characteristic.

d "Proportion AIH" meams the proportion of the physician's artificial insemination practice in the pest 12 months in which husband or partner sperm (rather than donor sperm)

used

e Cross-sectional sample physicians who have accepted 4 or more patients for artificial insemination in the past year

SOURCE Office of Technology Assessment, 1988
52

Awareness of professional standards is important because it is virtually tantamount to

adoption of at least some of those procedures,

although the gap between professional society

recommendations and screening for infectious

and heritable diseases indicates that some physicians are ❑ ot following all the guidelines of

which they are aware. Guidelines include procedures for screening recipients and donors, quarantining semen, and testing semen for motility,

morphology, and other fertility indicators.

Among those aware of such guidelines or procedures, 9 out of 10 have adopted those standards

(table 2-55), with adoption widespread even

among practices with only 4 to 10 patients (86

percent) and those that do only AIH (72 percent).

Among those who have adopted some professional guidelines, the vast majority report that

they use those of the American Fertility Society

(85 percent) (see box 2-A). The other guidelines

used by significant numbers of practitioners are

those of the American College of Obstetricians

and Gynecologists (ACOG) (7 percent) and the

American Association of Tissue Banks (6 percent) (AATB). ACOG, it should be noted, has

adopted the guidelines of the American Fertility

Society. IMTB, an organization concerning itself

with tissue banking in general, issues standards

Table 2-55.-Adoption of Professional Guidelines a

(Question 59):b Have you adopted any of these guidelines or procedures as your protocol for artificial insemination?

Base: Accepted 4 or more patients for artificial insemination in the past year and are aware of guidelines

Practice

only artificial

Unweighted insemination No response/

basec

Yes No by husband not applicable

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (278)

Insemination patients/past year

4-10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 74)

11-50 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (127)

51-100 ...., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 43)

>100 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 34)

Proportion AIH d

100% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 25)

75-99% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 55)

25-74% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (120)

O-24% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 77)

Practice

Office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (217)

Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 60)

Age

Under 35 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 17)

35 to 49 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (172)

50 or older . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 66)

sex

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (253)

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 25)

Cross-sectional sample?. . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 16)

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

91

86

91

93

94

72

94

91

94

89

97

88

92

89

90

100

81

8

11

8

7

6

20

6

8

6

10

3

12

7

10

9

0

19

<0.5

0

1

0

0

4

0

0

0

<0.5

0

0

0

1

<0.5

0

0

1

3

0

0

0

4

0

1

0

1

0

0

1

0

1

0

0
53

Box 2-A.-American Fertility Society Guidelines for Physician Practice of Artificial Insemination by Donor

In 1986, the American Fertility Society issued revised guidelines for physician practice of artificial insemination by donor. They called for “careful consideration . . . to the possible need for psychologic evaluation and

counseling” for the recipient and her partner, appropriate warnings of the emotional and psychological risks of

the procedure, evaluation and correction if possible of any male partner infertility before resorting to AID, and

careful evaluation of the recipient’s reproductive health, including tests for antibodies to HIV and

cytomegalovirus (CMV).

Sperm donors are to have their sperm screened for motility, morphology, concentration, and other indicators

of fertility, and donors themselves are to undergo physical examination and blood testing for indications of syphilis, hepatitis B, gonorrhea, chlamydia, CMV, and HIV infection. The guidelines do not direct physicians to reject

donors testing positive to CMV, as some physicians might still choose to use them for women who also test

positive. Rescreening at 6-month intervals is suggested for all but syphilis. Fresh semen donation was permitted

under the 1986 guidelines, with proper attention given to identifying donors at higher than average risk for HIV

infection. Matching to recipient-specified physical characteristics was deemed appropriate, but mixing of donor

and husband sperm was discouraged, as possibly interfering with fertilization.

In 1988, the American Fertility Society revised its guidelines to suggest to practitioners that they use only

frozen semen following a minimum 6-month quarantine and after the donor had been retested and found once

again to be seronegative to HIV. The AFS announcement coincided with announcements by the Centers for

Disease Control and the Food and Drug Administration to the same effect.

SOURCES: American Fertility Society, “New Guidelines for the Use of Semen Donor Insemination: 198&- Fertility and Sterility 46 (Supp. 2): 95S-110S, 1986 American Fertility

Society, “Revised New Guidelines for the Use of Semen-Donor Insemination,” Fertility and Sterility 49: 211, 1988 U.S. Department of Health and Human Servces.

Public Health Service. Centers for Disease Control. “Semen Banking, Organ and Tissue Transplantation, and HIV Antibody Testing.” Morbidity and Mortality Weekly

Report 37:57-63, 1986.

that are mandatory for its member sperm banks. use or homosexual contacts) and rejecting doThe other practitioners who have adopted professional guidelines report using those of their

sperm bank (3 percent), their own guidelines (4

percent), or some other guidelines (6 percent)

(table 2-56).

The widespread adoption of some of the AFS

guidelines by practitioners has to be qualified by

the recognition that the vast majority of the sample are members of AFS. Yet the same can be

said about the vast majority of physicians who

conduct artificial insemination on a regular basis.

Although the cross-sectional sample is too small

for any confidence in its estimates, over half the

practitioners in this sample who use professional

guidelines also use AFS guidelines.

As noted above, AFS guidelines changed in

early 1988, in conjunction with a joint statement

from the Centers for Disease Control and the

Food and Drug Administration (U.S. DHHS,

1988). This survey, conducted in 1987, reflects

adherence to earlier professional society guidelines, which permitted donation of fresh semen

but recommended taking a medical history that

would elicit risk factors (such as intravenous drug

nors who appeared to be at risk. - -

Adequacy of Professional Practices

Most physicians regularly doing artificial insemination feel current practices are adequate

or more than adequate to protect donors’ privacy

(89 percent), recipients’ safety (83 percent), offsprings’ rights (80 percent), and physicians’ freedom from liability (59 percent) (table 2-57).

Thirty-five percent of the physicians feel that

protection against liability is inadequate. Survey

data indicate that the incidence of legal problems

is 2 percent among those with 4 to 10 patients a

year, 4 percent among those 11 to 100 patients

per year, and 11 percent for those with more than

100 patients annually. Legal problems can be associated, for example, with screening for sexually

transmitted or genetic diseases. Insurance, while

available, can be quite expensive (Rothman,

1988).

Quality Assurance

A majority of practitioners regularly doing artificial insemination (i.e., accepting more than

four insemination patients a year) approve of the

current situation regarding involvement of State
54

Table 2-56.-Guideiines Useda

(Question 53):b What is the name of those guidelines that you use? (verbatim)

Base: Accepted 4 or more patients for artificial insemination in the past year and have adopted guidelines

Unweighed Sperm bank Own Other Don’t

baseg

AFS C ACOGd AATBe guidelines guidelines guidelines know

Totalf

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (252) % 85

73

88

95

88

83

86

84

86

83

91

93

85

85

85

92

54

7

11

5

5

6

0

4

7

10

8

3

0

6

9

8

0

15

6 3 4 6 4

8

3

0

3

6

4

1

7

5

0

0

4

4

4

0

0

Insemination patients/past year

4-10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 64)

11-50 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (116)

51-100 . . . . . . . . . . . . . . . . . . . . ( 40)

>100 . . . . . . . . . . . . . . . . . . . ( 32)

%

%

%

%

o

4

10

22

6

4

0

0

5

2

8

3

3

6

10

3

Proportion AIH h

100% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 18)

75-99% . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 52)

25-74% . . . . . . . . . . . . . . . . . . . . . . . . . . . (109)

O-24% . . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 72)

%

%

%

%

o

2

6

0

11

0

4

4

6

12

5

3

6

8

6

4

Practice

Office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (193)

Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 58)

4

3

5

9

%

%

7

5

4

0

Age

Under 35 . . . . . . . . . . . . . . . . . . . . . . . . . . ( 15)

35 to 49 . . . . . . . . . . . . . . . . . . . . . . . . . . . (158)

50 or older . . . . . . . . . . . . . . . . . . . . . . . . . ( 78)

o

3

4

7

1

6

7

6

5

%

%

%

o

8

5

sex

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (227)

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 25)

5

8

%

%

4

0

4

0

7

4

Cross-sectional sample 0 23 i . . . . . . . . . . . . . . . . ( 13) % o 0

a Except as noted otherwise in last line, the sample is the fertility society sample.

b The code number of the question in the survey instrument (see app. B).

c American Fertility Society.

d American College of Obstetricians and Gynecologists

e American Association of Tissue Banks.

f Since multiple choices were permitted, percentages may add to more than 100%.

g Percentages are preseanted as weighted sample estimates. The Unweighted sample base is presented in parentheses so that the sampling variance for these estimates can be

calculated Unweighed sample base does not add to 252 where physicians failed to respond to particular question concerning demographic characteristic

h "Proportion AIH" means the proportion of the physician's artificial insemination practice in the past 12 months in which husband or partner sperm (rather than donor sperm) was

used

i Cross-sectional sample physicians who have accepted 4 or more patients for artificial insemination in the past year, and who adopted guidelines

SOURCE: Office of Technology Assessment, 1968

A minority would like to see the current involvement of Federal public health agencies (29

percent) and State public health agencies (23

percent) either reduced or eliminated. A somewhat smaller minority, on the other hand, would

like to see Federal (12 percent) and State (16

percent) public health agencies more involved.

public health agencies (56 percent), local medical

boards (54 percent), Federal public health agencies (52 percent), and national medical societies

(51 percent) with respect to artificial insemination (table 2-58). Nearly half, however, would

like to see the involvement of courts either decreased (12 percent) or eliminated (36 percent),

and that of hospital professional review organizations either decreased (9 percent) or eliminated (40 percent). In contrast, 34 percent would

like to see the involvement of national medical

societies increased.

National Standards

Most physicians regularly doing artificial insemination favor national standards (unspecified as voluntary or mandatory) for donor
55

Table 2-57.-Adequacy of Professional Practicesa

(Question 54):b How adequate do you think that present professional practices of artificial insemination are in terms of protecting the:

Base: Have accepted 4 or more patients for artificial insemination in the past year

Unweighed base (367) c Practice

More Less only artificial sperm

than than insemination bank Don’t

adequate Adequate adequate by husband only know

Donor’s privacy . . . . . . . . . . . . . . . . . . . . ... . . . . % 34 55 5 2 0 4

Recipient’s safety . . . . . . . . . . . . . . . % 22 61 11 2 0 4

Offspring’s rights . . . . . . . . . . . . . . . . . . . . . . . . . % 18 62 12 2 0 6

Physician’s liability . . . . . . . . . . . . . . . . . . . . % 9 50 35 2 0 4

a The sample is the fertility society sample.

bThe code number of the question in the survey instrument (see app. B).

c Percentages are presented as weighted sample estimates. The unweighted sample base is presented in parentheses so that the sampling variance for these estimates can be

calculated

SOURCE: Office of Technology Assessment, 1988

Table 2-58. - Roles in Quality Assurance’

(Question 55):b For each of the following agencies, would you Iike to see their involvement in the quality assurance of artificial insemination

procedures increased, remain the same, decreased, or eliminated?

Base: Have accepted 4 or more patients for artificial insemination in the past year

Unweighed base (367) c Remain Don’t

Increased the same Decreased Eliminated know

National medical societies . . . . . . . . . . . . . . . . . . . . . . . % 34 51 2 7 6

Local medical boards . . . . . ., . . . . . . . . . . . . . % 16 54 3 22 6

State public health agencies . . . . . . . . . . . . . . . . . . . . . . . . % 16 56 7 16 6

Federal public health agencies . . . . . . . . . . . . . . . . . . . . . . . . . . % 12 52 8 21 6

Hospital peer review organizations ., . . . . . . . . . . . . . . . . . . . . . . . . % 6 39 9 40 7

courts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . % 6 40 12 36 6

a The sample IS the fertility society sample

b The code number of the question in the survey instrument (see app. B).

c Percentages are presented as weighted sample estimates. The unweighed sample base is presented in parentheses so that the sampling variance for these estimates can be

calculated

SOURCE Office of Technology Assessment, 1988

screening by sperm banks (80 percent), donor

screening by private practitioners (68 percent),

recipient screening (57 percent), and recordkeeping (58 percent) (table 2-59), but strongly

oppose releasing identifing information about

sperm donors to any children conceived with

those individuals’ sperm. Support for national

standards for donor screening did not significantly vary with size of practice, age or sex of the

physician, or whether the practice was office-or

hospital-based. Standards for recipient screening engendered the same uniformity of support,

except that smaller, office–based practices were

somewhat less enthusiastic, perhaps reflecting

the fact that physicians with those practices tend

to do more AIH than AID.

Regulation of surrogate motherhood, an arrangement in which a woman is artificially inseminated with the intention of relinquishing the

child at birth to the genetic father, should take

place on the State (29 percent) or Federal (42

percent) level, according to fertility society practitioners regularly doing artificial insemination,

but a substantial minority (27 percent) feel no

law should regulate this variation on artificial in-
56

Table 2-59.-National Standards for

Artificial Inseminatlon.

semination practice (table 2-60). Support for

regulation was somewhat greater among

(Question 56):b Would you tend to favor or oppose the establish- younger, female, and hospital-based physicians

ment of national standards for artificial insemination for: with large practices.

Base: Have accepted 4 or more patients for artificial insemination

in the past year

Unweighed base (367) c Don’t

Favor Oppose know

Donor screening by sperm banks . . % 80 15 5

Donor screening by private

practitioners . . . . . . . . . . . . . . . . . . % 68 26 5

Recordkeeping requirements . . . . . . % 58 37 5

Recipient screening . . . . . . . . . . . . . . % 57 38 6

a The sample is the fertility society sample.

b The code number of the question in the survey instrument (see app. B).

c Percentages are presented as weighted sample estimates. The unweighted sample

base is presented in parentheses so that the sampling variance for these estimates

can be calculated

SOURCE: Office of Technology Assessment, 1988

Table 2-60.– Regulation of Surrogate Motherhood ●

(Question 57): bDo you believe that the procedures for surrogate motherhood should be regulated by federal legislation, state legislation or

not regulated by legislation?

Base: Have accepted 4 or more patients for artificial insemination in the past year

Do not

believe in

Unweighed Federal State No surrogate Don’t

baseclaw law law motherhood know

Total ... . . . . . . . . . . . . . ... . . .

Insemination patients/past year

4-10. , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11-50 ......, . . . . . . . . . . . . . . . . . . . . .

51-100 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

>100 . . . . . . . . . . . .

Practice

office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . .

Age

Under 35 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35 to 49 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

>50 . . . . . . , . , . . . . . . . . . . .

sex

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(367) % 42 29 27 1 5

11

2

4

3

4

4

5

4

7

5

4

(1 15)

(169)

( 47)

( 36)

%

%

%

%

35

47

44

42

27

28

28

39

27

28

28

19

0

1

0

0

(296)

( 66)

%

%

41

53

28

33

30

15

<0.5

0

( 21)

(221)

(121)

52

44

38

33

32

23

%

%

%

19

24

33

0

< 0 5

1

(339)

( 28)

%

%

42

43

28

46

28

18

1

0

a The sample is the fertility society sample

b The code number of the question in the survey instrument (see app. B).

c Percentages are presented as weighted sample estimates. The unweighted sample base is presented in parentheses so that the sampling variance for these estimates can be

calculated. Unweighted sample base does not add to 367 where physicians failed to respond to particular question concerning demographic characteristic

SOURCE: Office of Technology Assessment, 1988
5 7

GENERAL PHYSICIAN ATTITUDES

The survey instrument asked all physicians, regardless of the size of their artificial insemination practice, to respond to a series of questions

concerning their attitudes toward the practice.

Physicians as a whole split almost evenly over

whether requests for artificial insemination

ought to be honored ‘regardless of marital

status or sexual orientation” (table 2-61). Looking more closely at those who are fertility society

members, those “agreeing strongly” were equally

likely to be male or female, younger or older.

Those disagreeing strongly were more likely to

be older. Data concerning the attitudes of female

physicians are subject to error due to the small

size, but indicate that a larger percentage of female physicians than male physicians disagree

strongly with the statement.

With regard to self-insemination, once again

physicians split over whether this is a ‘reasonable alternative to physician assisted insemination” (table 2-62). Neither fertility society members (10 percent) nor physicians from the

cross-sectional sample (8 percent) strongly

agreed with the statement. In each case, an additional third of the respondents agreed “somewhat” with the statement. Here, female physicians showed a significantly greater tolerance for

self-insemination than did male physicians, as

did those with smaller practices compared with

those with larger practices. This latter finding

may reflect the greater proportion of AIH cases

seen by those with smaller practices.

Table 2-61. - Recipient Acceptance Factorsa

(Question 63d):b Patient requests for artificial insemination should be honored, regardless of marital status or sexual orientation.

