Wayne R. Gillett

Telling donor insemination offspring about their conception: The nature of couples' decision-making

The issue of openness and secrecy in the use of donor gametes is the subject of considerable disagreement and debate, not only for social scientists and health professionals, but also for the recipients of donor gametes. This paper has its origins in a study of 58 couples who had a child/children as a result of donor insemination (DI) at the Dunedin Infertility Clinic. Respondents completed questionnaires and took part in an interview during which they were asked whether they intended to tell their offspring about their DI conception. The nature of agreement/disagreement between partners on this issue, the dynamics operating between couples that may affect decision-making, and the views of couples in a time-frame perspective are the focus of this paper. Transcripts from some of the interviews are presented to illustrate the points made and commentary and discussion is provided.

Prioritising for fertility treatments—the effect of excluding women with a high body mass index

The effect of clinical priority access criteria for access to infertility treatment was examined for women outside the body mass index (BMI) range of 18–32 kg/m2. Treatments and outcomes were analysed from 1280 cases referred from 1998 to May 2005. Sixteen percent of women had a BMI of >32 kg/m2. Overall, 38% of these women had a birth from conceiving a treatment‐related pregnancy or spontaneous pregnancy, compared with 52% of women with BMI < 32 kg/m2. Weight loss allowed women in the BMI group >32<35 kg/m2 to access treatment, but women in higher BMI groups were less successful.

Factors associated with parents’ decisions to tell their adult offspring about the offspring's donor conception

BACKGROUND Tensions and anxieties surround secrecy within families in the context of gamete donation and family building. This paper presents the views of parents who had kept their use of donor insemination a secret from their offspring. A sub-set of these parents said that they wished to tell their now-adult offspring, and discussed the questions and issues this secrecy raised to them. METHODS In-depth interviews were undertaken with heterosexual parents (of 44 families) who had given birth to children conceived via donor insemination between 1983 and 1987. These interviews comprised a follow-up study, with the first interviews being undertaken when the children were aged up to seven. In this paper, qualitative data relating to a sub-set of 12 parents (from seven families) who now wished to tell their offspring are presented. RESULTS The parents describe the pressures that the secret-keeping had created for them as well as the impact of those pressures. They report on the reasons they now want to share the family building history and the associated fears and anxieties about doing so. The parents all say that they wish they had told their offspring much earlier. In five of the seven families, parents describe how the offspring had raised questions concerning a perceived genetic disconnection between them and their parents. CONCLUSIONS Keeping the use of donor insemination a secret from offspring created considerable pressure for these parents. Despite the secrecy, offspring can become aware of the genetic disconnection.

Prioritising for fertility treatments—should a high BMI exclude treatment?

CM Farquhar,a WR Gillettb a Fertility Plus, Auckland District Health Board and Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand b Department of Obstetrics and Gynaecology, University of Otago, Dunedin, New Zealand Correspondence: Dr CM Farquhar, Fertility Plus, Auckland District Health Board and Department of Obstetrics and Gynaecology, University of Auckland, Auckland 1020, New Zealand. Email c.farquhar@auckland.ac.nz

Purification of granulosa cells from human ovarian follicular fluid using granulosa cell aggregates

Human follicular fluid can provide a source of human granulosa cells for scientific study. However, removing potentially contaminating cells, such as white and red blood cells, is important for molecular and in vitro studies. We have developed a purification technique for human granulosa cells based on the selection of cellular aggregates. Human granulosa cells from 21 IVF patients were collected. A 50% Percoll gradient was used to remove red blood cells, and granulosa cell aggregates were collected, washed and processed for histology, electron microscopy, flow cytometry analysis, cell culture and RNA extraction. Granulosa cell aggregates were found to be homogeneous and free of white blood cells after histological and electron microscopic analysis. White blood cell contamination, measured by flow cytometry, was found to be between 2 and 4%. Polymerase chain reaction analysis revealed expression of known human granulosa cell genes and a white blood cell marker. Human granulosa cells grown in vitro showed flattened fibroblast-like morphology with lipid droplets consistent with previous reports. Cultured cells expressed the FSH receptor. Selection of human granulosa cell aggregates following centrifugation through a Percoll gradient provides an efficient method of selecting granulosa cells, suitable for both molecular and in vitro studies.

Development of clinical priority access criteria for assisted reproduction and its evaluation on 1386 infertile couples in New Zealand

