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Characterizing the Material
In 1909, a short article appeared in Medical World, a "practical medical monthly." The author, Addison Hard, described a scene from twenty-five years before, when he and fellow medical students were observing Dr. William Pancoast's practice in Philadelphia. The doctor was approached by a wealthy merchant and his wife who confided their difficulties in conceiving a child. After discovering that the merchant had no sperm in his semen, one of the students joked that it was time to "call in the hired man." The doctor requested a sperm sample from the "best-looking member of the class" but did not inform the couple of his plans. He called the merchant's wife into his office, administered chloroform, and inseminated her with the student's sperm sample. She gave birth to a healthy baby boy. Eventually, Dr. Pancoast informed the merchant, who was "delighted with the idea," but both decided not to tell his wife.
Several aspects of this story foreshadow the organization of gamete donation in the United States, including the centrality and power of physicians, the endemic secrecy associated with what was considered a morally questionable practice, and the selection of donors thought to have superior qualities. In tracing the development of the medical market for sex cells, from its earliest incarnations to the present day, focusing on information—what physicians wanted to know about the men and women providing gametes as well as what they shared with recipients—reveals stark differences in the management of sperm and egg donation. In this chapter, I look at how the process of characterizing reproductive material and the people donating that material have changed over time.
SPERM: FROM MEDICAL SERVICE TO COMMERCIAL PRODUCT
As the nineteenth century gave way to the twentieth, physicians began coupling the technology of artificial insemination with the use of donated sperm, but they did not trumpet the availability of this service, either to patients or to other physicians. An American doctor writing in the 1930s reported finding just a few scattered articles about this "therapy" for male infertility in the medical literature. In part, this was due to continuing questions about its legality, as there had been court rulings defining the use of donated sperm as adulterous and the offspring as illegitimate. The rulings concerned physicians in the newly formed American Society for the Study of Sterility (later the American Fertility Society and now the American Society for Reproductive Medicine), who singled out artificial insemination as one of the issues they intended to address in the very first issue of their journal, Fertility and Sterility, published in 1950.
In fact, the nascent society had already formed a special committee headed by Alan Guttmacher, who had also been an advocate for access to birth control and abortion. A survey of the society's ninety-six members in 1947 revealed that the majority approved of donor insemination, and the forty-four physicians who reported offering it had inseminated a total of 568 women that year. Just a few years later, the following resolution was overwhelmingly approved by the full membership.
If it is in harmony with the beliefs of the couple and the doctor, donor artificial insemination is a completely ethical, moral, and desirable form of medical therapy. Conditions under which donor artificial insemination is acceptable include:
1. Urgent desire of the couple to have such therapy applied to the solution of their infertility problem.
2. Careful selection by the physician of a biologically and genetically satisfactory donor.
3. The opinion of the physician, after thorough study, that the couple will make desirable parents.
Publicized as one of the society's first major policy statements, it was covered by the New York Times, Reader's Digest, and McCall's.
In defining sperm donation as a medical therapy, physicians sought to dismiss the claims of legal and moral authorities over the procedure in a process that Peter Conrad has labeled "medicalization." Such appeals to the professional and cultural power of medicine were particularly effective in the middle of the twentieth century, a period known as the "golden age" of medicine, when physicians retained wide latitude in defining matters of health and the body, including reproduction.
To find "biologically and genetically satisfactory" donors, physicians generally looked to the ranks of medical students and residents, calling them in as necessary to provide a fresh sample in exchange for a small fee. For each sample, donors were paid around $20 to $35, a rate that did not change much over the course of the twentieth century. In matching donors with recipients, the 1947 survey demonstrated that physicians prioritized "physical resemblance" to the recipient's husband, with "racial identity" at the top of the list while many also attempted "mental similarity" and "religious equality." Physicians undertook these efforts to facilitate the recipient couples' ability to keep donor insemination a secret, and physical resemblance to the husband remained paramount over the years. Additional criteria for the donor eventually came to include minimum sperm count, satisfactory family health history, and tests for sexually transmitted diseases.
Doctors maintained strict anonymity between donors and recipients, leading some support staff, often women working as nurses or secretaries, to conduct surreptitious screening of the men who applied to donate. CryoCorp, now one of the largest sperm banks in the country, was founded by a physician in the 1970s, and here he explains his initial procedures for screening donors.