Base: Have accepted 4 or more patients for artificial insemination in the past year

Unweighed Agree Agree Disagree Disagree Don’t

basecstrongly somewhat somewhat strongly know

Total

Fertility society sample ., . . . . . . . . . . (646)

Cross-sectional sample ... . . . . . . . . . . . (827)

Insemination patients/past year

None . , (155)

1 3 . . . . . . . . . . . .:.:,:.::::”:,: :::::::’:”::: (122)

4-10. ... . . . . . . . . . . . (1 15)

11-5 0 . . . . (169)

51-100. . : : : : : . . . ., ., ( 47)

>100 . . . ( 36)

Recipients rejected in past

None . . . . ... . (166)

1 -4., . . . . . . ., : : : : : : : ., . . . . . . . ., . . . . ( 68)

>5 . . . (131)

Age

Under 35 . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 38)

35 to 49 . ., (367)

>50 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (232)

sex

Male . . . . . . . . . . . . (594 )

Female . . . . . . ., ~ ( 50)

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

10

9

24

19

27

29

37

40

2

4

11

9

5

13

6

22

24

32

22

19

35

16

24

28

32

26

26

24

39

30

39

41

33

38

2

1

2

2

2

0

14

9

7

24

18

21

34

22

23

27

51

48

1

2

2

11

10

10

32

23

25

35

28

24

24

38

40

0

1

1

10

10

24

28

28

10

36

48

1

4

a Except as noted in second line, the sample is the fertility society sample.

b The code number of the question in the survey instrument (see app. B).

c Percentages are presented as weighted sample estimates. The unweighted sample base is presented in parentheses so that the sampling variance for these estimates can be

calculated. Unweighted sample base does not add to 646 where physicians failed to respond to particular question concerning demographic characteristic

SOURCE: Office of Technology Assessment, 1966
58

Table 242. - Self Insemination a

(Question 63c): b Self insemination is a reasonable alternative to physician assisted insemination in many cases.

Unweighed Agree Agree Disagree Disagree Don’t

base’ strongly somewhat somewhat strongly know

Total

Fertility society sample . . . . . . . . . . . . . . . . . . . . . . . . . . . (646)

Cross-sectional sample . . . . . ., . . . . . . . . . . . . . . . . . (827)

Insemination patients/past year

None . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (155)

1-3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (122)

4-10 (1 15)

11-50 “:: :::::::::::::::::::::::::::::::::: (169)

51-100, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 47)

>100 . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 36)

%

%

%

%

%

%

%

%

%

%

10

8

10

12

5

13

6

3

9

14

34

33

40

37

28

34

37

22

33

46

29

26

24

24

42

29

33

24

30

18

24

23

20

25

21

23

22

49

24

18

3

9

6

2

3

1

4

3

3

4

a Except as noted in second line, the sample is the fertility society sample

b The code number of the question in the survey instrument (see app. B).

c Percentages are presented as weighted sample estimates. The unweighted sample base is presented in parentheses so that the sampling variance for these estimates can be

calculated. Unweighted sample base does not add to 646 where physicians failed to respond to particular question concerning demographic characteristic

SOURCE. Office of Technology Assessment, 1988

Offspring rights to ‘communicate with their

genetic fathers” were uniformly and strongly opposed by the surveyed physicians, regardless of

age, sex, or size of practice, although members of

a fertility society were distinctly more likely (74

percent) than physicians from the cross-sectional sample (48 percent) to strongly oppose

them (table 2-63).

The issue on which physicians’ exhibited the

greatest diversity of attitudes concerned favored

trait specialization (table 2-64). When asked if

they agreed that “there is nothing wrong with

sperm banks that specialize in donors with intellectual, artistic, or athletic gifts,” 58 percent of

the fertility society practitioners and 49 percent

of the cross-sectional physicians strongly or

somewhat agreed. Women were somewhat less

likely than men to agree, and physicians under

age 35 or with practices of over 100 insemination

patients a year were the least likely to strongly

agree. Nevertheless, in general, roughly equal

proportions of physicians agreed strongly,

agreed somewhat, disagreed somewhat, or disagreed strongly with the statement.
5 9

Table 2-63.-Offspring Rights a

(Question 63e): b Offspring of artificial inseminations should have a right to communicate with their genetic fathers.

Unweighed Agree Agree Disagree Disagree Don’t

basecstrongly somewhat somewhat strongly know

Total

Fertility society sample . . . . . . . . . . . . . . . . . ... . .

Cross-sectional sample ... . . . . . . . . . . . . . . . . . . .

Proportion AIHd

100% ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75-99% . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-74% . . . . . . . . . . . . . . . . . . . . . . . . . . .

0-24% .. . . . . . . . . . . . . . . . .

sex

Male . . . . . . .

Female. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(646)

(827)

(61)

( 70)

(144)

(91)

(594)

( 50)

%

%

%

%

%

%

%

%

3

6

3

3

1

1

3

0

6

15

8

1

2

4

6

4

15

25

20

14

9

10

15

16

74

48

68

78

87

83

75

72

2

6

0

3

1

1

1

8

a Except as noted in second Iine, the sample is the fertility society sample.

b The code number of the question in the survey instrument (see app. B).

c percentage are presented as weighted sample estimates. The unweighted sample base is presented in parentheses so that the sampling variance for these estimates can be

calculated. Unweighted sample base does not add to 646 where physicians failed to respond to particular question concerning demographic characteristic

d "Proportion AIH" means the proportion of the physican's artificial inseminatlon practice in the past 12 months in which husband or partner sperm (rather than donor sperm) was

used

SOURCE Office of Technology Assessment, 196$
6 0

Table 2-64. - Favored Trait Specialization a

Unweighed Agree Agree Disagree Disagree Don’t

base’ strongly somewhat somewhat strongly know

Total

Fertility society sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . (648)

Cross-sectional sample . . . . . . . . . . . . . . . . . . . . . . . . . . . (827)

%

%

22

17

36

32

22

21

19

26

2

4

2

2

2

1

2

0

0

3

1

1

0

<0.5

2

2

4

Insemination patients/past year

None ... ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (155)

1-3 ...., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (122)

4-1o . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (115)

11-50 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (169)

51-100 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 47)

>100 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 38)

%

%

%

%

%

%

21

24

30

20

13

8

31

45

37

35

30

30

22

20

18

28

17

32

23

10

13

16

39

30

Proportion AIHd

100% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 61)

75-99% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 70)

25-74% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (144)

O-24% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (91)

%

%

%

%

23

29

18

20

35

36

38

32

23

20

23

27

20

13

21

21

Age

Under 35 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 38)

35 to 49 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (387)

>50 .,,,,,,,, ,,,,,,,,,,,,,,, ,,, ....... .

(232)

%

%

%

8

23

23

62

35

33

30

22

22

3

19

21

sex

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (594)

Female . . . . . . . . . . . . . . . . . . . . . . ., . . . . . . . . . . . . . . . . . ( 50)

%

%

22

18

36

24

22

30

18

24

a Except as noted in second Iine, the sample is the fertility society sample.

b The code number of the question in the survey instrument (see app. B).

CPercentages are presented weighted sample estimates. The unweighted sample base is presented in parentheses so that the sampling variance for these estimates can be

calculated. Unweighted sample base does not add to 646 where physicians failed to respond to particular question concerning demographic characteristic.

d "Proportion AIH" means the proportion of the physician’s artificial insemination practice in the past 12 months in which husband or partner sperm (rather than donor sperm) ‘as

used

SOURCE: Office of Technology Assessment, 1988

CHAPTER 2 REFERENCES

Mikesell, S., Washington, DC, personal communication, Apr. 29, 1988.

Raboy, B., Director, Sperm Bank of Northern

California, Oakland, CA, personal communication, Dec. 22, 1986.

Rothman, C., Director, Southern California

Cryobank, Century City, CA, personal communication, May 2, 1988.

U.S. Congress, Office of Technology Assessment, Infertility: Medical and Social Choices,

OTA-BA-358 (Washington, DC: U.S. Government Printing Office, 1988).

U.S. Department of Health and Human

Services (U.S. DHHS), Public Health

Service, Centers for Disease Control, “Semen

Banking, Organ and Tissue Transplantation,

and HIV Antibody Testing,” Morbidity and

Mortality Weekly Report 37;57-63, 1988.
n
CONTENTS

Page

Recipient Specifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Donor Selection . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Donor Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Recordkeeping ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Quality Assurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Attitudes ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Boxes

Pages
Chapter 3

Survey Data: Sperm Bank Practice

Commercial sperm banks provide donor semen to 52 percent of the physicians in the fertility society sample, drawn from the American

Fertility Society and the American Society of

Andrology members, who regularly perform artificial insemination (i.e., more than four insemination patients per year). Hospital-based sperm

banks also supply semen (see ch. 2) but not as frequently (see box 3-A). Most of the 15 facilities

that responded to the survey store semen for

both artificial insemination by husband (AIH)

and artificial insemination by donor (AID), although 2 sperm banks reported providing services only for the latter.

Men most commonly apply to store semen in

order to preserve their future ability to have children. Reported reasons include “about to undergo vasectomy” (13 of 15 banks), “fear of gamete damage due to radiation or chemotherapy”

(13 of 15), unspecified “fear of future infertility”

(8 of 15), “fear of damaging occupational exposures” (7 of 15), “geographical separation from

spouse” (4 of 15), “back-up for in vitro fertilization or gamete intrafallopian transfer” (4 of 15),

and “desire to have children after death”

(1 of 15).

Slightly more than half the sperm banks (8 of

15) require consent of a man’s spouse before

they will agree to store specimens for possible future use in AIH. All the banks charge an upfront

fee of, on average, $100, but fees may range from

$40 to $350 and often include the first year of

storage. Fourteen sperm banks reported they

will store specimens for as long as requested. The

average storage fee was $84, and ranged from

$12 to $200.

In the event of a donor's death, 12 of 15 sperm

banks claim to apply specific protocols to manage specimens stored for artificial insemination

by husband. Almost half (7 of 15) will request instructions from the deceased’s wife or relatives

and will respond accordingly. Another 7 of the

sperm banks will destroy the specimen in case of

a man’s death, and specify no other procedure.

However, 12 of 15 banks claimed that they would

honor instructions from the donor for postmortem insemination of a spouse or designated representative of the estate.

The sperm banks in the survey tend to sell

samples from anonymous donors to doctors

rather than directly to recipients: Of the 15 facilities sampled, 9 will sell samples only to doctors and 5 will sell samples to both doctors and

recipients (1 bank did not respond). (See box

3-B for information on one bank that will teach

women self-insemination. ) No banks reported

selling samples only to recipients. The number of

semen samples sold for AID varies widely. Based

on their responses, in the course of 1 month an

average of 300 semen samples are sold, but the

number can range anywhere from 5 to 2,000 samples per month. The standard charge is on average $83, but it ranges from $50 to $125.

RECIPIENT SPECIFICATIONS

Almost half the sperm banks (7 of 15) reported Only 9 facilities responded to the survey question

that they would reject requests for specimens if on recipient rejection, however; most that did

the recipient, as reported by her physician or as not respond claimed that they were not involved

seen by them, seemed unsuitable. Two indicated with recipient selection. The 9 sperm banks rethat such recipient qualification decisions are the spending were most likely to reject a recipient

responsibility of the physician handling the case. who is HIV-positive (6 of 9) or who shows evi63
64

Box 3-A.–Hospital-Based Sperm Bank Practice

In the summer of 1986, Dr. William Schlaff of the Johns Hopkins University and Dr. Janet Kennedy of the

University of Maryland surveyed hospital-based sperm banks providing artificial insemination by donor. Four

hundred facilities associated with obstetrics/gynecology departments around the country were identified and

asked to respond to a survey questionnaire concerning their practice and protocols. One hundred and thirty

responded, but a number incompletely filled out the survey questionnaire. Thus, the number responding to

each question varies somewhat.

The respondents included 35 public facilities in existence an average of 8.4 years (range, 1 month to 25

years) and 32 private facilities in existence an average of 10 years (range, 6 months to 35 years). Overall, these

facilities averaged nearly 27 inseminations per month.

Sixty-four of 64 facilities screened donors with an interview, oral genetic history, blood screen, and medical

history. Thirty-six of 61 (59 percent) performed a physical examination, and 12 of 64 (19 percent) did a

karyotype. These proportions are similar to the 10 of 15 commercial facilities surveyed by OTA that performed a physical examination, and 5 of 15 that did a karyotype.

Donors were also screened for a variety of infectious diseases. Sixty-two of 64 (97 percent) screened for

human immunodeficiency virus (HIV) infection, with 36 facilities (56 percent) doing followup testing on average every 4.7 months. Syphilis was screened for by 55 of 62 (88 percent) hospital-based facilities, with 24 (38

percent) doing repeat testing. Fifty-four of 64 (84 percent) screened for hepatitis, with 22 (34 percent) repeating the test within a year. As hospital-based sperm banks, drawing largely on medical staff for donors, the risk

of hepatitis infection within the donor pool is particularly acute. Fifty-one of 74 (69 percent) screened for

gonorrhea, with 24 (32 percent) doing followup testing. Chlamydia was screened for by 41 of 64 (64 percent),

with 18 (28 percent) doing repeat tests. A minority of hospital-based facilities tested for mycoplasma (28 of

64), cytomegalovirus (20 of 64), and herpes (10 of 64).

Followup testing is of interest, because 22 of 67 (33 percent) facilities used fresh semen only, and another 29

(44 percent) used a mix of fresh and frozen; without retesting, it is not possible to be sure that the donor is still

free of transmissible diseases, and HIV infection may not be detectable until several months after a donor has

had contact with the virus. Therefore, his semen may be carrying the virus even if he tests negative. To avoid

this problem, commercial sperm banks surveyed by OTA in 1987 generally quarantined a frozen specimen,

releasing it only after the donor retested negative.

Public facilities paid donors an average of $34 per visit, while private facilities offered an average of $44.

Forty-one of 61 facilities had a limit of 2 to 20 (average, 9) pregnancies that could be initiated by the same

donor. Nineteen of 62 facilities would sometimes tell donors whether pregnancies had occurred with their

semen, with one facility doing this routinely. However, the genetic parentage might not be readily apparent; 20

of 67 facilities reported that they mix donor semen with that of the recipient’s husband.

SOURCE: W. Schlaff, Johns Hopkins University, personal communication. Jan. 5, 1988.

dence of drug abuse, alcohol abuse, or child weight, eye color, hair texture, and body type.

abuse (5 of 9) (table 3-l). Psychological immaturity and diseases such as hepatitis or cytomegalovirus are also conditions that determine rejection for 4 of 9 facilities. Sexually transmitted

diseases such as syphilis and gonorrhea were

cited by 3 of 9 banks as reasons for rejection.

All 15 of the sperm banks in the survey reported that they would allow recipients or their

physicians to provide specifications for particular donor traits. Nearly all the banks (14 of 15)

match physical characteristics such as height,

Similarly, 14 facilities match recipients and donors by race, ethnic group, or national origin (table 3-2). Twelve will match by religion and 11 by

educational attainment, special abilities, hobbies, or interests. Seven sperm banks are willing

to match by intelligence quotient. Income is the

characteristic that sperm banks are least willing

to match (3 of 15).

Another option available to recipients is

sperm separation for preconception sex selection. Slightly more than half the banks (8 of 15)
65

offer this service. The average charge for preconception sex selection is $220, and can range anywhere from $140 to $400. The survey, being retrospective, cannot substitute for a clinical trial of

Box 3-B.–The Sperm Bank of

Northern California

Oakland, CA, is home to the Sperm Bank of

Northern California, a feminist-run facility known

as one of the minority of sperm banks in the

United States committed to providing artificial insemination services to any healthy woman or couple regardless of marital status, sexual preference,

age, race, or religion. The most notable fact about

the Sperm Bank of Northern California is its commitment to providing services to single and lesbian

women.

Unlike some facilities, the Sperm Bank of

Northern California offers artificial insemination

services as well as distributing semen nationwide.

Insemination can be done by sperm bank personnel, or women can choose to be taught to self-inseminate, at home or in a room provided for that

purpose at the facility.

Recipient screening and counseling is rather

stringent. The facility requires women to attend

an orientation session describing the medical and

legal risks of artificial insemination, and counseling is available upon request before undergoing

insemination. Women are also required to undergo a physical examination to identify any fertility problems or risks associated with pregnancy before insemination is available. The screening process may take as long as a month. Women who are

emotionally disturbed or addicted to drugs or alcohol will not be accepted; rather, they are referred

for counseling, and may be accepted after completing therapy.

The facility’s donor screening practices accord

with those of the most rigorous banks, but its donor population is somewhat unique; this facility

seeks donors who are willing to donate without pay

and to be contacted by their offspring. Although

donors who wish to remain anonymous are accepted, information about their willingness to be

contacted is provided to recipients before their semen is chosen.

SOURCE : B. Raboy, Director. Sperm Bank of Northern California, Oakland.

CA. personal cornmunication, Dec. 22, 19&6.

the efficacy of sperm separation techniques, but

in general the survey data did not indicate that

the methods are unequivocally effective.

