Donor Egg Disclosure- The Great Debate

Phyllis Martin, M.Ed., LPC

Whether and when to tell a child conceived through donor gametes about how they were conceived has been a heated topic since 1984, when the first donor egg baby was conceived. As a counselor specializing in infertility, and specifically in donor egg, I've heard every potential donor egg recipient ask me "should I say something, to whom, when and how?!" If you have ever participated in online discussion groups, you will see supporters at both ends of the spectrum fighting their fears and each other by asking if the child's right to know is greater than the right of the parents to privacy. Over the years, the debate has shifted from secrecy to a more open public discussion.

Fear and protection are the two main motivators for parents to keep their method of conception to themselves and not disclose to anyone, including the child, that donor gametes were used. The fears are numerous. Parents worry that their angst and grief will pass to their child when they disclose. They fear that the grief over the genetic loss will make a child feel second best. They worry that the child will not feel part of the family or will not view his/her parents as "real" parents. The most pervasive fear tends to be that disclosure will open their child up to potential judgment, teasing, ridicule and, therefore, emotional turmoil. Some parents worry that disclosure could even result in some sort of parental rejection by the child. Mistakenly, they assume that the painful rollercoaster of infertility will never subside and that by telling a child of his/her conception, the pain will return in its full force and the parents will feel loss again, as well as burdening their child emotionally.

Some parents decide that they will remain silent until the child is an adult and better able to understand the concept and their decision, while having enjoyed a normal childhood.

Others intend to keep conception a private matter and try to ensure that a donor has the same blood type as the mother and that the physical characteristics are as close as possible to her as well. Some of the reasons for these choices are religious, familial, or cultural.

The second school of thought is to disclose their origins to the child. Parents who choose disclosure often say that "the child has a right to know", "I would want to know" and "I could not keep something like that a secret". These parents have a general sense that secrets in families can take on a life of their own and become damaging. They see the press accounts about some adoptions and other experiences and realize that when conception information is withheld, there is a sense of betrayal, anger and turmoil as adult children try to make sense of their history and selves.

Within the disclosure group, parents are usually confused about how and when to proceed. In my experience, there are some basic rules of thumb. First, keep the number of people who know your conception story small until you know how you plan to proceed. This will keep you in control of your information and minimize worry that someone will make a comment to your child too soon or in a manner with which you are not comfortable. Second, think about your own feelings about using a donor and what you would want to tell a child. Think of the positive aspects of why you chose a donor. Third, think about at what age you would want to disclose to your child and why. Are you telling him/her what hardship and misery you went through and how this was not a first choice or are you telling her how you tried and tried and are so thrilled that there was a process that could allow you to be his/her mother?

Some parents opt for explanation right from the beginning and tell their infant his/her conception story. While an infant cannot comprehend anything about this topic, starting early and repeating it often allows parents to practice their story and shape it into a comfortable story that the child will grow up having always known. This model is based primarily on adoptive families and we have seen the benefits in adult adoptees. Rather than feeling betrayed or labeled, these adoptees report always knowing. They do not recall a big discussion, but know it is part of their history.

Others wait until a child is old enough to understand reproduction and privacy -- generally when they are between eight and ten years old. Discussion may begin because a child asks questions about reproduction or where he/she came from. It may occur because the parents do not want to wait too long and risk avoiding the topic or having a teenager question his identity because he or she just found out and feels shocked. I do not recommend waiting until a child is a teenager or a preteen, as the main developmental task at this stage is to break from parents, gain independence and discover one's self. Adding a conception story at this stage that makes a teen different from peers, could cause the emotional turmoil so many parents worry about.

Each developmental stage requires age-appropriate language. I recommend that parents do not personify the anonymous donor or refer to her as someone in a parenting role ("other mommy", "egg mommy") and use the words "helper" "nice lady" or "donor" instead. This highlights the point that these donors have generally donated on condition of anonymity and their rights and contractual understanding need to be respected. The same rule applies for a known donor, when clear boundaries must be discussed before even proceeding with a donor cycle to ensure that each woman is very clear about the role, if any, she will have in the child's life.

Whatever you decide to do regarding disclosure, proceed slowly and understand that talking about using a donor is not a one time conversation, no matter what type of discussion you plan to have. If you do not intend to tell your child of his/her conception, it is important to ask yourself why and what will you do should something force the issue to be known.

Finally, donating an ovum does not make one a mom or mother. The definition of mother is defined by the role a woman has with a child. Adopted families understand that they are the parents. Parenting is not dependent on the genetic contribution, instead it is the lifelong doing, nurturing, loving and emotional support that parents provide.

Phyllis Martin counsels infertility and donor egg patients and prospective patients at the Genetics & IVF Institute in Fairfax, Virginia.

Is Pregnancy Possible After Tummy Tuck?

By: Stephen R. Lincoln, MD, FACOG

I had a tummy tuck. Is it still possible to go through pregnancy?
A "tummy tuck", or abdominoplasty, is a surgical procedure generally performed by plastic surgeons. The procedure is often described as removing extra fat and skin from the abdominal wall, with surgical tightening of the abdominal muscles. This type of procedure generally does not affect one's ability to get pregnant, but there can be theoretical concerns for the actual pregnancy. If there is not enough room for the uterus to fully expand, there could be compromises in fetal growth and possible complications during the need for a Cesarean section, if a C-section is indicated.