Founder: We would advertise at [the university], and then I would do a physical on a donor, a history. I would get a sperm count, freeze the sample to see if it was good when we recovered it.
Rene: What kind of things were you looking for in that screening?
Founder: Evidence of congenital anomalies, sexually transmitted diseases, some reason they should not be a donor. Medications, drugs, sometimes arrogance, ugly, father with diabetes or heart attack, sibling that died unexpectedly.
Rene: If they were ugly or arrogant?
Founder: With me, I was working up a donor who seemed acceptable. He was a college student, had a good semen analysis. But when he left my office, the three women working for me at the time put their head in and said, "Doctor, you can accept him, but we're never going to send his sperm out. He's ugly." Okay, something I didn't put on my criteria at the time, but I had three somewhat articulate, vocal, outspoken women that let me know what they thought. They did not want ugly donors. I guess in some way they could identify, "If I don't want him, I'm not going to have him in here." So they reached the point that they would actually screen the donors to make sure that they weren't ugly or something just unappealing about them. Not that unappealing is a genetic trait.
In another donation program across the country, a laboratory technician described a similar dynamic. "Anybody that was butt-ugly, there was something wrong with his semen analysis [laughs]. We tried to keep them average- to good-looking. I just feel like the patients thought that was real important." In response to my question about whether she spoke to the physician about it, she explained, "This was kind of happening between the nurse and me. Generally we pretty much agreed to give a bad post-thaw motility. If I just let [the sperm sample] sit for a couple hours instead of checking it within five minutes, it'd make a big difference."
It was not until the last quarter of the twentieth century that physicians began to cede control of donor selection to commercial sperm banks like CryoCorp. Doctors had long been suspicious of such banks, raising questions about the commercialization of sperm donation that are similar in tone to Titmuss' warnings about blood donation. For example, here is part of a commentary by Guttmacher in a 1958 issue of Fertility and Sterility.
I must raise my voice against semen banks ... The chronic, professional blood donor is hardly the Platonic image of an ideal source of the male element in the process of fertilization. A physician must choose the donor with the specific requirements of each insemination in sharp focus and not on a mass basis ... I doubt that a semen bank with its assembly-line mechanisms could and would do the assignment satisfactorily. Experience has shown me that the most trustworthy donors are married house-staff physicians or medical students who have already fathered normal children. They are most likely to disbar themselves as donors for eugenic or health reasons. It is unnecessary to emphasize to readers of this Journal that in the ethical sense, whenever a physician performs donor insemination he is substituting for the Creator. This is no mean responsibility.
Relying on the rhetoric of industry ("mass basis" and "assembly-line mechanisms"), Guttmacher underscores the importance of physician control in ensuring quality providers of the "male element."
The first commercial banks did not open until the 1970s, offering frozen sperm stored in tanks of liquid nitrogen, but they struggled against the perception that frozen-and-thawed sperm resulted in lower rates of conception than "fresh" sperm. As a result, most physicians continued to use fresh sperm from donors they selected themselves, which distinguished them from clinicians in other countries. For example, France had more frozen sperm banks than the much larger United States, because American doctors preferred to control all aspects of donor insemination, despite the scheduling inconveniences associated with using fresh samples.
The advent of the AIDS epidemic changed this calculus, however, in that frozen sperm could be quarantined, making it possible to wait for several months after a donation before testing the donor again for HIV. But even as the threat of AIDS became more clear in the 1980s, physicians were loath to give up control. In a 1986 article introducing the American Fertility Society's latest guidelines regarding donor insemination, the past president of the society bucks the recommendations of the American Association of Tissue Banks, concluding that patients would be best served by the continued use of fresh semen provided by physician-screened donors. He specifically references distrust of commercial banks, the greater chance of pregnancy with fresh sperm, and the importance of physician control.
Given the strong and continuing endorsement of fresh sperm by the major professional association in the field, it is not surprising that a 1987 survey of physicians found 22% continued to rely solely upon fresh semen for donor insemination. It was not until 1988 that the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) recommended, but still did not require, the use of frozen sperm, and then the American Fertility Society updated its 1986 guidelines, stating "the use of fresh semen is no longer warranted." Between 1986 and 1989, six women in the United States were infected with HIV after being inseminated with donated sperm.