Table 3-1.-Crlteria for Rejection: Recipients”

(Question 10b):b Have you ever rejected or would you be likely to

reject a request for artificial insemination from a potential recipient

because she was /has:

Would be Not

Have likely to likely to

rejected reject reject

Over 40 years old . . . . . . . . . . . . 1 c

Less than average intelligence . . 1

Less than high school degree . . 1

Gonorrhea . . . . . . . . . . . . . . . . . . 2

Cytomegalovirus . . . . . . . . . . . . . 1

Syphilis . . . . . . . . . . . . . . . . . . . . 1

Genital herpes. . . . . . . . . . . . . . . 1

Welfare dependent . . . . . . . . . . . 0

Less than 18 years old . . . . . . . . 1

Hepatitis . . . . . . . . . . . . . . . . . . . 1

History of serious

genetic disorders . . . . . . . . . . 1

Criminal record . . . . . . . . . . . . . . 1

Evidence of drug abuse . . . . . . 2

Evidence of alcohol abuse . . . . 2

Psychologically immature . . . . 1

HIV (HTLV) positive . . . . . . . . . 1

Evidence of child abuse . . . . . . 1

0

0

0

1

3

2

1

2

3

3

2

2

3

3

3

5

4

5

5

5

4

4

4

4

4

3

3

3

3

2

2

2

0

0

a The sample IS the sperm bank sample.

b The code number of the question in the survey instrument (see app. B)

C Responses are not weighted. Not all sperm banks answered all questions

SOURCE: Office of Technology Assessment, 1988

Table 3-2.-Specific Donor Characteristics a

(Question 11):b Which of the following donor characteristics are

you normally willing to try to match, if requested?

Not

Willing willing

Race . . . . . . . . . . . . . . . 14 c

Body type . . . . . . . . . 14

Weight ... . . . . . . . . . . 14

Eye color . . . . . . . . . . 14

Height ., . . 14

Hair texture ., . . . . . . . . . ., ., 13

Complexion . . . . . . . . . . . 13

Ethnic/national origin 13

Religion . . . . . . . . . . . . 12

Educational attainment . . . . . 11

Special abilities . . . . . . . . . . . . 11

Hobbies or interests . . . . . . . . . . . . . . . 11

Age . . . . . . . . . . . . . . . . . . . . . . . 10

I.Q. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Income . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

0

0

0

0

0

0

1

1

3

3

3

3

4

7

11

a The sample is the sperm bsnk sample

b The code number of the question in the survey instrument (see app. B).

C Responses are not weighted. Not all sperm banks answered all questions.

SOURCE: Office of Technology Assessment, 1988
66

DONOR SELECTION

Sperm banks obtain donors using a variety of

formal and informal methods (table 3-3). Almost all (13 of 15) state that “word of mouth” is a

useful means of acquiring donors. Another common method (reported by 9 of 15 banks), especially for facilities located near universities, is

various advertising vehicles such as student

newspapers or magazines. Referrals from other

sperm banks, physicians, other health care professionals, or other donors were also cited as a

method to recruit donors.

Table 3-3.-Obtaining Donors a

(Question 15):b How do you obtain donors?c’

d

Word of mouth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Advertisement in student newspapers

or magazines . . . . . . . . . . . 9

Advertisement in general interest newspapers

or magazines . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Flyers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Direct mail or telephone solicitation . . . . . . . . . . . . . . . . . . . . 3

Referral from another sperm bank . . . . . . . . . . . . . . . . . . . . . 2

Referral from physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Because sperm banks are most often located in

or near universities and hospitals, their inventories are characteristically dominated by donors

who live or work in these areas. All the facilities

mentioned that their inventories contain samples

from students (undergraduate, graduate, or

medical); in some cases almost 90 percent of

a sperm bank’s inventory is specimens from

students. Other common sources include

physicians, hospital personnel, and nonhospital

personnel.

A majority of sperm banks claim that their inventories contain an overrepresentation of donor characteristics such as ‘college or graduate

degree holder” (12 of 15), ‘better than average

IQ” (8 of 15), and ‘better than average occupational status/achievements” (7 of 15) (table 3-4)

(see box 3-C). There is, however, an “about normal” representation of religious groups or

nationalities, as stated by 12 of 15 banks.

a The sample is the sperm bank sample

b The code number of the question in the survey instrument (see app. B).

c Answers not mutually exclusive

d Responses are not weighted Not all sperm banks answered all questions

SOURCE: Office of Technology Assessment, 1988

Table 34.-Sperm Donor Characteristic Inventory

(Question 14):b Are the following characteristics deliberately overrepresented in your inventory, deliberately underrepresented, or about

normal? c

Over- Under- About Not

represented represented normal sure

College/graduate degree holder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12C o 2 0

Better than average IQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 0 5 1

Better than average occupational status/achievements . . . . . . . . . . . . . . . . . . . . 7 0 6 1

Greater than average height for ethnic group . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 0 12 1

Better than average athlete . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 0 11 2

Better than average looks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 0 7 2

Better than average artistic ability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 0 12 2

Member of a particular religious group . . . . . . . . . . . . . . . . . . . . . . . . . . 0 0 12 2

Member of a particular nationality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 0 12 1

a The Sample IS the sperm bank sample

b The code num e o b r f the question in the survey Instrument (see app B)

c Responses are not weighted Not all sperm banks answered all questions

SOURCE: Office of Technology Assessment, 1988

DONOR SCREENING

All the facilities reported they require some of the 15 banks in the survey, 11 require screenform of screening before accepting donors. Out ing only of men whose semen is to be used for
67

Box 3-C.–The Repository for Germinal Choice

Escondido, CA, is home to one of the only sperm banks known to specialize in offering semen samples from

unusually well educated donors. Erroneously known as the “Nobel Prize Winners’ Spermbank,” the Repository

for Germinal Choice in fact does not have any specimens from such prizewinners. Rather, its inventory largely

consists of men who have impressed the sperm bank’s director, retired optometrist Robert Klark Graham, with

their reported accomplishments, primarily in the “hard” sciences. One donor is an accomplished athlete.

The staff is small, consisting of Dr. Graham, his assistant Ms. Vaux, and one to two physicians retained when

needed. From its opening in 1979 through the end of 1986, the Repository had recorded 35 births resulting from

its services. There has been no formal study of the children.

Donors are solicited by letter or telephone by the Repositort. If they choose to participate, they are asked to

complete a lengthy questionnaire concerning their health, genetic histories, and personal accomplishments. Evidence of serious genetic disorders in the family result in exclusion. So too does evidence of the potential donor’s

own homosexuality, or a strong family history of homosexuality. If accepted to this point, donors are asked to see

a local physician, who is to do a physical examination and blood tests, although as of December 1986 no blood

test for HIV infection was required; direct semen tests were preferred. Direct semen testing is not reliable.

If physicians retained by the Repository are satisfied by the test results, a donor is accepted. It is not necessary

to travel to Escondido in order to donate a specimen. The donor is supplied with instructions, express post packages, and liquid nitrogen storage tubes. No compensation is offered for the samples.

Recipients are not sought, but are chosen from those who contact the Repository by telephone or letter. They

are screened almost as rigorously as donors for evidence of disease or genetic disorders. Single or lesbian women

are not accepted. If a recipient is approved, she is given samples at no charge. The Repository is financed by the

“Foundation for the Improvement of Man,” rather than by user fees.

SOURCE: R.IC GalIarn. Dwector, Repository for Gxrnmal Choice, Escondido, C.A. personal communication, Dec. 30, 1986.

Table 3-5.-Donor and Client Depositor Screening a

(Question 21):b Prior to acceptance as a donor, do you normally require the following from heterologous donors only, homologous donors

only, both, or neither? c

Heterologous d Homologouse Both Neither

Family medical and genetic history ., ... . . . . . . . . . . . . . . . . . . 13 0 2 0

Personality assessment ., . . . . . . . . . . . . . . . . 13 0 0 2

Personal medical history . . . . . . . . . . . . . . . 11 0 4 0

Physical examination . . . . . . . . . . . . . . 10 0 2 2

Fertility history . . . . . . . . . . . . . . . . . . . . . . . . . 8 0 5 2

Karyotyping ., . . . . . . . . . . . . . . . . . . . . . . . ... , 5 0 0 9

a The sample IS the sperm bank sample

b The code number of the question in the survey Instrument (see app. B)

c Responses are not weighted Not all sperm banks answered all questions

d "Heterologous” donors are those whose semen wiII be used for artificial Insemination by donor

e Homologous” donors are client depositors whose semen wiII be used by them at some future time for artificial insemination by husband

SOURCE: Office of Technology Assessment, 1988

anonymous donation; the remaining 4 always re- rejected a man whose semen was to be used for

quire screening, whether the semen is to be used AID because he had a history of serious genetic

for AIH or AID (table 3-5). Although all the fa- disorders, was over 40 years old, or showed evicilities require some sort of testing, the nature dence of alcohol abuse. Other reasons for rejecand extent of the tests vary. All the banks require tion encountered by a majority of facilities have

a donor’s personal and family medical history, as been hepatitis infection, HIV infection, psychowell as his genetic history. In addition, a donor’s logical immaturity, low intelligence quotient, lack

fertility history, a physical examination, and a of education, or evidence of risk factors for HIV

personality assessment are required by 13 of the infection (table 3-6).

15 banks. Over two-thirds of the facilities have
68

Table 3-6.-Criteria for RejectIon: Donors a

(Question 24):b Have you ever rejected a donor because he was/has:c

Have Have Have

rejected rejected never

homologous heterologous rejected for

donor ddonor ethis reason

History of serious genetic disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Over 40 years old . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Evidence of alcohol abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Genital herpes... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Evidence of drug abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Less than 18 years old . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

HIV (HTLV) positive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Psychologically immature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Homosexual contacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Less than average intelligence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Less than high school degree . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Multiple heterosexual partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sexual contact with AIDS cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cytomegalovirus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Gonorrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Intravenous drug use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Syphilis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Criminal record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Evidence of child abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Welfare dependent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Less than average height . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Residence in high AIDS area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Married . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0

0

0

1

1

0

0

2

1

0

0

1

0

0

1

1

0

1

0 

o

0

0

0

0

12

11

10

9

9

9

9

8

8

8

8

7

7

7

6

6

6

5

5

4

3

3

2

1

0

2

3

2

3

2

3

3

3

3

3

5

6

4

7

4

5

6

6

7

8

10

10

10

a The sample is the sperm bank sample.

b The code number of the question in the survey instrument (see app. B).

c Responses are not weghted. Not all sperm banks answered all questions.

d "Homologous” donors are client depositors whose semen will be used by them at some future time for artificial insemination by husband

e "Heterologous" donorsmarethosewhosa semen will be used for artificial insemination by donor.

SOURCE: Office of Technology Assessment, 1988

In addition to heritable diseases or HIV infection, the following donor characteristics would

lead to donor rejection by at least 7 sperm banks:

“less than 18 years old," "over 40 years old,"

“psychological immaturity," “less than average

intelligence,” “less than high school degree,"

“evidence of drug abuse,” “evidence of alcohol

abuse,” “homosexual contacts," and diseases

such as hepatitis or genital herpes.

It is interesting to note that sperm banks report rarely, if ever, rejecting men who store semen for future use in AIH, despite histories of

child, alcohol, or drug abuse. These conditions

are the basis for frequent rejection of recipient

requests for artificial insemination (see ch. 2).

Thirteen sperm banks screen donors for genetic defects or diseases that tend to be of ethnic

origins, such as Tay-Sachs disease (in Jewish donors), sickle cell anemia (in black donors), and

thalassemia (in donors of Mediterranean origins). Twelve banks reported that they perform

diagnostic testing for a range of sexually transmitted diseases, including syphilis, gonorrhea,

and herpes.

All 15 sperm banks reported that they screen

donors for antibodies to human immunodeficiency virus, regardless of whether their semen

is intended for use in artificial insemination by

husband or by donor. One facility would screen

for HIV only if the donor were considered to be

from a high-risk group; the other l4 banks routinely screen all donors for HIV, regardless of

supposed risk group status. All 15 banks use diagnostic testing, rather than reliance on a donor’s

personal statement, to screen for exposure to the

virus. Part of the screening procedure for HIV

antibodies often involves the routine quarantine

of samples so that the donors may be periodically
69

retested to see if the virus is present later. If a donor tests negative to the presence of HIV antibodies, 13 banks quarantine the sample pending

further donor testing, which will occur, on average, every 1.9 months but which may range anywhere from every 1 to 6 months. Current American Association of Tissue Banks (AATB)

standards for sperm banking require a minimum

3-month quarantine, and American Fertility Society, Centers for Disease Control, and Food and

Drug Administration guidelines recommend

6-month quarantines, as noted in chapter 2.

In the event that a donor tests positive for

HIV, every bank surveyed reported it would notice the donor of the test results. The 12 banks

that responded to questions concerning HIV

testing and semen storage for AIH differed on

whether to inform the spouse or partner of a man

who tests positive for HIV and other infectious

diseases (table 3-7). Three banks claimed they

would inform the spouse if the donor tests positive for HIV, 4 said they would not inform the

spouse, and 5 were “not sure.” Of the 14 banks

that responded to the same question regarding

HIV testing of men offering to become anonymous sperm donors, 7 banks reported that they

“would inform,” 5 claimed that they “would not

inform,” and 2 were “not sure” (table 3-8). So

far, 8 banks report that they have already rejected someone as an anonymous donor because ,

he tested positive for the HIV antibody, and 2

banks have refused to store semen from an HIVpositive man (table 3-6). In addition, 7 banks reported rejecting donors because of indicated

“multiple heterosexual partners” or “sexual contact with HIV cases.”

To determine which heritable characteristics

would disqualify a donor, the survey asked sperm

banks to report whether they would accept a donor with a particular disorder, reject a donor who

has it, or reject a donor whose family history includes someone with the disorder (table 3-9). In

general, the survey found that sperm banks are

reluctant to accept donors with even a family

history of genetic disorders, including those that

are correctable, avoidable, or socially tolerated.

In a number of cases, a majority of sperm banks

would reject donors with family histories of disorders that are not widely recognized as predominately genetic.

In addition, a number of sperm banks would

reject donors with family histories of hemophilia

or Duchenne’s muscular dystrophy but who were

themselves healthy, despite the fact that the diseases are sex-linked and therefore cannot be

passed on by a man not himself suffering from it

(table 3-9).

Sperm banks also frequently screen out

healthy donors with family histories of TaySachs disease, sickle cell anemia, or thalassemia.

These autosomal recessive disorders are identifiable by biochemical testing. Sperm banks could

Table 3-7. - Informing Spouse of

Homologous Donor of Donor’s Health Status.

(Question 31a):b Would you inform the wife or partner of a

homologous donor, if tests indicated that the donor had:c,d

Would

Would not Not

inform inform sure

HIV positive . . . . . . . . . . . . . . . . . . . . 3 4 5

ARCe or full-blown AIDS . . . . . . . . . . 3 4 5

Other infectious disease . . . . . . . . . . 4 3 5

High risk of severe genetic

defect for offspring . . . . . . . . . . . . 5 2 5

a The sample is the sperm bank sample

b The code number of the question in the survey instrument (see app. B).

C Responses are not weighted. Not all sperm banks answered all questions.

d “Homologous” donors are client depositors whose semen wilI be used by them at

some future time for artificial insemination by husband

e “ARC” is AIDS-related complex, a collection of diseases suffered in conjunction with

HIV-infection

SOURCE: Office of Technology Assessment, 1988

Table 3-8. - Informing Spouse of Heterologous

Donor of Donor’s Health Status.

(Question 31b):b Would you inform the wife or partner of a

heterologous donor, if tests indicated that the donor had:c’

d

Would

Would not Not

inform inform sure

ARCe or full-blown AIDS. . . . . . . . . . 8 5 1

High risk of severe genetic

defect for offspring . . . . . . . . . . . . 8 4 2

HIV positive . . . . . . . . . . . . . . . . . . . . 7 5 2

Other infectious disease . . . . . . . . . . 7 4 3

a The sample is the sperm bank sample.

b The code number of the question in the survey Instrument (see app. B).