There are a few reported cases in the medical literature of patients having normal pregnancies after a tummy tuck/abdominoplasty surgery without any complications. The risks are generally thought to be theoretical, but attempting pregnancy is generally believed to be safe with careful monitoring. There is also a risk of developing weakness in the surgically repaired abdominal area, particularly in the third trimester. Most plastic surgeons would recommend waiting at least six to twelve months after the procedure before attempting pregnancy to try and maximize the healing process.

Patients considering pregnancy after the procedure should consult with the plastic surgeon who performed the procedure as well as the obstetrician who will be caring for them throughout the pregnancy.

Secondary Infertility

By: Sunita Kulshrestha, MD, FACOG

Sometimes, men and women who conceived one or more children without medical assistance are surprised to find that they are having difficulty conceiving again. This kind of infertility is called secondary infertility, and is defined as the inability to achieve pregnancy after having had a previous pregnancy. The previous pregnancy(ies) may have ended in a miscarriage, abortion or a delivery.

A woman who is under the age of thirty-five, should consult a specialist if she fails to conceive within the first twelve months of trying to conceive. If she is over age thirty-five or if she needed fertility treatment for her first pregnancy, she should seek help if she has not conceived within the first 6 months, or earlier if she or her partner have a known fertility problem.

Secondary infertility is often unexplained. Sometimes, all of the historical factors and testing are normal and there is no identifiable cause of infertility. Although a previous pregnancy implies that at one point in time, egg quality, sperm quality, ovulation, timing of egg-sperm exposure, uterine factors and tubal status (with at least one open tube) were all normal, all of these factors can change. A new partner may have a fertility problem or the female may have previously had her tubes tied or the male may have had a vasectomy.

As a woman ages, the quality of her eggs declines. This decline accelerates after the age of thirty-five and becomes even more rapid after the age of forty. Older women also have eggs that are more likely to have chromosomal abnormalities. Both of these factors can decrease the chance of achieving pregnancy and increase the chance of early miscarriage.

Ovulatory patterns can change with time. Ovulation may be affected by extremes of stress, weight, diet and exercise. Other hormonal abnormalities may develop, including abnormalities of the thyroid gland, an overproduction of the hormone prolactin and exacerbation of polycystic ovary syndrome.

With time, some women develop fibroids (nodules of benign smooth muscle in the uterus) or their existing fibroids enlarge. Women can also have endometrial polyps. Fibroids or polyps may affect fertility if they involve the uterine cavity. If a woman has had any instrumentation or surgery involving the uterus (including a dilation and curettage for a miscarriage or an abortion), or a complicated delivery, she may develop intrauterine adhesions (scar tissue) inside the uterus. The chance of developing scarring in the uterus from any of these procedures, however, is quite low.

Fallopian tubes can become blocked if any inflammatory process involves the pelvis. This primarily occurs in the setting of a pelvic infection (most often chlamydia, gonorrhea or PID (pelvic inflammatory disease). Any surgical procedure in the abdomen or pelvis (including appendectomies, myomectomies (removal of fibroids), and tubal surgery can cause pelvic adhesions (scarring) and these adhesions can cause tubal obstruction. Some women have endometriosis, a progressive condition which can also be a cause of new adhesions in the pelvis.

At the same ages, the male does not have a comparable decline in sperm quality. However, some men as they age can develop varicoceles (dilated blood vessels on the scrotum). This may affect sperm quality. Additionally, sperm is far more sensitive than eggs are to environmental factors and these factors may have changed. Sperm can be affected negatively by certain medications, medical problems, fever, viral illnesses, excessive alcohol consumption and exposure to heat.

A woman who believes she has secondary infertility should consult a physician who is an expert in fertility. Based on the situation, the physician may order tests to include an assessment of ovarian reserve (egg quality), a semen analysis, a hormonal evaluation, and an evaluation of the anatomy (uterus and/or fallopian tubes).

The treatment is based on first identifying the cause and trying to correct it. Possible treatments may be as simple as lifestyle changes (appropriate weight loss, reducing excessive alcohol intake , smoking cessation and/or, stress management).

If testing reveals a hormonal problem, oral medications can be taken to help restore normal hormonal balance and to induce ovulation.

If a woman is of advanced reproductive age or has decreased ovarian reserve (problems with egg quality or response to medications), she may wish to be aggressive and consider IVF (if possible) or use a donor egg and have the embryos transferred into her own uterus. IVF with the use of donor eggs is a highly effective tool to bypass the issue of ovarian aging.

If a woman has tubal disease or has had a tubal ligation in the past, IVF will bypass the need for open tubes. The role of the tube is to collect the eggs and fertilize them. In IVF, the eggs are collected in a procedure called an egg retrieval and fertilization occurs in a dish in the lab. Surgical correction of tubal disease may also be an option in select cases. Fibroids, polyps and intrauterine adhesions can all be managed surgically.

For unexplained infertility, the goal is to improve the efficiency of the conception process. This can be accomplished by 1) Superovulation, a technique to enable the release of more than one egg; 2) Intrauterine insemination in which a higher concentration of sperm is delivered closer to the egg, and 3) In-vitro fertilization (IVF), in which normally fertilized eggs (embryos) are directly replaced into a receptive uterus. Of all these techniques, IVF offers the best success rates.

Conversely, if a problem with the sperm is identified, modalities used may include a urological evaluation and intrauterine inseminations (IUI) if it is a mild problem or in-vitro fertilization with intracytoplasmic sperm injection (IVF/ICSI) for moderate to severe problems. If the male has had a vasectomy then IVF/ICSI can be performed with an NSA (non-surgical testicular sperm aspiration). In IVF/ICSI, only one normal sperm is needed for each egg.