At this point, most physicians had little choice but to turn to commercial banks, which had the infrastructure necessary to freeze sperm, quarantine the samples, ship them, and monitor donors for months and months on end, i.e. the "assembly-line mechanisms" that had concerned Guttmacher. As small, physician-run programs at universities and private practices closed their doors and began referring patients to the large commercial banks, the total number of sperm donation programs in the United States plummeted from 139 to 28 between 1989 and 2001. Just 5 of those 28 programs had more than 90 donors, and their combined offerings constituted about half of the donors available nationwide.
Indeed, founders of some of the first commercial sperm banks, which had been open but not necessarily thriving, point to AIDS as a key moment of "market expansion." The founder of Gametes Inc., which opened in 1975, described why the company's initial growth occurred at "glacial speed."
People said the vitality, the viability of non-frozen semen is so much better than [frozen and] thawed semen. Well, yeah, duh. We could look through a microscope and see that most people's sperm didn't freeze very well, and we felt like our job is to go out and find people that had freezable sperm. We contended that our thawed sperm was just as fertile as non-frozen sperm, because we selected for really good thawed specimens. Eventually those people who were disparaging couldn't fight the utilization of frozen sperm because of the AIDS epidemic and CDC saying semen ought to be quarantined for six months. So that was a major impetus for market expansion.
Similarly, the founder of CryoCorp, which opened in 1977, sketched the growth of his company, which started out as a "one-man show."
I found the donors, I evaluated the donors, I did the semen analysis, I did the storage, I did the freezing, I did the thawing, and I did the insemination. The clinical need for it became evident in the community, and then more and more doctors asked me to provide them with the service. With the advent of AIDS in 1984, as soon as quarantine became an accepted standard of practice, then you needed a sperm bank if you were going to provide services for infertile couples. So from there, we kept on growing and growing and growing until now we distribute about 2,500 ampules of sperm every month all over the world, and we have more donors than any of our competitors.
Given the medical profession's preference for retaining control over sperm donation, it was not happenstance that the founders of CryoCorp and Gametes Inc., one a physician and the other a PhD-trained scientist, cultivated ties to the medical establishment, maintaining appointments at local medical schools, publishing peer-reviewed articles, and giving lectures. CryoCorp's founder pointed out, "I was very academic at the time. I've written a lot about it, I lectured a lot about it, and I went to probably every hospital in [the area] discussing male infertility and sperm banking." Moreover, to this day, both banks require that a physician be involved in ordering sperm for recipients. Gametes Inc.'s founder explained, "Our service is a medical product. It is well-characterized material intended for use with counseling by a physician, just like a prescription drug."
The process of characterizing the material grew more elaborate over the years, as commercial banks provided additional details about donors' characteristics. CryoCorp's founder noted, "At first [patients] had one line, then one page, then two pages. Now I think the short form is three pages, and the long form could be thirty-five to fifty pages. Basically, if my wife, and I'm married thirty-eight years, read information on a donor, she would know more about the donor than she does of me." For Gametes Inc., supplying recipients with more information about donors became an explicit business strategy. The founder explained,
We realized we could compete on technical excellence, like providing 55 million [motile sperm cells per milliliter] or more and more lab tests, but we also realized that was a sink hole, a black hole. There was always something else you could do, and the more you did, the more costly it was, not that the market could afford more. So we found it convenient to compete on a basis of providing information about our donors, and we found refuge in state regulatory authorities telling us what expectations are in terms of testing.
Such detailed information about the men producing sperm is designed to appeal to recipients, who were increasingly involved in selecting donors, another shift away from physician control that is described here by the founder of Gametes Inc.
Founder: [In the 1970s,] the principal thing was to have an inventory of freezable sperm, and we thought an inventory of ten donors was probably pretty doggone good. If you had many more than ten, the market would be just overwhelmed with choices. But it wasn't women choosing; it was physicians choosing. Later on, we got more selective with donors' physical characteristics.
Rene: When did this start to change?
Founder: In the early days, the physicians we relied on for insight into the marketplace pretty much said any donor will do. My patient simply wants to get pregnant. It just doesn't matter who the donor is, so long as you give a Caucasian donor to a Caucasian woman and a Black donor to a Black woman. So if physicians really don't care about matching recipient and donor, ten is probably more than you really need.
Excerpted from Sex Cells by Rene Almeling. Copyright © 2011 The Regents of the University of California. Excerpted by permission of UNIVERSITY OF CALIFORNIA PRESS.
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