C Responses are not weighted. Not all sperm banks answered all questions.

d “Heterologous” donors are those whose semen will be used for artificial insemination by donor

e “ARC” is AIDS-related complex, a collection of diseases suffered in conjunction with

HIV-infection

SOURCE: Office of Technology Assessment, 19SSi
70

Table 3-9. - Medical Conditions and

Donor Rejection a

(Question 25):b For each of the following conditions, would you

be likely to reject a heterologous donor only if he had the

condition, if anyone in the donor’s immediate family had the

condition, or would you not reject a donor even if he had the

condition? c’

d

Reject Not

only if Reject reject even

donor if family if donor

has

e history has

Tay-Sachs f . . . . . . . . . . . . . . . . . . 5

Diabetes . . . . . . . . . . . . . . . . . . . 11

Hemophilia . . . . . . . . . . . . . . . . . 6

Depression . . . . . . . . . . . . . . . . . 8

Asthma . . . . . . . . . . . . . . . . . . . . 7

Cystic fibrosis . . . . . . . . . . . . . . . 5

Mental retardation . . . . . . . . . . . 6

Obesity . . . . . . . . . . . . . . . . . . 6

Huntington’s chorea . . . . . . . . . . 5

Duchenne muscular dystrophy . 5

Sickle cell anemia . . . . . . . . . . . . 6

Thalassemia . . . . . . . . . . . . . . . . 6

Hypercholesterolemic

heart disease . . . . . . . . . . . . . . 6

Neurofibromatosis . . . . . . . . . . . . 4

Malignant melanoma . . . . . . . . . 6

Alzheimer’s disease . . . . . . . . . . 3

Severe astigmatism . . . . . . . . . . . 7

11

8

13

9

6

14

13

6

14

14

11

11

12

14

8

12

5

1

0

0

2

5

0

0

5

0

0

0

0

1

0

1

2

3

a The sample is the sperm bank sample.

b The code number of the question in the survey instrument (see app. B).

C Responses are not weighted. Not all sperm banks answered all questions

d “Heterologous” donors are those whose semen wiII be used for artificial insemination by donor

e Responses not mutually exclusive

f Items in order as on survey instrument

SOURCE: Office of Technology Assessment, 1988

do such testing to limit the potential donors rejected to those who actually carry the trait, but

this survey indicates that a number of banks

screen out all at-risk donors on the basis of a

family history. Some autosomal recessive disorders, such as cystic fibrosis, have no reliable carrier test, and all but one surveyed sperm bank

would exclude donors with a family history of this

most common of genetic disorders among

American caucasian children. Fourteen of 15

sperm banks also excluded potential donors with

a family history of Huntington’s chorea, which,

due to its late onset and complicated carrier

status diagnosis, is difficult to detect. (This can

be compared to the two-thirds of individual physicians who responded that they would screen

out a donor with a family history of Huntington’s.) As an autosomal dominant, the disorder can be passed on to a child even if only one

parent carries the trait.

It is interesting to note three disorders that

would not disqualify a donor at 20 to 30 percent

of the banks. One, severe astigmatism, is probably heritable, and tolerance for donors with the

condition may reflect its prevalence and the public’s comfort with corrective lenses. Family history of obesity would lead 6 of the banks to reject

a donor, but 5 would accept a donor even if he

were himself obese. There is widespread suspicion that some individuals have a genetic predisposition to obesity, but environmental factors

make it impossible at this time to state with certainty the precise genetic relationship. Asthma

was another trait that would cause rejection at

some banks and not at others. Some forms of

asthma are autosomal dominant, although its genetic transmission is complex, and environmental factors may make the symptomatology

vary greatly. Therefore, it is interesting that 5 of

the banks would accept a donor who himself suffered from the disease.

RECORDKEEPING

At least 11 of the 15 sperm banks keep detailed ents, recipients’ partners, or the donors themrecords for each donor, which often includes in- selves access to these records (table 3-10).

formation such as the number of women inseminated, number of pregnancies achieved, number Partial access, however, such as providing doof children born, the donor’s physical examina- nor records without the donor names, is granted

by some banks. Although a few will permit access

tion, the donor’s family genetic history, and any without donor names to the donor (3 of 15) or to

followup examinations of the donor. The major- offspring (2 of 15), recipients and their partners

ity of facilities will not allow offspring, recipi- are more likely to be able to obtain these records
71

Table 3-10.-Access to Donor Records a

(5 to 7 of 15). Public health departments, researchers, and courts are most likely to be able to

(Question 37):b Would you permit access to donor records, obtain nonidenti&fyng records. including the name of the donor, only excluding the name of the

donor, or not at all, to: c

Access Access

with without No

name name access

Research scientists . . . . . . . . . . . 0 8 5

Public health department . . . . 1 7 5

Recipient . . . . . . . . . . . . . . 0 7 7

Judicial requests . . . . . . . . . . . . 2 6 5

Recipient partner . . . . . . . . . . . . 0 5 9

Donor . . . . . . . . . . . . . . 2 3 9

Offspring of insemination . . . . . . 1 2 11

a The sample is the sperm bank sample

b The code number of the question in the survey Instrument (see app. B).

c Responses are not weighted. Not all sperm banks answered all questions

SOURCE. Office of Technology Assessment, 1988

QUALITY ASSURANCE

The sperm banks surveyed have generally Despite adherence to professional guidelines, 4

adopted professional guidelines and procedures banks indicated that the current practice of artias part of their protocols for artificial insemina- ficial insemination does not sufficiently protect

tion, with most using those set forth by the the safety of the recipient or the rights of the offAmerican Association of Tissue Banks (see box spring (table 3-11). Six said that there is “less

3-D) or the American Fertility Society. Mem- than adequate” protection of physicians in terms

bers of the AATB are bound by their standards of their liability for the practice of artificial inof practice. semination. Thirteen, however, regarded protecBox 3-D.–AATB Standards of Sperm

Bank Practice

The American Association of Tissue Banks publishes and periodically revises its Standards for Tissue Banking,

including special addendum material from AATB’s Reproductive Council concerning semen banking.

As of 1988, AATB directed its member sperm banks to maintain complete donor records, but to ensure that the

donor’s actual identity never be revealed. Donor selection requires a personal, physical, sexual, and genetic history

of the individual. Abuse of alcohol or drugs is grounds for automatic rejection. So are a variety of genetic conditions

present in the donor or his family, including mental retardation (unless of intrauterine or environmental origin),

diabetes before age 50 in a first- or second-degree relative, heart disease before age 50 in a first - or second-degree

relative, schizophrenia or manic depressive disorder in a first-degree relative, muscular dystrophy (unless a known

dominant with full penetrance or sex-linked), and “any medical problem which has a possible genetic etiology.”

The AATB directs member banks to do a minimum of two-generation (and preferably three-generation) family

history for its genetic screening, with biochemical tests done when indicated by a family history of such diseases as

Tay-Sachs and thalassemia.

Semen is to be tested for sperm count, motility, morphology, and other indicators of fertility. It is also to be tested

for evidence of gonorrhea, and donors’ blood is to be tested for syphilis, hepatitis, and human immunodeficiency

virus antibodies. No donor semen may be used until after a 3-month quarantine period at the end of which the

donor has been rechecked for HIV antibodies. Retesting for hepatitis and syphilis is also required for long-term,

repeat donors.

SOURCE: America Association of Tissue Banks, Standards for Tissue Banking (Arlington, VA: 1%8).
72

Table 3-11.–Adequacy of Professional StandardsaTable 3-12.-National Standards for Sperm Banksa

(Question 41):b How adequate do you think that present professional practices of artificial insemination are in terms of protecting

the:c

More Less

than than

adequate Adequate adequate

Donor’s privacy . . . . . . . . . 2 11 1

Offspring’s rights . . . . . . . 2 8 4

Recipient’s safety . . . . . . . . 1 9 4

Physician’s liability . . . . . . . 1 7 6

a The sample is the sperm bank sample.

b The code number of the questions in the survey instrument (see app. B).

C Responses are not weighted. Not all sperm banks answered all questions.

SOURCE: Office of Technology Assess ment, 1988.

tion of the donor’s privacy as adequate or more

than adequate.

Establishing national standards (unspecified

as voluntary or mandatory) for donor insemination would be favored by most banks, with 14 supporting national standards for donor screening,

13 favoring standards for recordkeeping, and 11

favoring standards for recipient screening (table

3-12).

Involvement by national medical societies and

Federal public health agencies to assure the

safety and quality of artificial insemination

practice is more favored than involvement by

(Question 43):b Would you tend to favor or oppose the eatablishment of national standards for artificial insemination for: c

Favor Oppose

Donor screening . . . . . . . . . . . . . . . . . . . . . . 14 1

Recordkeeping requirements . . . . . . . . . . . . 13 2

Recipient screening . . . . . . . . . . . . . . . . . . . 11 4

a The sample is the fertility society sample.

b The code number of the question in the survey instrument (see app. B).

c Responses are not weighted.

SOURCE: Office of Technology Assessment, 1988

peer review organizations (table 3-13). Practically all the banks wanted the involvement of

these two groups either increased or to remain

the same. Involvement of State public health

agencies also received support from 10 banks.

Only about half the facilities supported the involvement of local medical boards, with 4 recommending elimination of such involvement. More

than half also favored reducing or eliminating

the involvement of hospital professional review

organizations. Finally, the involvement of courts

evoked a mixed response, with 8 recommending

elimination, and 7 recommending that it remain

the same.

ATTITUDES

Those responding for the sperm banks gener- sexual orientation. A smaller proportion of

ally disapproved of facilities that specialize in sperm banks than of physicians (see ch. 2) viewed

donors with intellectual, artistic, or athletic self-insemination as a reasonable alternative to

gifts, despite the fact that their own donor pools physician-assisted insemination. Like physiand screening processes tend to overrepresent cians, however, they overwhelmingly believed

educational attainment (table 3-14). They did, that children conceived by AID should not be

however, split evenly on screening recipients for permitted to know the identity of their genetic

social characteristics, such as marital status or fathers.
73

Table 3-13.– Roles in Quality Assurance.

(Question 42): b For each of the following agencies, would you like to see their involvement in the quality assurance of artificial insemination

procedures increased, remain the same, decreased, or eliminated?

Remain

Increased the same Decreased Eliminated

National medical societies . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . 6 8 1 4

Federal public health agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 10 2 1

State public health agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 8 1 4

Local medical boards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 7 3 4

Hospital PROsd ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 5 1 7

courts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o 7 0 8

a The sample in the fertility society sample.

b The code number of the question in the survey instrument (see app. B).

c Responses are not weighted. Not all sperm banks answered all questions.

d "PROs" are peer review organizations.

SOURCE: Office of Technology Assessment, 1988

Table 3-14.-Attitudes Toward Artificial Insemination Practicea

(Question 46):b How do you feel about the following general statements concerning artificial insemination? For each statement, please

indicate whether you agree strongly, agree somewhat, disagree somewhat, or disagree strongly.c

Agree Agree Disagree Disagree

strongly somewhat somewhat Strongly

Artificial insemination should be more widely used to treat

infertilit y

d 

.., . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 8 1 0

Physician acceptance of recipients should be based solely

on health issues . . . . 5 1 5 3

Self insemination is a reasonable alternative to physician

assisted insemination in many cases 1 2 3 8

Patient requests for artificial insemination should be honored. . . . . . . . . . . . . . . . . . . . . . . .

regardless of marital status or sexual orientation . . . 4 4 4 3

Offspring of artificial insemination should have a right to

communicate with their genetic fathers . . . . . . . . . . . 0 0 1 14

Patient requests for artificial insemination frequently raise

moral issues for physicians . . . 1 9 2 3

There is nothing wrong with sperm banks which specialize

in donors with intellectual, artistic, or athletic gifts . . . . . . . . . 1 2 5 7

a The sample is the sperm bank sample

b The code number of the question in the survey instrument (see app B)

c Responses are not weighted. Not all sperm banks answered all questions

d Items in order as on survey instrument

SOURCE: Office of Technology Assessment, 1988
Appendixes
Appendix A

Study Procedures

QUESTIONNAIRE

A survey questionnaire was developed by the

contractor- in-concert with OTA according to the

detailed research objectives set forth by OTA.

OTA staff, along with the OTA advisory panel

and specially selected outside experts, reviewed

the draft questionnaire. A final pretest version of

the questionnaire incorporated the suggestions

and criticisms of the advisory panel and outside

experts.

DEVELOPMENT

The survey instrument was pretested among

30 physicians in April 1987. The findings of the

pretest concerning areas of difficulty or confusion for the respondent were used to revise the

questionnaire. This revised questionnaire was

approved by OTA on June 5, 1987, as the final

version of the instrument. An amended version

of the survey instrument was used for the survey

of sperm bank practice.

SAMPLED POPULATIONS

Cross-Sectional Sample

In order to generate sample estimates that

could be projected to the total population of U.S.

physicians who conduct artificial insemination, a

national cross-sectional sample was drawn from

the universe of currently practicing physicians

whose primary specialty was likely to include

some infertility therapy, based on the American

Medical Association (AMA) physician listings.

The target population was primary care physicians likely to become involved in infertility therapy – those in general practice and family practice or in reproductive care specialties

(gynecology, obstetrics/gynecology, and urology). These specialties could be sampled from

the AMA sampling frame, which allows classification according to both primary and secondary

specialties. The sampling frame included both

office-based and hospital-based physicians; however, interns and residents were excluded.

A proportionate sampling of the population

(see table A-1) would have led to relatively small

sample sizes for some specialties most likely to

treat fertility problems. Hence, it was decided to

sample the four specialties disproportionately,

to yield 1,600 cases for the cross-sectional sample

of physicians, of whom 1,575 were actually

sampled.

Table A-1. - Distribution of Physicians by Specialty

Specialty Population Proportion Sample size

General practice 25,807 242

Family practice ., 43,221 40.6 650

Gynecology/obstetrics 28,511 268 428

Urology ... ... 8,94 4 8 4 134

Total ... 106,483 1,600

SOURCE American Medical Associatlon Physician Listings, 1987

Fertility Society Sample

Given the anticipated low physician involvement in artificial insemination and fertility treatment, this cross-sectional approach was not expected to yield a large enough sample of

practitioners to permit detailed analysis. A second sampling frame was therefore constructed

from the membership lists of two national professional societies, the American Fertility Society (AFS) and the American Society of Andrology. The memberships of the two organizations

77
78

are currently estimated at 11,000 and 1,000,

respectively.

A prior screening of the AFS membership for

fertility practices had been conducted by the association between October 1984 and March

1985. A total of 8,500 survey forms had been

mailed to members and 3,200 had been returned.

Among those returned, 2,736 physicians reported some practice of artificial insemination

– either by donor (AID) or by husband (AIH)

or both. This prescreened sample of AFS members who had identified themselves as providing

artificial insemination services of any kind was

used as part of the sampling frame of fertility

specialists. Since no such prescreening information was available for the Andrology Society

SAMPLING

For all three physician samples, selection of

sample within stratum was by simple random

sampling, a method of selecting n units out of the

N such that everyone of the distinct elements has

an equal chance of being drawn. A simple random sample is drawn sequentially in practice. At

any point in the draw there must be an equal

chance of selection for any element in the population not already drawn.

Simple random sampling has the distinct advantage of reducing the variance of sample estimates, under most circumstances, compared

with the alternative of stratified cluster sampling.

Statistical formulas for specifying the sampling

precision associated with particular sample sizes

are based upon the assumption of simple random

sampling. Cluster samples introduce a design effect into these calculations, which normally inmembership, the full membership list was used

as the basic sampling frame.

The total size of the sample drawn of fertility

specialists was 1,213. This included 1,000 from

the AFS prescreened sample and 213 from the

Andrology Society lists.

Sperm Bank Sample

A list of 30 separately owned or operated commercial sperm banks in the United States was developed by OTA on the basis of most current lists

from the American Fertility Society and the

American Association of Tissue Banks. All

sperm banks were contacted with the same double mailing approach used for the physician survey. Fifteen sperm banks responded, a response

rate of 50 percent. Some responses were somewhat incomplete.

METHOD

creases the expected sampling error relative to

that which would have been obtained.

Simple random sampling is done by systematically selecting every “ith” person in the sampling

universe. In this case the “ith” refers to a constant interval, which is determined by the formula: i = N/n, where N is the number of elements in the population and n is the desired

number of elements in the sample. The elements

in the sampling universe are listed in a random

order. A computer-generated random number is

used to select an initial number between 1 and i

to establish a random start. The constant interval

“i” is sequentially accumulated until all sampled

elements have been designated. This procedure

can be demonstrated to be statistically identical

to the method whereby individual elements are

selected at random without replacement from

the population.

FIELD PROCEDURES

The field procedures used in this study were sicians from the two sampling frames. These prodesigned to produce an unbiased sample of phy- cedures included:
79

an advance letter sent to all sample respondents indicating that the questionnaire

would follow,

a first mailing of the questionnaire with

cover letter,

a followup letter to individuals whose replies

were not received within 4 weeks of the first

mailing,

a second questionnaire mailing approximately 1 week after the followup letter, and

a telephone followup of nonrespondents

the sample to find out why the person had

not responded.

The survey was conducted between June and

August 1987. The schedule for the study did not

permit a third mailing, which would have required another month for data collection. The

resources available to the study did not permit

the use of incentives to increase response rate.

Similarly, a telephone followup with all nonrespondents was not possible within the resource

among a predesignated 20 percent subset of limitations of the study.

