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Is it okay to offer cut-price IVF in return for a patient's sperm?
They call it "sperm sharing" but "sperm bartering" is probably more accurate: infertile couples can cut the cost of their IVF if the man first deposits his sperm for other patients to use. Is this ethical?
It was many years ago when I first heard about egg sharing. The idea is that a woman with eggs to spare but no money for her own IVF can get a discount on her fertility treatment if she donates half her egg harvest to a woman who pays extra.
In Canada, offering "consideration" for gametes is prohibited, and so egg sharing is not allowed. In the UK, however, where there is also a law against payment for eggs and sperm, an exception is made for so-called egg-sharing. The Human Fertility and Embryology Authority (HFEA), the fertility regulator, decided in 1992 that the arrangement provided an acceptable trade-off. The decision hinged on the fact that egg sharing reduced harm overall: only one woman would undergo ovarian stimulation and retrieval but two would have a shot at babies. A win-win, some declared.
I've never bought this argument. First of all, if you are against using money to lure someone into doing something they might not otherwise choose to do — one of the reasons payment is generally banned — this is very much that. But second, if you are going to use money to persuade people to donate eggs, the last people you should be recruiting are people struggling to have a child. I am not the first person to point out just how devastating it would be to fail at having a child through your subsidized IVF only to find out the woman who took half your eggs had succeeded. Your only genetic child in the world is being raised by someone else.
And while I'm here, if ovarian stimulation and retrieval are so dangerous that reducing their frequency warrants making an exception to the law, then why do we allow elective egg freezing?
But enough about eggs. This item is about sperm. The question at hand is whether sperm can be bartered for a discount in IVF prices without encountering the same sorts of ethical challenges.
Nathan Hodson, a psychiatrist at Warwick Medical School in Coventry, UK, began pondering that. Contrary to what he expected at the outset, he concluded that sperm sharing presents even greater ethical concerns than egg sharing.
And, to his surprise, it's already happening, and has been for years. Hodson found six separate UK clinic websites offering reduced-price IVF if the male in an opposite-sex couple agreed to donate sperm. The earliest reference he found dates back to 2006. Despite that, there appears to have been no academic or ethical scrutiny. And although the HFEA tracks egg sharing, it somehow does not track sperm sharing.
Read on to hear Hodson's compelling arguments.
My opinion is simple. Don't do this. Stop now.
6 minute read
Paying for eggs and sperm in the UK is not allowed, but there is an exception: gamete sharing. That's when an infertility patient swaps some gametes — to be used by another patient — in exchange for a price reduction on their own care.
Where eggs are concerned, the idea has come under a lot of ethical and academic review. But there has been no such scrutiny of sperm sharing, says Nathan Hodson, a psychiatrist at Warwick Medical School in Coventry, UK. And it is needed.
In his recent paper "Differences between sperm sharing and egg sharing are morally relevant," published in the Journal of Medical Ethics, Hodson reminds us that a key justification for allowing egg sharing is that it is deemed to reduce overall medical risk: one cycle, two beneficiaries. Notably, when the question was raised about whether the egg-providing woman could undergo two stimulations — one for each woman — it was turned down. There had to be a risk reduction.
But there is no such risk reduction with sperm sharing, he points out, because extracting sperm is not risky.
How did the other concerns around gamete sharing compare between sperm sharing and egg sharing? Was there some other rationale for allowing sperm sharing? There was the worry that giving steep discounts in exchange for gametes would commodify them, but the concern seemed the same with both eggs and sperm. There was the worry that it was impossible to get meaningful consent, but that seemed similar too. Another issue was that the arrangement could lead to "sharer regret" — when the gamete provider did not have a child but the recipient did.
Here Hodson lingered to think things through. In a typical egg sharing agreement, a woman shares a single batch of eggs with just one other woman. The two have roughly equal chances of succeeding. In a typical sperm sharing arrangement, however, a man is asked to donate ten or more times for the creation of up to ten families. How likely was it that a man would end up with no genetic child of his own, but with several being raised by others?
It seemed quite likely, Hodson concluded. "This is almost too obvious for anyone to have missed," he says.
The man trades ten donations to others for one round of IVF for himself and his partner. We can presume the sperm is of excellent quality because only men with top-notch sperm are accepted into the arrangement. That means two things, says Hodson. One, there is a strong likelihood that it will bring success to recipients. Two, his own family's infertility issues are with the female.
So who is getting the sperm samples? "Plausibly single women and lesbians with a really high chance of success," says Hodson. "Or couples that need donor sperm, not couples that have female factor infertility." This makes it very likely that there will be live births among the ten recipient families.
But who are the couples "sharing" the sperm? Hodson doubts they are on their first round of IVF. They've likely been through a round or two and have exhausted their savings, he suspects. "This is low-prospect IVF," he says.
He reckons that the sperm-provider has a roughly 80 percent chance of not getting a live child of his own out of the arrangement but only a five or six percent chance of not having at least one donor child born to a recipient.
This is a bad deal for the sperm-provider, and potentially even worse for his partner, says Hodson. "We completely ignore, once again, the actual infertile person in this situation," he says, "which is the woman who needs the IVF." He says sperm sharing puts the infertile person in the worst possible situation, by essentially arranging for her partner to have kids with someone else. She is meanwhile very likely left childless. "And she loses even the right for them both to be childless together."
What's more, he says, the feelings of donor-conceived people are as usual being overlooked. Children born to the recipients may learn that the gametes used to conceive them were bartered by their genetic parent in an attempt to have a family of their own. Offspring may view estrangement from their genetic family "as a kind of human price for both families," Hodson writes. While some may not see it this way, some may.
Donor anonymity is forbidden in the UK. Any person born through such an arrangement will have the right to know their genetic parent's identity at age 18. It's reasonable to expect that many more such children will be produced through sperm sharing than egg sharing. If sperm-sharing started around 2006, the first of those children will be adults soon. "No man has yet had the 18-year-old come and knock on the door and say, 'I'm your kid,'" says Hodson. But if the man had no children of his own, despite wanting to, it may be bittersweet. And for his wife, it may be the worst thing that ever happens to her, he says.
The HFEA tracks how many people engage in egg-sharing — there were 381 egg shares in 2018, for instance — but, to Hodson's astonishment, they do not bother to track the number of sperm shares.
It's possible, Hodson concedes, that no one is sharing their sperm this way, and so it's not something we need to worry about. But that seems unlikely, given that it's been on websites for years. He believes the HFEA should start collecting data. "Having data showing whether it's taking place or not would be a nice start," he says. And after that, someone should investigate who is taking home babies out of these arrangements.
Infertile couples may feel like they're trading sperm donations for a baby, but in fact, all they're getting in return is, at most, a single IVF procedure. The chance of success is modest, but the potential harms great. It's a "terrible deal," says Hodson, and it's being offered to the most vulnerable people. "That's when something starts to really look like exploitation."
Nathan Hodson. "Differences between sperm sharing and egg sharing are morally relevant." Journal of Medical Ethics. 2022.