BACKGROUND In New Zealand ranking patients for elective, publicly funded procedures uses clinical priority access criteria (CPAC). A CPAC to prioritize patients seeking assisted reproductive technology (ART) was developed in 1997 and implemented nationwide in 2000. This study describes the development of the ART CPAC tool and its evaluation on 1386 couples referred to a single tertiary service from 1998 to 2005. METHODS A total of 48 health professionals and consumers assisted in criteria development. A score between 0 and 100 points was calculated for each couple and those who reached ≥65 points were eligible for publicly funded ART. Couples beneath the treatment threshold were placed on active review; the review being the date the score was calculated to reach the treatment threshold. Couples who would never be eligible or who were on active review were offered private treatment. Treatments and outcomes (spontaneous and treatment dependent live birth pregnancies) were used to evaluate the criteria. RESULTS Three social criteria (duration infertility, number of children and sterilization status) and two objective criteria (diagnosis and female age) formed the priority score. Of the evaluated couples, 643 (46%) were eligible within 1 year of referral (Group 1), 451 (33%) >1-5 years from referral (Group 2) and 292 (21%) couples were never eligible (Group 3). The predominant ART was IVF. A total of 480 couples had at least one IVF treatment with 404 (84%) having publicly funded treatment. A total of 762 (55%) women gave birth, 473 from treatment and 289 spontaneously. Group 1 had more pregnancies from treatment while Group 2 had most pregnancies overall being mainly from spontaneous pregnancies. Compared with Group 3 cases the hazard ratio using time to spontaneous live birth pregnancy for Group 1 couples was significantly lower, 0.51 (95% confidence interval 0.36-0.74) and for Group 2 cases significantly higher, 1.86, (1.35-2.58). Treatments using ART were evaluated for the three eligibility groups, with the never eligible divided into women age <40 (Group 3a) and woman age ≥40 at referral (Group 3b). Compared with Group 1 cases the hazard ratio to treatment dependent live birth pregnancy was similar for Groups 2 and 3a but significantly lower for Group 3b (0.37, 0.14-0.90). CONCLUSIONS The clinical priority access score was able to discriminate between the chance of pregnancy with and without treatment and those offered and not offered treatment. The CPAC is a useful model for informing the allocation of public funding for ART in other countries.

Tubocornual anastomosis: surgical considerations and coexistent infertility factors in determining the prognosis

To assess factors that may alter the pregnancy rate in women undergoing tubocornual anastomosis, the cases of 42 women were studied. Because a combination of surgical procedures was performed, the operative side deemed to be the best side was distinguished from the other side. The overall cumulative normal pregnancy rate was 56.0% after 2 years. Deep resection of the intramural tube and cases with technical difficulty had a reduced pregnancy rate. Neither the cornual pathology nor the presence of adnexal adhesions adversely affected the pregnancy rate. Associated infertility factors reduced the chances of conceiving. These factors should give a reliable prognosis to aid in the direction of postoperative management, particularly with regard to in vitro fertilization.

Cumulative incidence of infertility in a New Zealand birth cohort to age 38 by sex and the relationship with family formation

OBJECTIVE To estimate the cumulative incidence of infertility for men and women in a population-based sample. DESIGN Longitudinal study of a birth cohort. SETTING Research unit. PATIENT(S) A population-based birth cohort of 1,037 men and women born in Dunedin, New Zealand, between 1972 and 1973. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Cumulative incidence of infertility by age 32 and 38, distribution of causes and service use for infertility, live birth subsequent to infertility, and live birth by age 38. RESULT(S) The cumulative incidence of infertility by age 38 ranged from 14.4% to 21.8% for men and from 15.2% to 26.0% for women depending on the infertility definition and data used. Infertility, defined as having tried to conceive for 12 months or more or having sought medical help to conceive, was experienced by 21.8% (95% confidence interval [CI], 17.7-26.2) of men and 26.0% (95% CI, 21.8-30.6) of women by age 38. For those who experienced infertility, 59.8% (95% CI, 48.3-70.4) of men and 71.8% (95% CI, 62.1-80.3) of women eventually had a live birth. Successful resolution of infertility and entry into parenthood by age 38 were much lower for those who first experienced infertility in their mid to late thirties compared with at a younger age. CONCLUSION(S) Comparison of reports from two assessments in this cohort study suggests infertility estimates from a single cross-sectional study may underestimate lifetime infertility. The lower rate of resolution and entry into parenthood for those first experiencing infertility in their mid to late thirties highlights the consequences of postponing parenthood and could result in involuntary childlessness and fewer children than desired.

Survey of Australasian clinicians’ prior beliefs concerning lipiodol flushing as a treatment for infertility: A Bayesian study

Objective:  To evaluate clinicians’ beliefs concerning the effectiveness of lipiodol flushing as a treatment for unexplained infertility, and to integrate these prior beliefs with evidence from randomised trials.

The Retained Twin/Triplet Following a Preterm Delivery‐An Analysis of the Literature

Summary: We summarized the overall experience of the management and outcome of the retained twin/triplet and statistically analyzed the effects of the different variables such as cervical cerclage, tocolysis, use of antibiotics etc. on the retained fetal survival; 45 case reports in English were analyzed. The survival rate of the first born was very poor in contrast to the second and third‐born infants. Spontaneous rupture of the membranes was the most common cause of the loss of the first born, whereas for the second born, premature labour was the commonest cause. Despite substantial obstetric events leading to delivery of the first‐born infant, interval problems were uncommon. The mean period of retention of the surviving retained twin/triplet was 48.9 ± 37.9 days compared to 25.7 ± 31.6 days for the dead retained twins/triplets (p = 0.08). The female retained twins/triplets were retained much longer than the males (p = 0.008). The pregnancies lasted 45.9 days in the tocolytic group and 37 days in the nontocolytic group (p = 0.51). The delivery interval of the second born in the cerclage group was 52 ± 42 days compared to 34 ± 30 days in the noncerclage group (p = 0.1). The longer the twins/triplets were retained the better was their survival. Tocolysis, cervical cerclage and prophylactic use of antibiotics failed to make a statistically significant difference in the fetal outcome. The birth‐weights, gestations and sex of the retained twins/triplets affected their survival significantly.