PARTICIPATION RATES

These procedures yielded a total of 1,558

questionnaires completed and returned by an

adjusted sample of 2,569 physicians. The overall

response rate was 61 percent: 692 surveys out of

an adjusted sample of 1,098 (63 percent) for the

members of the fertility society sample, and 866

surveys out of an adjusted sample of 1,471 (59

percent) among respondents in the cross-sectional sample. Broken down by fertility society,

596 surveys out of an adjusted sample of 960

were completed among respondents in the AFS

sample (62 percent), and 96 surveys out of an adjusted sample of 138 (70 percent) were completed among respondents in the American Society of Andrology sample (table A-2).

The survey was designed to permit a systematic effort to define the sources of nonresponse

on a limited basis. A random sample of one-fifth

of the total was predesignated for followup before the field work began. As the field period

ended, all outstanding cases from this sample

were contacted in an attempt to learn why they

were not responding. No attempt was made to

administer the survey over the telephone or to

collect demographics; rather, the telephone followup aimed to identify any source of systematic

bias in the achieved sample.

Roughly 35 percent of the contacted nonrespondents reported that they had already completed the survey and just recently returned it by

mail, that they intended to reply, or that they

were in the process of replying as of the date of

the telephone followup call. It seems that additional prodding, in the form of the followup call,

actually improves overall response rates, as indicated by this high “will reply” response (table

A-3). This also suggests that a third-wave mailing

might have produced a higher response rate, possibly 70 percent.

A large percentage of the nonresponses involved those who were unreachable at the time of

the followup call. Almost 25 percent of the nonresponse sample were on vacation, not at home,

or otherwise unreachable at the time.

Another important cause for nonresponse is

straightforward refusal to participate in the survey. Roughly 15 percent of the non response sample refused to participate for a variety of reasons,

most of which involved the length and/or complexity of the survey instrument or the respondents’ actual time available to complete the survey. The construction of the survey did not seem

to be a factor in nonresponse, with only a few respondents citing this as a reason for refusal. A

few physicians cited issues of privacy, lack of incentive or benefit in completing the survey, or a

policy of refusal to participate in surveys.

Other sources for nonresponse include those

“ineligible” for a variety of reasons, such as those

no longer practicing, those no longer at the prestated location who left no forwarding address,

and those deceased. Ineligibility accounted for
80

Table A-2.-Sample Disposition

Cross-section AFS Andrologists

Total sampled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ineligible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

No infertility work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Not a practicing MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Moved out of U.S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Deceased . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Retired . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other misc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Bad address/no forwarding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Adjusted sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

No return . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Remails . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

No reply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

On vacation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

New address from AFS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Not listed by AFS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Refused . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Completes received . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

>4 inseminations . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0-3 inseminations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Unspecified . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Completes used in analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

>4 inseminations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Completes received too late . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1,575

76

26

9

0

2

37

2

28

1,471

3

578

3

0

0

21

37

819

10

827

36

791

39

1,000

15

5

1

1

1

5

2

25

62

232

0

32

9

29

361

231

4

569

223

27

213

47

2

43

0

1

0

1

28

138

38

0

38

0

0

0

4

96

24

71

1

77

21

56

19

SOURCE: Office of Technology Assessment 1988

30 percent of the nonresponse for the pre- the AFS and the cross-sectional samples. Overselected group derived from the Andrology Soci- all, the followup contact did not reveal any unety sample, but accounted for no more than 8 derlying problem of sample bias among nonPercent of those preselected respondents from respondents.

DIFFERENTIAL RESPONSE RATES AND SAMPLE WEIGHTING

Differential response rates by physician speci- four sampled fields of medical practice. To corality and professional society membership can rect for such biases, the distribution of the

produce some sample distortion from true popu- achieved sample was compared with the actual

lation distribution. Further, for the cross-sec- distribution by specialty and society for these

tional sample, the sample drawn was not repre- groups, and sample weights were applied to cortentative of true population distribution for the rect for differences.

PRECISION OF SAMPLE ESTIMATES

The objective of the sampling and field proce- from which it is drawn, subject to a certain level

dures is to produce an unbiased sample of the of sampling error. This means that with a proptarget population, one that shares the same prop- erly drawn sample, statements can be made

erties and characteristics of the total population about the properties and characteristics of the
81

Table A-3.– Phone Results of Telephone Followup Among Outstanding Cases In Predesignated

Followup Sample

Cross-section AFS Andrologists

Total sampled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Outstanding cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Survey is in the mail . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Will reply/in the process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Remails . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Remail to new address.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Need new copy (same address) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Have not received (same address) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ineligible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Screen out.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

No longer at location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Deceased . . . . . . . . . . . . . . . . . . . . . . . . . . .

Not reached . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

On vacation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Call back for doctor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

No answer/busy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Left message on answering machine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Have not called . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Insufficient time since last remail of survey . . . . . . . . . . . . . . . . . .

Wrong telephone number . . . . . . . . . . . . . . . . . . . . . . .

Tel. number not listed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Tel. number unpublished . . . . . . . . . . . . . . . .

Refusals

Survey is too long/complex . . . . . . . . . . . . . . .

Do not have time..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Survey is poorly constructed . . . . . . . . . . . . . . . . . . . . . . . . . . . .

No benefit in doing survey . . . . . . . . . . . . . . . . . . . . . . . . . . .

Privacy/no reason for info requested . . . . . . . . . . . . . . . . . . . . .

Mad at government/lower taxes, etc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Doctors should be paid . . . . . . . . . . . . . . . . . . . . . . . . . . .

Do not do surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other/unspecified reason . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Request remail -too late to comply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Duplicate/same clinic (won’t reply) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Completed surveys . . . . . . . . . .

Adjusted sample . . . . . . . . . .

316 201

107

9

43

144 14

1

2

9

29 24

31

9

13

9

11

5

1

5

2

1

0

1

10

9

1

0

2

0

2

0

4

2

1

1

22

3

12

2

5

24

9

14

1

0

3

0

2

1

0

30

0

1

25

4

21

11

1

9

0

0

0

0

0

0

2

4

0

1

1

2

1

1

1

5

5

2

0

0

0

0

0

3

0

0

1

0

0

0

0

0

0

0 0 0

0 1 1

30 22 3

104 63 9

SOURCE: Office of Technology Assessment, 1988

total population within certain specified limits of where:

certainty and sampling variability. var (x) = the expected sampling error of the

The expected sampling error for sample estimates of population proportions, using simple

random sampling without replacement, is calcu- P

=

lated by the following formula:

q

=

mean of some variable, expressed

as a proportion;

some proportion of the sample displaying a certain characteristic or attribute;

(1-p);

the standardized normal variable, given

a specified confidence level; and

the size of the sample.
82

The maximum expected sampling error at the

95 percent confidence level (i.e., in 95 out of 100

repeated samples) for a total physician sample of

827 (the cross-section) is +/- 3.4 percentage

points. It should be noted that the maximum

sampling error is based upon a certain response

distribution (i.e., a 50/50 split). The expected

sampling error is less for other response distributions with a sample size of 827. For example, the

estimate that 9.6 percent of a sample of 827 physicians have accepted patients for artificial insemination in the past year is subject to an expected sampling error of +/- 2.0 at the

95-percent confidence level. However, as sample

size declines, as in the case of subsamples of the

total physician sample, so too will the expected

sampling precision of the estimates. Table A-4

presents the expected size of the sampling error

for specified sample sizes of 1,500 and less, at different response distributions on a categorical

variable. This table may be used to project the estimated precision of sampling estimates for the

total sample and naturally occurring subsets of

the sample, e.g., particular medical specialties,

number of years in practice, and so on.

Table A4.-Expected Sampling Error (plus or minus)

at the 95 Percent Confidence Level

(simple random sample)

Percentage of the sample or subsample giving

Size of a certain response or displaying a certain

sample or characteristic for percentages near: a

subsample 10 or 90 20 or 80 30 or 70 40 or 60 50

1,500 . . . . . . 1.5

1,300 . . . . . . 1.6

1,200 . . . . . . 1.7

1,100 . . . . . . 1.8

1,000 . . . . . . 1,9

900, . . . . . 2.0

800 . . . . . . 2.1

700 . . . . . . 2.2

600 . . . . . . 2.4

500 . . . . . . 2.6

400 . . . . . . 2.9

300 . . . . . . 3.4

200 . . . . . . 4.2

150 . . . . . . 4.8

100 . . . . . . 5.9

75 . . . . . . 6.8

50 . . . . . . 8.4

2.0

2.2

2.3

2.4

2.5

2.6

2.8

3.0

3.2

3.5

3.9

4.5

5.6

6.4

7.9

9.1

11.2

2.3

2.5

2.6

2.7

2.8

3.0

3.2

3.4

3.7

4.0

4.5

5.2

6.4

7.4

9.0

10.4

12.8

2.5 2.5

2.7 2.7

2.8 2.8

2.9 3.0

3.0 3.1

3.2 3.3

3.4 3.5

3.6 3.7

3.9 4.0

4.3 4.4

4.8 4.9

5.6 5.7

6.8 6.9

7.9 8.0

9.7 9.8

11,2 11.4

13.7 14.0

a Entries are expressed a percentage points (+ or -).

SOURCE: Office of Technology Assessment, 1988

ESTIMATING STATISTICAL SIGNIFICANCE

The estimates of sampling precision presented

in the preceding section yield confidence bands

around the sample estimates, within which the

true population value should lie. This type of

sampling estimate is appropriate when the goal

of the research is to estimate a population distribution. When the goal is to compare the survey

responses between two or more populations,

however (i.e., to determine whether the characteristics of two populations are different), it is

necessary to consider whether differences obSewed between the samples are statistically significant (i.e., beyond the expected limits of sampling error for both sample estimates).

To test this, a rather simple calculation can be

made. Call the total sampling error (i.e., var (x) in

the previous formula) of the first sample S1 and

the total sampling error of the second sample s2.

The sampling error of the difference between

these estimates is sd, which is calculated as:

sd =

Any difference between observed proportions

that exceeds sd is a statistically significant difference at the specified confidence internal. Note

that this technique is mathematically equivalent

to generating standardized tests of the difference

between proportions.

An illustration of the pooled sampling error

between subsamples for various sizes is presented in table A-5.
83

Table A-5.–Pooled Sampling Error Expressed As

Percentages for Given Sample Sizes

(assuming p=q)

Sample

size

2,000 10.0 7.2 6.1 54 4.9 4.6 43 4.1 4.0 3.8 3.1

1,000 10.3 7.6 6.5 5.8 54 51 49 4.7 4.5 4.4

900 10.3 7.6 6.6 5.9 5.5 5.2 50 48 4.7

800 10.4 7.7 6.7 60 5.6 53 5.1 5.0

700 10.5 7.8 6.8 6.1 5.8 5.4 52

600 10.6 8.0 7.0 6.3 59 5.7

500 10.7 82 72 6.6 6.2

400 11.0 85 75 69

300 11.3 9.0 8.1

200 12.0 9.8

100 13.9

Sample

size 100 200 300 400 500 600 700 800 90010002000

SOURCE: Office of Technology Assessment, 1988
Appendix B

Survey Instrument: Physician Practice

84

QUESTIONNAIRE: [1-51

NATIONAL INFERTILITY SURVEY 6-1

PLEASE READ THE QUESTION AND MARK THE SPACE BELOW THE QuESTION

THAT MOST NEARLY CORRESPONDS TO YOUR ANSWER. AFTER EACH ANSWER

CONTINUE WITH THE NEXT QUESTION UNLESS THERE IS AN INSTRUCTION

TO SKIP TO A PARTICULAR QUESTION. EVERYONE SHOULD ANSWER THE

QUESTIONS ON PAGES 16 AND 17

la As part of your practice , would you provide infertility services or

treatment for Infertility ?

------- No. . . . . . . . . . . . . . . . . . . . . . . . .—- 1

Yes. . . . . . . . . . . . . . . . . . . . . . . . . . . . - - 2

lb. In the past twelve months, approximately

you treated for infertility problems?

—— — Number treated

(SKIP TO Q.2a)

how many patients have

1c. Which of the following types of infertility therapies would y o u

perform as part of your practice?

No Yes

Fertility drug therapy. . . . . . . . . . . . , . . . . . . . .—-1 — - 2

Surgical therapy. . . . . . . . . . . . . . . . . . . . . . . . . -—1 — - 2

In vitro fertilization/embryo transfer. . . .

-—1 —- 2

Gamete intrafallopian transfer. . . . . . . . . . . . .—-1 —- 2

Surrogate mother matching. , . . . . . , . . . . . . . . --1 —- 2

Artificial insemination from husband. . . . . . -—1 — - 2

Artificial insemination from donor. . . . . . . . . -1 - 2

In the past twelve months how many requests have you received for

artificial insemination, including requests for insemination with

either husband or donor sperm .

2b.

------ -

2c.

,

t

v

—— — Requests for artificial insemination

None. . . . . . . . . . . . . . . . . . . . . . . . . . . . . -0 (SKIP TO PAGE 16)

How many patients have you accepted for artificial insemination,

with either husband or donor sperm, in the past twelve months?

. — — Number accepted

None. . . . . . . . . . . . . . . . . . . . . . . . . . . .

.—- Ø

What Is the main reason you have not accepted any requests for

artificial insemination in the past year?

IF FOUR OR MORE PATIENTS HAVE BEEN ACCEPTED FOR ARTIFICIAL INSEMINATION IN

THE PAST YEAR, PLEASE CONTINUE ON NEXT PAGE. IF THREE OR FEwER, GO TO PAGE 16

[71

[0-10]

[11]

[12]

[13]

[14]

[15]

[16]

[17]

[18-20]

[21]

[22-24]

[25]

(26-271

[28-291

[30-31]
85

GENERAL CHARACTERISTICS

— — Number turned dow n

-------- None. . . . . . . . . . . -0 (SKIP TO Q.4a )

,# 3b. Could you describe the main reason(s) that YOU did not accept

certain requests for artificial insemination ?

,

,

,

,

v

4 0 . What proportion of the patients who hove requested artificial insemination

in the past year were:

Married couples. . . . . . . . . . . . . .— . . %

Unmarried couples (heterosexual). . —— — %

Unmarried couples (lesbian). . . . . . .— — —%

Females without a partner . . . . .... — — —%

Don’t know marital status. . . . . . . — — —%

4b. What proportion of patients whom you accepted for artificial inseminatio n

in the post year sought artificial insemination because of :

No male partner. . . . . . . . . . , . . . . . . . . .— %

Impotence of male partner. . . . . . . . .—

— —

%

Infertility of male partner, , , . , , . —

— —

%

Genetic disorder of male partner. . . —

— —

%

Rh Incompatibility of male partner .

— —

—— —%

Exposure of male partner t o

mutagens. . . . . . . . . . . . . . . . . . . . . . . —— —%

Male partner has sexuall y

transmitted disease. . . . . . . . . .— %

Other (PLEASE SPECIFY)

. —

--------------------------- . . . — — — %$

4c. What percentage of these requests were from out-of-state patients ?

.— —%

None . . . . . . . . . . . . . . . . . . . . . . . . . . . - - Ø

4 d. In what proportion of artificial Inseminations was the sperm from :

Husband/partner. . . . . . . . . . . . .— %

Donor provided by recipient. . .

— —

%

Donor selected by you. . . . . . .

—— —

—— —%

Sperm bank. .. . . . . . ,. . . . ...— %

Other (PLEASE SPECIFY)

— —

[32-34]

[35]

[36-37]

[38-39]

[40-41]

[42-44]

[45-47]

[48-50]

[51-53]

[54-56]

[57-59]

[60-62]

[63-65]

[66-68]

:69-71]

[72-74]

[78-80]

ST CD 2

DUP 1-5

6-2

[7-9]

[10]

. . . . . . . —— —%
86

RECIPIENT SCREENING

5. Prior to accepting a patient for artificial insemination, do you

normally require that the patient undergo/provide:

No Yes

a . Personal medical history -1 -2

b . Family medical an d

genetic histor y -1 - 2

c. Fertility histor y -1 - 2

d. Physical examination -1 - 2

e, Personality assessment -1 - 2

f . Karyotyping -1 - 2

6 a . Do you ever require special screening for genetic defects or diseases

from any patients, prior to accepting them for artificial insemination?

------- No. . . . . . . . . . . . . . . . . . . . . -I ( SKIP TO Q.6c)

, Yes. . . . . . . . . . . . . . . . . . - - 2

6b. Under what circumstances do you require special screening for

4 genetic defects or diseases?

,

,

v

6c. Do you require any other diagnostic tests of potential recipients, prior

to accepting them for artificial insemination?

------- No. . . . . . . . . . . . . . . . . . . . . . . -1 (SKIP TO Q.7)

1 Yes. . . . . . , . . . . . . . . . . . . . . . -2

,

, 6d. Which diagnostic tests do you require in all instances ?

o

,

6e. Which other diagnostic tests do you require in some instances ?

, v

{NEXT PAGE]

[26]

[271

[281

[291

[301

[311

[32]

[33-341

[35-36]

[37-381

[39]

[id-+11

[42-43]

[44-45]

[46-47]

[48-49]

[50-51]
87

7

a.

b.

c.

d.

e.

f.

g.

h.

i.

j.

k.

1.

m.

n.

o.

p.

q.

r.

s.

t .

u.

v.

w.

x

RECIPIENT SCREENING

Have you ever rejected or would you be likely to reject a request for

artificial insemination from a potential recipient because she was/has :

Have

Rejected

Less than 18 years old. . . . . . . . . . . . . . . . ..—- 1

Over 40 years old. . . . . . . . . - — 1

Welfare dependent. . . . . . . . . . . . . - — 1

Psychologicaly immature. . . . . . . . . . . .

- — 1

Unmarried with a partner . . . . . . . . . . . . . - - 1

Unmarried without a partner . . . . . . .-— 1

Less than high school degree. . . . . . . . .-— 1

Less than average Intelligence. . . . . .

- - 1

Criminal record. . . . . . . . . . . . . . . . . . . . . - — 1

Evidence of drug abuse. . . . . . . . . . . . . . . . . - 1

Evidence of alcohol abuse. . . . . . . .—- 1

Evidence of child abuse. .. . . . . . . -— 1

Homosexual . . . . . . . . . , . , . . . . , . . - 1

Other living children. . . . . . . . . . . .—- 1

Prior miscarriage. ,, . . . . . . . . . . . . . . . . .

- — 1

Medical risks from pregnancy. . . . . ,

- - 1

History of serious genetic disorders, .

.-— 1

Syphills. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

- — 1

Gonorrhea, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - 1

Genital herpes. . . . . . . . . . . . . . . . . . . . . .

 -— 1

Cytomegalovirus. . . . . . . . . . . . . . . . . . . . .

- — 1

Chlamydia. . . . . . . . . . . . . . . . . . . . . . , . . . , . .

 .—- 1

Hepatitis. . . . . . . . . . . . . . . . . , . . . . . . . . . — - 1

HIV (HTLV) positive. . . . . . . . . . . . . . . . . . . .

- — 1

Would Be

Likely t o

Rejec t

-2

-2

-2

-2

-2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

-2

-2

-2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

Not

Likely t o

Rejec t

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

-3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

[52]

[53]

[54]

[55]

[56]

[57]

[58]

[59]

[60]

(61]

[62]

[63]

[64]

[65]

[66]

[67]

[68]

[69]

[70]

[71]

[72]

[73]

[74]

[75]

ST CD 3

DUP 1-5

5-3
88

DONOR SELECTION

8. In what proportion of requests does the recipient (or recipient’s partner )

have a donor already selected ?

—— —%

9 . In what proportion of cases does the recipient ask you to select a

donor who meets certain specifications or characteristics?

—— —%

1 0 . Are you generally willing to select donor characteristics to recipient

specifications?

------- No.. . . . . . . . . . . . . . -1 (SKIP TO Q.12a)

,

,

4

I

1

Yes. ,.,.. . . . . . . . -2

11. Which of the following donor characteristics ar e

to try to match, if requested :

Willin g

Age. .....,..,,., .,,,.. . . . . . . . . . . . . . . . . . . . . . .

- — l

Height. ,. ....,, . . . . . . . . . . . . . . . . . . . . . . . . . .

- — 1

Weight, .... . . . . . . . . . . . . . . . . . . . . . . . . . . . .

- - 1

Eye color. . . . . . . . . . . . . . . . . . . . . . . . .

- — 1

Hair texture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

- - 1

Complexion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

- - 1

Body type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

- — 1

Race. . . . . . . . . . . . . . . . . . . . . . . . .

- — 1

Ethnic or national origin. . . . . . . . . . . . . .

- — 1

Religion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

- — 1

I.Q... . . . . . . .......... . . . . . . . . . . . . . . . . . - — 1

Income. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - — 1

Educational attainment . . . . . . . . . . . . . . . . - — 1

Special abilities. . . . . . . . . . . . . . . . 1

Hobbies or interests . . . . . . . . . . . . . . . . . . . - - 1

You normally willin g

Not Willin g

-2

-2

-2

-2

-2

-2

-2

-2

-2

‘ - 2

-2

-2

-2

-2

-2

12a. Do you offer sperm separatio n for preconception gender selection ?

,

------ NO. . . , . , . . . . . . -1 (SKIP TO Q.12c )

v

12c

13

Yes. . . . . . . . . . - 2

12b. What technique for sperm separation do you normally use?

What is the main reason you don’t offer preconception gender selection ?

In your experience , in what proportion of cases where sex selectio n

is attempted is the selection successful ?

.— —%

Don’t Know -88 8

[7-9]

[131

[14]

[15]

[16]

[17]

[181

[191

[201

[211

[22]

[23]

[24]

[25]

[26]

[27]

[28]

[29]

[30-31]

[32-33]

[34-35:

[36-37!

[38-40]
89

PROTOCOL FOR INSEMINATION

14 How many appointments do you require with a patient, on average ,

before insemination con take place ?

— — Appointment s

15. Do you routinely presen t other options to patients who reques t

artificial insemination ?

------ No. . . . . . . . . . . . -I (SKIP TO Q.17a)

# Yes . . . . . . . . . . . . . . . - 2

,

, 16. Which other options do you normally present ?

t

,

t

,v

170. Do you routinely present possible risks of artificial inseminatio n

to patients who request artificial insemination ?

------ No. . . . . . . . . . . . . . . . -1 (SKIP TO Q.18a)

, Yes. . . . . . . . . . . . . - 2

17b Which risks do you normally present ?

#

,

1

18a . Do you require patients to sign a consent form prior to insemination ?

------ No . . . . . . . . . . . . . -1 (SKIP TO Q.19 )

,

I

t

4

v

1 9 .

2 0

Yes . . . . . . .-—2 ‘

18b. Do you require both partners of a couple to sign a consent for m

or only the patient ?

Both partners. . . . .

- — 1

Only patient. . . , . - — 2

[41-42]

[43]

[44-45]

[46-47]

[48-49]

[50-51]

[52]

[53-54]

[55-561

[57-58]

[59-60]

[61 ]

[621

On what day In the menstrual cycle do you normally commence insemination?

[65-641

On average, how many inseminations do you usually make per cycle ?

— — Number [66-66]
90

PROTOCOL FOR INSEMINATION

2 1 ,

22.

After the initial insemination within a cycle , do you normally schedul e

subsequent inseminations in that cycle for every day, every other day o r

something else ?

Only once per cycle . - 1

Every day. . . . . . . - 2

Every other day. . . . . .-— 3

Other (Specify )

. . . . . . - 4

Normally , is the sperm deposited :

Intravaginally. .

- - 1

Cervicovaginally .

- - 2

Intrauterinally. .

- - 3

Cervicol cap. . - 4

23a.

------ Use single donor. . . -2 (SKIP TO Q.23c )

Do you normally restrict all inseminations of a particular patient t o

sperm from a single donor, or not ?

Use multiple donors. . - 1

,

23b. Do you use sperm from multiple donors for inseminations withi n

the same cycle or not ?

,

(

, Use multiple donor. . .

- — 1

I Use single donors. . . -2

v

23c . Do you mix the sperm of the spouse/partner with the donor sperm fo r

insemination on a regular basis , only upon request or never ?

On a regular basis. . . - 1

Only upon request . - 2

Never , . . . . - — 3

23d. Prior to insemluation , which of the following procedures do yo u

always require as part of the insemination protocol, whic h

do you sometimes require , and which do you not require ?

Alway s Sometimes Neve r

Sperm washing. . . . . . - 1 - 2 - 3

Spilt ejaculate. . . . . . . . . . . - 1 - 2 - 3

Bacteriocide. . . . . . . . . . . . . . . . - 1 -2 -3

23e. IF SOMETIMES REQUIRE. Under what conditions do you use this

procedure?

Sperm washing. .

Spilt ejaculate. .

Bacteriocide. . . .

[57!

[68]

[69]

[711

[72]

[73]

[74]

[75-76]

[77-78]

[79-80]
91

OUTCOMES

ST CO 4

In what percentage of cases that YOU have treated by artificial inseminatio n DUP 1-5

do you know whether pregnancy i s achieved as a result or not ? 6-4

24.

—— —% [7-91

Based on your experience , what is the average number of insemination s

needed to achieve pregnancy ?

25.

—— — Insemination s [10-121

Based on your experience , what is the average number of cycles that it take s

for a patient to achieve pregnancy by means of artificial insemination?

2 6 .

— — Cycle s [13-14]

What proportion of the patients that you have accepted for artificia l

insemination have achieved pregnancy as a result of the treatment ?

27

— — % [15-17] —

Do you normally follow the full course of the pregnancy for patient s

successfully inseminated ?

2 8

------- No..,. . . . . . . . . . . -I (SKIP TO Q.30a ) [181

Yes. . . . . . - 2

2 9 . Approximately what proportion ended in live births ?

[19-2’ ]

30a . Do you follow the outcomes of live births of patients you hav e

inseminated ?

------- No. . . . . . . . . . . . - I ( SKIP T) Q.31 )

Yes . . . . . . . -2

[221

t 30b. How many cases of birth defects have you encountered ?

1 <--------- None. . . . -0 (SKIP TO Q.31 ) [231

— — cases with birth defects [24-25; I

30c What was/were the birth defects in those cases?

[26-27]

[28-29]

[30-31]

v

31 Do you follow the health and developmen t

inseminations subsequent to birth ?

No... . - 1

Of children from thes e

Yes. ..... . . . . . . . . . . . -2
92

FRESH SPERM

32a. Have you performed any artificial inseminations in the past year

fresh sperm was used?

------- No. . . . . . . . . . . . . . . . - I (SKIP TO Q.35 )

,

,

,

,

t

4

v

35

Yes . . . . . . . . . . . . . . . . . -2

32b. Approximately how many Inseminations have you performed i n

33

34

a.

b.

c.

d.

e.

f.

g.

year , using fresh sperm ?

—— — Number using fresh sper m

Do you use the sperm of husbands or partners ?

No . . . . . . . . . . . . . . . . . . . - 1

Yes. . . . . . . . . . . . -2

in whic h

the pas t

Which of the other following sources have you used to obtain fres h

sperm in the past year ?

Self . . . . . . . . . . . . . . . . . . . . . . . - 1

Other doctors. . . . . . . . . . . . . - 1

Medical students, . . . . . . . . . . - 1

Graduate students. . . . . . . . . . . . . . . . . . - 1

Hospital personnel. . . . . . - 1

Non-hospital personnel . . . . . . . . . - 1

Andrology laboratories. . . . . . . . . . . . . . - 1

DONOR SCREENING PROTOCOL

Prior to acceptance as a donor, which of the following do you normally requir e

[33]

[34-36]

[371

[38]

[39]

[40]

[41]

[42]

[43]

[44]

from donors selected by the recipient (eg. husbands, partners), which do Y O U

require from other donors, and which do you require from neither ?

RECIPIENT OTHER DON’ T

SELECTED DONO R DONORS REQUIR E

a Personal medical history. . . . . - 1 - 2 - 3

[45]

b Family medical an d

genetic history. . . . . . . . . . . . . . . . . - 1 - 2 - 3

[46]

c . Fertility history. . . . . . . . . . . - 1 - 2 - 3

[47:

d Physical examination. . . . . . . -—1 — - 2 - 3

[48]

e . Personality assessment. . . . . - 1 - 2 - 3 (491

f Karyotyping -1 - 2 - 3 [50] . . — -

36a Do you ever require special screening for genetic defects or diseases fro m

any donors . prior to accepting them for artificial insemination ?

_______ No . . . . -1 (SKIP TO Q.36c)

Y E S . . . -2

36b Under what circumstances do you require special screening of donor s

for genetic defects or diseases ?

[51]
93

DONOR SCREENING PROTOCOL

36c. DO you require any other diagnosti c tests for donors prior to initia l

acceptanc e not counting analysis of sperm ?

------- N o -1 (SKIP TO Q 37)

Yes . . . - 2

36d which diagnostic tests do you require in all instances ?

36e ‘Which other diagnostic tests do yo u require in some instances ?

v

37 Do you normally require screening of the semen of donors for fertility or not ?

---_-—-- Don’t require screening . -1 (SKIP TO Q 40 )

Require screening . . . . . . . -2

38 Which of the following criteria do yo u

samples (semen) of donors ?

USE

Sperm count. . . . . . . . . - — 1

Motilit y ..,. . . . . - 1

Linearit y -1

Speed . . . . - 1

Morphology ... . . . . . . . . . - 1

White blood count. . . ,. . . . . . . . . . . - 1

Viscosit y - 1

Ph . . -1

Post-thaw motilit y -1

normall y

[7]

[81

[91

[10]

[11]

[12]

[13]

[14]

[15]

use in screening sper m

Q 39

MINIMUM CRITERIA

— — MILLION

— — PERCEN T

— — PERCENT

— — PHF

PERCENT-

— —

39 FOR EACH “YES" ABOVE: Would you describe the minimum criteria fo r

acceptanc e

n

[59-60]

[61-62]

[63-64]

[71]

ST CO 5

DUP 1-5

6-5

[16-17]

[’0-191

[20-21]

[22-23]

[24-25]

[26-27]

[28-29]

[30-31]

[32-33]
94

DONOR SCREENING PROTOCOL

40

a.

b

c

d.

e .

f

g.

h.

i

J

k

l.

m

n

o

P

q.

r

s

t

u.

v .

w

x .

41

a .

b

c

d

e .

f ,

9

h

1

J

k

1

m

n

o

p.

q.

Have you ever rejected or would you be likely to reject a dono r

because he was/has:

Have Would Be Not

Rejecte d Likely to Likely to

Reject Reject

Less than 18 years old. . . . . . . . .

 -— 1

Over 40 years old. . . . . . . . . . . . . . . . .

 -— 1

Psychologicaly Immature. . . . . . . . . . .

..—- 1

Married. . . . . . . . . . . . . . . .

- — 1

Less than average height. . . . . . . . . . . .

.—- 1

Less than high school degree. . . .

- — 1

Less than average intelligence . . .

.—- 1

Criminal record. . ..... . . . . . . . . .

- - 1

Evidence of drug abuse. . . . . . . . . . .

 -— 1

Evidence of alcohol abuse. . . . . . . . . . . . . . - 1

Evidence of child abuse . . . . .

- - 1

Homosexual contacts. .., . . .

- — 1

Syphilis . . . . . . . . . . . . - 1

Chlamydia . . . . . . . . . .

- — 1

Gonorrhea. . . . . . . . . . . . .

- — 1

Genital herpes. .., . . . . . . . . . . . . .

 -— 1

Cytomegalovirus. . . . . . . . . . . . . . . . . . . . . .

 .—- 1

History of serious genetic disorders. . .

- — 1

Hepatitis . . . . . . . . . . . .. . . . . . . . . . . . .

.—- 1

HIV (HTLV) positive, . . . . . . .

- — 1

Intravenous drug use. ...., . . . . . . . . . . . .

- — 1

Multiple heterosexual partners. . . .

.—- 1

Sexual contact with AIDS cases. . . . . . .

.-— 1

Residences in high AIDS area. . . . . . .

- - -

-2

-2

-2

-2

-2

-2

-2

-2

-2

-2

-2

-2

-2

-2

-2

-2

-2

-2

-2

-2

-2

-2

-2

-2

-3

-3

-3

- 3

-3

-3

-3

-3

-3

-3

-3

-3

-3

-3

-3

-3

-3

-3

-3

-3

-3

-3

-3

-3

For each of the following conditions , would you be likely to reject a dono r

only if he had the condition , If anyone in the donor’s Immediate family ha d

the condition , or would you not reject a donor even if he had the condition ?

Rejec t

Only i f

Donor Has:

Toy-Sachs. . . . . . . . . . . . . . . . . . . . - 1

Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . - - 1

Hemophilia. ..,. . . . . . . . . . . . . . . . . . . - 1

Depression. ...., . . . . — - 1

Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . - 1

Cystic fibrosis . . . . . . . . . . . . . . . . . . . . . . - 1

Mental retardation. ..,. . . . . . . . . . - 1

Obesity . . . . . . . . . . . . . . . . . . . . . . . . - 1

Huntington’s chorea, . . - 1

Duchenne muscular dystrophy . . - 1

Sickle cell anemia .

Thalessemia. . . . . . . .

Hypercholesterolemi c

Neurofibrimatosis .

Malignant melanoma . . . .

Alzheimer’s diseas e

Severe astiamatism .

. - - 1

. -1

heart diseas e -1

-1

-1

-1

-1

Reject i f

Famil y

Histor y

-2

-2

-2

-2

-2

-2

-2

-2

- 2

Not Rejec t

Even i f

Donor Has

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

-3

- 5

- 3

- 3

- 2 - 3

[34]

[35]

[36]

[37]

[38]

[39]

[40]

[41]

[42]

[43]

[44]

[45]

[46]

[47]

[48]

[49]

[50]

[51]

[52]

[53]

[541

[551

[561

[571
95

DONOR SCREENING PROTOCOL

42a. Do you have any limit on the number of patients who can be inseminate d

from the sperm of the same donor?

-------- No . . . -1 (SKIP TO Q.43a )

Yes . . . . . - 2

42b. How many patients will You permit to be inseminated fro m

the sperm of the same donor?

— —

FROZEN SPERM

V

43a. Have you performed any artificial inseminations i n the past year in whic h

frozen sperm was used?

------- No.. , . . -1 (SKIP TO 0.48 )

Yes . . . -2

43b. Approximately how many patients have you inseminated in the past yea r

using frozen sperm ?

—— — Number using frozen sperm

44 Which of the following sources have you used in the past year to obtai n

frozen sperm? (CHECK ALL THAT APPLY)

Have Used

Own supplies. . . . . . . . . . . . . . . . . . . . . . . . .

..—- 1

Hospital supplies . . . . . . . . . . . . . . . . . . . . .

- — 1

Commercial vendor .,. . . . . . . . . . . . . . . . . . - 1

Other (PLEASE SPECIFY)

... . . . . . . - 1

45. Do you use a sperm bank that is located in you r

in another state or don’t you use a sperm bank ?

Same stat e - 1

Another stat e . - 1

No sperm ban k - 1

[ 7 ]

[8-9]

46. Do you or your supplier have a quarantine period prior to use of froze n sperm?

<-—---- No -1 (SKIP TO 0.48) [21]

Yes . . -2

47 How long is that quarantine period?

— — Months [22-23] V
RECORDKEEPING

48. Do YOU keep records that would permit you to identify the specific donor for

any specific pregnancy?

-------- No. . . . . . . . . . . . . - I ( SKIP TO 0.51)

,

0

,

,

0

,

#

,

,

,

0

4

,

I

4

1

I

1

v

51

Yes. . . . . . . . . . . . -2

49. Do you keep records for each donor of :

N o Y e s

Number of women inseminated. . . . . . . . . . . . . . . . . . . . .—- 1

- 2 [25]

Number of pregnancies achieved. . . . . . . . . . . . . . . . ..—- 1 - 2 [26]

Number of children born. . . . . . . . . . . . . . . . . . . . . .—- 1 - 2 [27]

Physical examination. . . . . . . . . . . . . . . . . . . . . . . . . . -1 - 2 [28]

Family genetic history. . . . . . . . . . . . . . . . . . . . . . . . . -1 - 2 [29]

Follow-up examinations. . . . . . . . . . . . . . . . . . . . . . . . . -1 - 2 [30]

50. Would you permit access to donor records , including the name of the donor,

only excluding the name of the donor, or not at all, to :

Access wit h Access With - No

Name out Name Access

Donor. . . . . . . . . . . . . . . . . . . . . . . . . . -1 - 2 - 3

Recipient. . . . . . . . . . . . . . . . . . . . . . -1 - 2 - 3

Recipient partner. . . . . . . . . . .. . . -1 - 2 - 3

Offspring of insemination. . . . .-—1 — - 2 - 3

Public health department. . . . . . -—1 —- 2 - 3

Research scientists. . . . . . . . . . ..—-1 — - 2 - 3

Judicial requests. . . . . . . . . . . . . . -1 - 2 - 3

QUALITY ASSURANCE

Are you aware of any specific professional guidelines or suggested procedures

for the selection recipients or donors for artificial insemination ?

-------- No . . . . . . . . . . . . -1 (SKIP TO 0.54)

I Yes. . . . . . . . . . . . - 2

1

,

, 52. Have you adopted any of these guidelines or procedures as your protoco l

I for artificial insemination ?

:-------- No. . . . . . . . . . . . , - I (SKIP TO Q.54)

,t Yes. . . . . . . . . . - - 2

53. What is the name of those guidelines that you use ?

[31]

[32]

[33]

[34]

[35]

[36]

[37]

[391

[4a?

v

[NEXT PAG E]
97

QUALITY ASSURANCE

54

55

a.

b.

c.

d.

e.

f

HOW adequate do you think that present professional practices of artificia l

insemination are in terms of protecting the :

More tha n Less tha n

Adequat e Adequat e Adequat e

a. Recipient’S safety . . . . . . .

.—-1 —- 2 - 3

b. Donor’s privacy . . . . . . . . .

— —

- 1 - 2 - 3

c. Offspring’s rights. . . . .

- 1 - 2 - 3

d. Physician’s liability. . .

. —

- 1 - 2 - 3

For each of the following agencies , would you like to see their involvemen t

in the quality assurance of artificial insemination procedures increased ,

remain the same, decreased, or eliminated ?

Remain

Increase d the Same Decrease d Eliminate d

Local medica l

boards . . . . . . . . . . -—1 — - 2 - 3 - 4 . —

National medica l

societies. .,... . . . . . . 1 — . — 2 3 - 4

State publi c

health agencies. . , — — 1 2 3 - 4

Federal publi c

health agencies. . . - 1 - 2 - 3 - 4

Hospital PROS. . . . . . . . - 1 - 2 - 3 - 4

Courts. ....,..,. . . . - 1 - 2 - 3 - 4

56. Would you tend to favor or oppose the establishment of national standards f o r

artificial insemination for :

Favo r Oppose

a. Recipient screening. .., . . . . . . . . - — 1

- 2

b. Donor screening by sperm banks . - 1 - 2

c Record keeping requirements. . .

- - 1

- 2

d Donor screening by privat e

practitioners. ., .,.,. .. . - 1 - 2

[411

[42]

[431

[44]

[45]

[46]

[48]

[49]

[50]

[511

[521

[531

[54]
98

QUALITY ASSURANCE

57. DO You believe that the procedures for surrogate motherhood should be

regulated by federal legislation, state legislation or not regulated

by legislation?

Federal low. . . . . . -1

State low. . . . - - 2

No law. . . . . . . . . . . -3

58a. Have you ever ● ncountered any

of artificial insemination ?

-------- No. . . . . . . . . . . . . . .—- 1

,

b

,

,

,

,

,

1

,

,

,

,

I

I

I

@

4

I

;

:

v

59.

60.

61.

[55]

legal problems as a result of your practice

Yes. . . . . . . . . . . . . - 2

58b. Could you describe generally the kind of legal problem that

you have encountered?

[56]

[57-581

[59-60]

[61-62]

[63-66]

COSTS

What do you estimate the average cost Is to your patient (or her Insurance

carrier) for the consultations , examinations and testing prior to the first

actual insemination? Your best estimate Is fine.

b

$ —,— — — “

What do you estimate the average cast Is to your patient (or her insuranc e

carrier) for each subsequent insemination?

$

[67-761 —,— —— ”

What proportion of the patients whom you have treated have health insurance

coverage for at least some of the costs associated with artificial Insemination?

%

[71-73]

—. .

62. For those who have insurance coverage, what proportion of the total costs of

artificial Insemination are covered by the insurance on average?

— — —% [76-76]

ST CO 7

DUP 1-5

6 - 7
99

EVERYONE SHOULD ANSWER THE FOLLOWING QUESTIONS

53 HOW do you feel about the following general statements concerning artificia l

insemination ? For each statement , please indicate whether you agree strongl y

agree somewhat disagree somewhat or disagree strongly .

Agree Agree Disagre e Disagre e

Strongl y Somewhat Somewhat Strongl y

a Artificial inseminatio n

should be more widely use d

when medically indicate d

to treat infertility. . . . . . . . - 1 - 2 - 3 - 4

b. Physician acceptance o f

recipients should be base d

solely on health issues . . . . . . . . - 1 - 2 - 3 - 4

c. Self insemination is a reasonabl e

alternative to physician assiste d

insemination in many cases . . . . . . - 1

d Patient requests fo r

artificial inseminatio n

should be honored, regardles s

of marital status or sexua l

orientation. . . . . . . - - 1

e. Offspring of artificia l

inseminations should hav e

o right to communicat e

with their genetic fathers. . . . . . . - 1

f. Potient requests fo r

artificial inseminatio n

frequently raise mora l

issue s for physicians . . . . . . . . . . - — 1

- 2 - 3 - 4

- 2

- 2

- 2

9 There is nothing wrong wit h

sperm banks which specializ e

in donors with intellectual ,

artistic or athletic gifts. . . . . . .

-—1 — - 2

DEMOGRAPHICS

D1. How long hove you been in active practice ?

YEARS .— —

D2. What is your age ?

— — AGE

D3. What is your primary specialty ?

General practice, . . . .

- — 1

Family practice. .,.,.,. . - 2

Internal medicine. . . . . . .~- 3

Gynecology . . . . . . . . . . . . . . -4

Andrology. . . . . . . . — - 5 . . —

-3 -4

- 3 - 4

- 3 - 4

[ 7 ]

[8]

[9]

[11]

- 3 - 4 [13]

Obstetrics/gynecolog y - 6

Surger y - 7

Urology. . - 8

Other (SPECIFY )

- - 9

[14-15]

[16-17]

[18]

[191
100

EVERYONE SHOULD ANSWER THE FOLLOWING QUESTIONS

DEMOGRAPHICS

D4a. Is your main practice, that is, where you have most of your contact wit h

patients , office-based or hospital based ?

---- - Hospital based. . . . . . . . . -I (SKIP TO Q.05 )

,

0

4

,

I

,

,

,

,

#

,

v

D5.

Office based . . . . . . . . . . . - 2

D4b. Is your main practice part of a health maintenance organization ,

an independent group practice, a solo practice or something else?

Health maintenance organization . . ,. .—- 1

Independent group practice . . . . . . . . ..—- 2

Solo practice . . . . . . . . . . . . . . . . . . . . . . . - 3

Partnership. . . . . . . . . . . . . . . . . . - 4

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - 5

Approximately how many different patients would you estimate that you see on

an outpatient basis during an average week ?

—. OUTPATIENTS .

D6a. Are you engaged in medical research as well as clinical activities ?

---------- No. . . . . . . . . . . . -1 (SKIP TO Q.D7a)

, Yes. . . . . . . . . . - 2

I D6b. Are you engaged in research related to infertility?

, No. . . . . . . . . . . . .—- 1

3 Yes. . . . . . . . . . - - 2

V

D7a. Do you belong to any state or national professional societies?

-------- No. . . . . . . . . . . . . . - I (SKIP TO Q.D8)

Yes. . . . . . . . . . . . .- 2

,

,1 D7b. Are any of these fertility societies ?

I

, Yes. . . . . . . . . . . . . -1

No. . . . . . . . . . . . . . - 2

V

08. Are you male or female?

Male. . . . . . . . .—- 1

Female. . . . . . . - 2

[201

[211

[22-24:

[251

[261

[27]

[281

[29]

THANK YOU FOR YOUR ASSISTANCE . PLEASE PLACE TH E

COMPLETED SURVEY IN THE RETURN ENVELOPE ENCLOSED .
Appendix C

Survey Instrument: Sperm Bank Practice

NATIONAL

SEMEN

QUESTIONNAIRE : —

INFERTILITY SURVEY

BANKING SEGMENT

PLEASE READ THE QUESTION AND MARK THE SPACE BELOW THE QUESTION

THAT MOST NEARLY CORRESPONDS TO YOUR ANSWER. AFTER EACH ANSWER

CONTINUE WITH THE NEXT QUESTION UNLESS THERE IS AN INSTRUCTION

TO SKIP TO A PARTICULAR QUESTION.

1. Does your organization provide homologous semen banking, heterologou s

semen banking, or both ?

Heterologous only. . . . -1 --> SKIP TO Q8

Homologous only, . . . . . - 2

Both. . . . . . . . . . . . . . . . .—- 3

IF NO SEMEN BANKING, PLEASE NOTE AND RETURN THIS QUESTIONNAIRE

2.

3.

4.

5.

6.

Do you require the consent of a donor’s spouse or partner befor e

agreeing to store semen ?

Yes. . . . . . .-— 1

No. . . . . . . - — 2

Which of the following ore cited os reasons for homologous storage ?

About to undergo vasectomy. . . . . . .—- 1

Fear of gamete damage due

to radiation or chemotherapy. . . - 2

Fear of damaging occupational

exposures. . . . . . . . . . . . . . . . . .

..—- 3

Fear of future infertility. . . . . . . - 4

Desire to have children afte r

death. . . . . . . . . , . . . . . . . . . . . . . ,

.—- 5

Other (SPECIFY )

. . . . . . . - 6

How long will you store the specimen ?

YEARS

As long as requested. . . .—- 1

What is the initial processing fee ?

$

What is the annual storage fee ?

$

101
102

7 a . Do YOU have a protocol for disposal of specimen after the death

of donor ?

I

I

v

8 .

7b. Which of the following do you normally do ?

Destroy sample . . . . . . . . . . . . . . . . . . . . . -1

Use for anonymous donation, . . . . . . . . — - 2

Request instructions fro m

wife or relatives. . . . . . . . . . . . . . . .

.—- 3

Other ( SPE CI FY )

- 4

7c. Would you honor instructions from the donor

mortem insemination of a wife or surrogate?

Yes. . . . . .

- — 1

No. , . . . . - - 2

for post -

Approximately how many semen samples for heterologous inseminatio n

do you sell per month ?

—. —

None, homologous only. . - — 1

--> SKIP TO 020

90. Do you sell semen samples to recipients directly or only throug h

doctors , clinics or other third parties ?

Directly to recipients. . - 1

~ Only through doctors. .

- - 2

--> SKIP TO QlOa

I

I

I

I

v

10a

Both. . . . . . . . . . . . . . . . . . .-— 3

9b. Do you require recipients to provide an accompanyin g

physician request ?

Yes. . . , - 1

No. . . .

- — 2

Do you reject requests for specimens if the recipient seem s

unsuitable?

Yes. . . . -1

No. . . - — 2

--> SKIP TO Q11a
103

10b. Have you ever rejected of would you be likely to reject a reques t

for artificial Insemination for a potential recipient because sh e

a .

b .

c .

d.

e .

f .

g

h.

i .

j

k

1.

m.

n.

o.

p.

q

r .

s

t.

u

v .

w.

x .

was/has :

Have

Rejecte d

Less than 18 years old. . . . . . . . . . . . . . . . ..—- 1

Over 40 years old. . . . . . . . . . . . . . . . . . . . . . . - 1

Welfare dependent. . . . . . . . . . . . . . . . . . . . . . .—- 1

Psychological immature. . . . . . . . . . . . . . . . . . - 1

Married. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - 1

Less than average height. . . . . . . . . . . . . . - - 1

Less than high school degree. . . . . . . . . . .-— 1

Less than average intelligence. . . . . . . . - - 1

Criminal record. . . . . . . . . . . . . . . . . . . . . . . . - — 1

Evidence of drug abuse. . . . . . . . , . . . . . . . . . - 1

Evidence of alcohol abuse. . . . . . . . . . . . . -— 1

Evidence of child abuse. . . . . . . . . . . . . . . . - — 1

Homosexual contacts. . . . . . . . . . . . . . . . . . . . - — 1

Syphillis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - 1

Gonnorhea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - — 1

Genital herpes. . . . . . , . . . . . . . . . . . . . . . . . . . - 1

History of serious genetic disorders. .

.-— 1

Hepatitis. . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . - 1

HIV (HTLV) positive. . . . , . . . . . . . . . . . . . . . . - 1

Cytomegalovirus. . . . . . . . . . . . . . . . . . . . . . . . . - 1

Intravenous drug use.. . . . . . . . . . . . . . . . . . . - 1

Multiple heterosexual partners. . . . . . . .

- - 1

Sexual contact with AIDS cases. . . . . . .

- — 1

Residences in high AIDS area. . . . . . . . . . - - 1

ha. Do you allow recipients or their physicians t o

for a donor or not ?

Yes. . . . . . . -1

No. . . . . . . . -2 --> SKIP TO Q.12 a

Would Be

Likely t o

Rejec t

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

N o t

Likely t o

Rejec t

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

provide specification s

11b. Which of the following donor characteristics or e

try to match, if requested :

Willin g

Age. . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - 1

Height. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - 1

‘Weight. . . , . . . . . . . . . . . . . . . . . . . . . . . - 1

Eye color. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - 1

Hair texture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - 1

Complexion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - 1

B O dy type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - 1

Race . ..... . . . . . . . . . . . . - 1

Ethnic or national origin. . . . . . . . . . . . . . . . - 1

Religion . . . . . . . . . . . . . . . . . . . . . . . . . . . . - 1

I.Q. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - - 1

Income, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - 1

Educational attainment. . . . . . . . . . . . . . . . - 1

Special abilities. . . . . . . . . . . . . . . . . . . . . . . - 1

Hobbies or interests. . . . . . . . . . . . . . . . . . . . . . . . . . - 1

you normally willing t o

Not Willin g

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- -2

- 2

- 2

- 2

- 2

- 2

- 2
104

12. Do you allow recipients to reserve a particular donor for future use?

Yes. . . . . . . . -1

No. . . . . . . . .—- 2

130 . Do you offer sperm separation for preconception gender selection ?

Yes. . . . . . . . . . . . . . . . - 1

~ No . . . . . . . . . . . . . . . . . . . . . . . . . .—- 2 --> SKIP TO Q1 4

I

I

‘J

1 4 .

15.

13b. What 1s your average charge for this service ?

$

13c . In your experience , in what proportion of cases where sex selectio n

is attempted is the selection successful ?

%

Don’t Kno w -88 8

Are the following characteristics deliberately overrepresented i n

your inventory , deliberately underrepresented, or about normal ?

OVER

REP.

College or graduate degree holder. . . . . . . . . . . . . -1

Better than average 10. . . . . . . . . . . . . . . . . . . . . . . . -1

Better than average occupationa l

status/achievements. . . . . . . . . . . . . . . . . . . . . . . . - — 1

Greater than average height for ethnic group. . - 1

Greeter than average athletic ability. . . . . . . . . ‘ - 1

Better than average looks. . . . . . . . . . . . . . . . . . . . - — 1

Better than average artistic ability. . . . . . .

..—- 1

Member of particular religious group. . . . . . . . . . - 1

Member of particular nationality. . . . . . . . . . . . . . - 1

How do you obtain donors?

Word of mouth. . . . . . . . . . . . . . , . . . . . . . . . . . . . - 1

Advertisement in genera l

interest newspapers or magazines. . . . . . - 2

Advertisement in student

newspapers or magazines. . . . . . .

 -— 3

Flyers. .,...... . . . . . . . . . . . . . . . . . . . . . - 4

Direct mail or telephone solicitation. .

- — 5

Referral from other sperm bank... . . . . . - 6

Referral from physicians. . . . . . . . . . . , . - — 7

UNDER

REP.

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

AB0UT

NORMAL

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

NOT

SURE

- 4

- 4

- 4

- 4

- 4

- 4

- 4

- 4

-4

Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - 8
105

16.

17

18

19

20

21

What percentage of the inventory that you offer comes from :

Yourself. . . . . . . . . . . . . . . . %

Other physicians. , . . . . . . %

Medical students. . . . . . . . %

Graduate students. . . . . . . %

University faculty. . . . . . %

Hospital personnel. . . . . . %

Nonhospital personnel. . . %

Andrology laboratory. . . . %

Other. . . . . . . . . . . . . . . . . %

How much do you pay donors per ejaculation ?

$

On average, how often do donors come to donate ?

Weekly. . . . . . . . . . . . . . . - 1

Monthly. . . . . . . . . . . . . - 2

A few times a year. . . - 3

Annually. . . . . . . . . . . - 4

Less often. . . . . . . . . . . - 5

On average , for how many years do donors continue to donate ?

YEARS

Do you require any form of screenlng before accepting donors ?

Yes , heterologous only. . . . . . . . . . . . . . . . . . . - 1

Yes , heterologous and homologous. . . . . .

- - 2

No, neither. . . . . . . . . . . . , . . . . . . . . . . . . . . . - 3 --> SKIP TO Q27 a

Prior to acceptance as o donor , do you normally require the followin g

from heterologous donors only, homologous donors only, both or neither ?

HETEROLOGU S HOMOLOGOUS BOTH NEITHER

a . Personal medlcal history. . . . . - 1 - 2 - 3 - 4

b. Family medical and

genetic history. . . . . . . . --l__ - 2 _

- 3 - 4

c. Fertility history. . . . . . - 1 - 2 - 3 - 4

d. Physical examination. . . . . . . . - 1 - 2 - 3 -4

e Personality assessment. . . . . - 1 - 2 - 3 - 4

f Karyotyping. . . . . . - 1 - 2 - 3 —4
106

22a. D o you ever require special screening for genetic defects or diseases from

donors, prior to accepting them for artificial insemination?

-1 --> SKIP TO Q22c

Yes, heterologous only. . . . . . . . . . . . . . . - 2

Yes, homologous and heterologus. . . . ..—- 3

22b. Under what circumstances do you require special screening of

donors for genetic defects or diseases ?

v

22c, Do you require any other diagnostic tests for donors prior to initia l

acceptance, not counting analysis of sperm?

-1 --> SKIP TO 023

Yes, heterologous only. . . . . . . . . . . . . . . . . . . . - 2

Yes, heterologous and homologous. . . . . . . . . . - 3

I 22d. Which diagnostic tests do you require?

v

23. DO

o r

you normally requir e screening of the seme n of donors for fertilit y

not ?

Don’t require screening. . . . . . . . . . . . . . . . . . . . . . . . - 1

Require screening for heterologous only. . . . . . . . .

- 2

Require screening for bot h

heterologous and homologous donors. . . . . . . . . . - 3
107

24. Have you ever rejected a donor because he was/has:

a .

b.

c .

d .

e.

f .

9“

h .

i .

j .

k .

1 .

m .

n .

o .

p .

q .

r .

s .

t .

u.

v .

w.

x .

2 5 .

Have

Rejecte d

Homologous

Dono r

Less than 18 years old. . . . . . . . . . . . . . . . .-— 1

Over 40 years old. . . . . . . . . . . . . . . . . . . . . . - — 1

Welfare dependent. . . . . . . . . . . . . . . . . . . . . . .—- 1

psychological immature. . . . . . . . . . . . . . . . . . -1

Married. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -1

Less than average height. . . . . . . . . . . . . . . . -1

Less than high school degree. . . . . . . . . . . -1

Less than average intelligence. . . . . . . . .-— 1

Criminal record. . . . . . . . . . . . . . . . . . . . . . . . . -1

Evidence of drug abuse. . . . . . . . . . . . . . . . -1

Evidence of alcohol abuse. . . . . . . . . . . . . . .-1

Evidence of child abuse. . . . . . . . . . . . . . . . . -1

Homosexual contacts. . . . . . . . . . . . . . . . . . . -1

syphillis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -1

Gonnorhea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -1

Genital herpes. . . . . . . . . . . . . . . . . . . . . . . . .-— 1

History of serious genetic disorders. .

 -— 1

Hepatitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . -1

HIV (HTLV) positive. . . . . . . . . . . . . . . . . . . . -1

Cytomegolovirus. . . . . . . . . . . . . . . . . . . . -1

Intravenous drug use. . . . . . . . . . . . . . . . . . -1

Multiple heterosexual partners. . . . . . . -1

Sexual contact with AIDS cases. . . . .

 -— 1

Residences in high AIDS area. . . . . . . . . . . -1

Hav e

Rejecte d

Heterologou s

Dono r

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

— - 2

Have neve r

Rejecte d

Donor

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

For each of the following conditions, would you be likely to reject a

heterologous donor only if he had the condition, if anyone in th e

donor’s immediate family had the condition , or would you not reject a

donor even if he had the condition ?

Rejec t

Only i f

Donor Has:

a. Toy-Sachs. . . . . . . . . . . . . . . . . . . . . . . . . . . - — 1

b. Diabetes, . . . . . . . . . . . . . . . . . . . . . . . . . . . . .-1

c. Hemophilia. . . . . . . . . . . . . . . . . . . . . . . . . . . . -1

d. Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . -1

e. Asthma. . . . . . . . , , . , . . . , . . . . . . . . . . . - 1

f. Cystic fibrosis. . . . . . , . . . . - 1

g. Mental retardation. . . . . . . . . -1

h. Cbesity . . . . . . . . • -- 1

i. Huntington’s chorea. . . . . . . . . . . . . . . - 1

j. Duchenne muscular dystrophy. . . . . . . - 1

k. Sickle cell anemia, . . . . . . . . . . . . . . . . . - 1

l. Thalessemia. . . . . . . . . . . . . . . . . . . . . . . . . . - 1

m. Hypercholesterolemic heart disease. .

 -— l

n. Neurofibramitois . . . . . . . . . . . . . . . . . . . . . - 1

o. Malignant melanoma . . . . . . . . . . . . . . . . . . . - 1

p. AIzheimer’s disease. . . . . . . . . . . . . . .

- - -

q. Severe astigmatism. . . . . . . . . . . . . . . . . - 1

Reject i f

Famil y

Histor y

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- k2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

- 2

Not Rejec t

Even if Dono r

Donor Has :

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3

- 3
108

2 6 . Do you inform donors who have been rejected about the reasons fo r

their rejection ?

Yes. . . . . -— 1

No. . . . . . . . .—- 2

27a . D O you routinely screen donors for AIDS ?

Yes, all donors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .—- 1

Yes , heterologous and homologou s

donors from high risk groups. . . . . . . . . . . . . . - 2

Yes, only high risk heterologous. . . . . . . . . . . . - — 3

No routine AIDS screening. . . . . . . . . . . . . . . . . . . . -4 - - > SKIP TO Q32

27b. Does your routine AIDS screening involve diagnostic tests ,

such os Western blot , or is it limited to self-reporte d

medical conditions ?

Diagnostic test. . . . . . . - — 1

SKIP TO Q28a

\ Self-report. . . . . . . . . . . . . - 2

I 27c . If high risk for AIDS is reported in medical history ,

do you conduct an y follow-up diagnostic tests or not ?

Yes. . . , . ,

.—- 1

No. . . . , .

.-— 2

v

28a. If a new donor tests negative to HIV do you quarantine seme n

for further testing of the donor or not ?

~ Yes, quarantine . . . . . . . . . . . . . . . . . . . . . . . . . .— -1 ANSWER Q28 b

- 1 No, don’t quarantine. . . . .

.-— 2

--> SKIP TO 02 9

!------1 Depends. . . . . . . . . . . . . . . . . . . . . . . - 3 --> SKIP TO 02 9

I

I

I

v

29

30

I

v

28b . How long is the quarantine period ?

— — MONTHS

H OW often are heterologous donors retested for AIDS ?

Before each donation. . . . . . . .—- 1

Every six months. . . . . . . . . . . . . - 2

Annually. . . . . . . . . . . . . . . . . . . . . - 3

Occasionally. . . . . . . . . . . . . --— 4

Never. . . . . . . . . . . . . . . . . . . . - 5

Do you tell donors if they have tested positive ?

Yes. . . . . . .—- 1

No. . . . . . . - 2 . —
109

.

31a . Would you inform the wife or partner of a homologous donor,

if tests Indicated that the donor had :

WOULD

INFOR M

WOULD

NOT INFOR M

NOT

SURE

a.ARC or full blown AID S

b.HIV positiv e

c.Other infectious diseas e

d.High risk to sever e

genetic defect fo r

offsprin g

-1 - 2 - 3

-1 - 2 - 3

-1 - 2 - 3

-1 - 2 - 3

31b Would you inform the wife or partner of o heterologou s

donor, if tests indicated that the donor had :

WOULD

INFORM

WOULD NOT

NOT INFOR M SURE

a.ARC or full blown AID S

b.HIV positiv e

c.Other infectious diseas e

d.High risk to sever e

genetic defect fo r

offsprin g

-1 - 2 - 3

-1 - 2 - 3

-1 - 2 - 3

-1 - 2 - 3

32. What is your standard charge for a semen sample?

33.

34.

$

How many inseminations con be made per sample ?

Do you inform donors of :

Yes No

a . Number of samples Sent out. . . . . . . . . . . . - 1 - 2

b . Number of women inseminated. . . , . . . . . - 1 - 2

c . Number of babies born as a result. . . . - 1 - 2
110

RECORDKEEPING

35. Do you keep records that would permit you to identify the specific donor f o r

any specific pregnancy ?

No. . . . . . . . . . . . . . -1 --> SKIP TO 03 8

Yes. . . . . . . . . . . . . - 2

36. Do you keep records for each donor of:

Yes No

Number of women inseminated. . . . . . . . . . . . . . . . . . . .

.—- 1

- 2

Number of pregnancies achieved. . . . . . . . . . . . . . . .

..—- 1 - 2

Number of Children born. . . . . . . . . . . . . . . . . . . . . . . . .—- 1

- 2

Physical examination. . . . . . , . . . . . . . . . . . . . . . . . , .

..—- 1

- 2

Family genetic history. . . . , . . . , . . . . . . . , . . . . . . .

..—- 1

- 2

Follow-up examinations. . . . . . . . . . . . . . . . . . . . . . . ,

.-— 1 - 2

37. Would you permit access to donor records, including the name of the

donor, only excluding the name of the donor, or not at all, to:

Access with Access With- No

Name out Name Acces s

Donor. . . . . . . . . . . . . . . . . . . . . . . . . . - 1 - 2 - 3

Recipient . . . . . . . . . . . . . . . . . . . . . . -1

Recipient partner . . . . . . . . . . . . . . -1

Offspring of insemination, . . . . . - 1

Public health department. . . . . . . - 1

Research scientists . . . . . . . . . . . . -1

Judicial requests. . . . . . . . . . . . . . -1

QUALITY ASSURA

— - — - 2 - 3

- 2 - 3

- 2 ‘ - 3

- 2 - 3

- 2 - 3

- 2 ‘ - 3

NCE

v

38. Are you aware of any specific professional guidelines or suggested procedure s

for the selection recipients or donors for artificial insemination ?

~ No. . . . . . . . . . . . . . . . . . . . . . . .— -1 --> SKIP TO 04 1

Yes. . . . . . . . . .-— 2

39. Have you adopted any of these guidelines or procedures as you r

protocol for artificial insemination ?

- No. . . . . . . . . . . . - — 1

--> SKIP TO Q4 1

\ Yes. . . . . . - 2

I

4 3 . What is the name of those guidelines that you use ?

I

v

[NEXT PAG E]
111

QUALITY ASSURANCE

4 1 . How adequate do YOU think that present professional practices of artificia l

Insemination are in terms of protecting the :

More tha n Less tha n

Adequat e Adequat e Adequat e

a. Recipient’s safety . . . . . . .

-—1 —- 2 - 3

b. Donor’s privacy . . . . . . . . . . . - 1 - 2 - 3

c. Offspring’s rights. .,.... . - 1 - 2 - 3

d. Physician’s Iiability . . . . . - 1 - 2 - 3

42. For each of the following agencies , would you like to see their involvemen t

in the quality assurance of artificial insemination procedures increased ,

rrmain the same , decreased, or

Increase d

a Local medica l

boards . . . . . . . . . . . -— 1

b. National medical

societies. . . . . . . . -1

c. State publi c

health agencies. . - 1

d. Federal public

health agencies. . . - 1

e.Hospital PROS. ,... - - 1

f Courts. ..... . . . - 1

eliminated ?

Remain

the Same

- 2

- 2

- 2

- 2

- 2

- 2

Decrease d

- 3

- 3

- 3

-3

- 3

- 3

Eliminate d

-4

-4

-4

-.4

-4

43 Would you tend to favor or oppose the establishment of national standards fo r

artificial insemination for :

Favo r Oppose

a Recipient screening. . . . . . . . . -—1 -2

b Donor screening . . . . . . . . . . . . -1 -2

c Record keeping requirement s - 1 - 2

44. Do you believ e that the procedures for surrogate motherhood should be

regulated by federal law, state law or not regulated by law?

Federal law . . . -1

State law . -2

No law . . . . -3
112

45a . Have you ever encountered any legal problems as a result of your practice of

artificial Insemination ?

No. . . . . . . . . . . . . . - — 1 --> SKIP TO Q.4 6

Yes. . . . . . . . . . . . . . - 2

45b . Could you provide a general description of the kind o f

legal problem that you have encountered ?

46. How do you feel about the following general statements concerning artificial

insemination ? For each statement , please indicate whether you agree strongly ,

agree somewhat , disagree somewhat or disagree strongly .

Agre e Agree Disagree Disagree

Strongl y Somewhat Somewhat Strongl y

a. Artificial Inseminatio n

should be more widely use d

to treat infertility. . . . . . . . . . . . . ..—- 1

b. Physician acceptance o f

recipients should be base d

solely on health issues. . . . . . . . . . ..—- 1

c . Self insemination is a reasonabl e

alternative to physician assiste d

insemination in many cases. . . . . . . . . - 1

d. Patient requests f o r

artificial inseminatio n

should be honored , regardles s

of marital status or sexua l

orientation. . . . . . . . . . . . . . . . . , . . . . . . .—- 1

e. Offspring of artificia l

Inseminations should hav e

a right to communicat e

with their genetic fathers. . . . . . .

 -— 1

- 2

- 2

- 2

- 3 - 4 - —

- 3 - 4

-3 - 4

- 2 - 3

- 2 - 3

f. Patient requests fo r

artificial inseminatio n

frequently raises mora l

issues for physicians. . . . . . . . -1 — -2 -3

- 4

-4

- 4

g There is nothing wrong wit h

sperm banks which specializ e

in donors with intellectual ,

artistic or athletic gifts. . . . . . . . .-—1 — - 2 - 3 -4

THANK YOU FOR YOUR ASSISTANCE. PLEASE PLACE THE COMPLETED SURVEY IN

THE RETURN ENVELOPE ENCLOSED.