Paid Parenthood

In the United States, there is a vast market for sperm and eggs to enable infertile couples, single women, and gay and lesbian couples to have children. The Centers for Disease Control and Prevention reported that over 17,000 in vitro fertilization cycles were initiated in the United States in 2009 with donor eggs, with perhaps a third of these resulting in live births. While statistics for artificial insemination are not as carefully tracked, estimates of the annual number of U.S. women who are inseminated with donor sperm are in the hundreds of thousands, and an estimated 30,000 to 60,000 children are born each year through sperm donation, although this number is only an educated guess.

In her new book Sex Cells, Yale sociologist Rene Almeling focuses on the people who provide the raw material sold on this market: the men and women who sell their sperm and eggs. Seeking to understand why people make the decision to sell their gametes, how they view the offspring conceived with their cells, and how the rapidly expanding fertility industry is making those gametes available to patients, Almeling interviewed thirty-nine sperm and egg donors as well as doctors and staff at sperm and egg agencies. These interviews provide the basis for a rich, detailed characterization of the origin and development of the market for sex cells in the United States and the way it operates today. While Almeling aims to describe that market, the manipulation and exploitation suggested by the book’s punning title ultimately raises a question that has not yet been widely asked: Should there be such a market at all?

The decision to sell one’s sperm or eggs — and it is a sale, despite the widespread use of the term “donation” to suggest otherwise — entails letting go of something that carries an important part of one’s personal identity and to make it available to someone else. Those who become sperm and egg “donors” must be able to accept, or even welcome, the likelihood that somewhere out in the world they have genetic offspring — perhaps many of them — whom they will not meet, in most cases being raised by someone they do not know.

Money is usually the initial reason that people decide to become gamete donors, Almeling reports. Compensation for sperm donation ranges from tens to hundreds of dollars per specimen, while women are paid many thousands of dollars per egg donation cycle. The difference can of course be chalked up to the fact that, unlike for men, the donation process for women is burdensome and risky, involving hormone treatments to induce ovulation of multiple eggs. That process can have potentially dangerous side effects, including ovarian hyperstimulation syndrome (OHSS). In relatively mild cases, this condition can lead to nausea, abdominal distension and pain, vomiting, and diarrhea; in rare, severe cases, it can result in liver dysfunction and ultimately in the potentially fatal clotting of blood vessels. While studies seem to indicate that egg donors are at less risk for OHSS than IVF patients, the egg-procurement procedure is identical for both, and severe cases of OHSS have been documented for egg donors. Furthermore, the actual collection of eggs is an outpatient surgical procedure that typically requires general anesthesia, which can pose its own risks.

For some donors, the motives do not run deeper than the financial. But Almeling finds that most donors have a more complicated view of the process. Many donors reported that their motives included a desire to help others, and interviewees included both men and women whose lives had been affected by infertility and who thus had a personal sympathy for the infertile.

One of the great achievements of Almeling’s book, however, is her investigation of the ways that men and women donors understand differently the meaning and significance of their participation in reproduction from afar, and her analysis of how the agencies who procure and sell gametes understand this and use it to tailor their recruiting to the different experiences of male and female donors.

Many sperm donors state frankly that their most compelling, often only, motive is the opportunity to earn money. Sperm donors who agree to contact with their potential offspring, thus becoming “identity-release donors,” are often given additional compensation. One young man told Almeling that the prospect of making $100 instead of $65 easily persuaded him to become an identity-release donor. He also described a common sentiment among donors: “For me to maintain my lifestyle, I need a steady paycheck coming in just like my other job.”

Almeling shows that sperm banks in fact work to reinforce the notion that recurring sperm donation is just like regular job: clinics typically shield donors from the broader context of their work by not letting them know when a pregnancy is established from their sperm; they are typically paid with a biweekly paycheck and they are often expected to produce at least once per week. The link to employment is reinforced by the fact that sperm donors are only paid for being productive — meaning only if their samples are sufficiently fertile — which, for most men, requires around forty-eight hours of abstinence prior to donation. Consequently, many men who are married or in committed relationships end up scheduling their sex lives around their weekly donations. Some reported being reluctant to engage in sex too frequently because of the reduction in wages.

The practices that reinforce the notion of donation as a job do not hold for women donors. Egg agencies pay women in lump sums per donation rather than on a regular schedule. Also, whereas men are only paid if the sperm count of their sample is high enough, women receive their compensation regardless of how many eggs their donation cycle produces. Egg agencies, unlike sperm banks, also frequently offer higher compensation for “high-quality” donors with ostensibly desirable traits, including education and race (with minority women often given greater compensation due to scarcity).

Just the same, female donors, like male donors, are initially attracted by money. And the money is considerable: many donors are paid more than $5,000, despite the statement by the Association of Reproductive Medicine that fees in excess of this amount “require justification and sums greater than $10,000 are not appropriate.” One manager at an egg agency reported that an egg donor received a standard $10,000 fee; the wealthy couple who received the eggs gave her an additional gift of $3,000 earrings, and, when the eggs resulted in twin girls, the mother decided to give the donor an additional gift, and reported (in the manager’s words), “I’ll give her $15,000, 7,500 [dollars] per girl.”

Despite the fact that women who become egg donors are initially attracted by the opportunity to earn a substantial sum, Almeling finds that women in the process of egg donation typically come to describe their eggs as a “gift” to the recipient to overcome the recipient’s infertility and also the money they receive for their eggs as a “gift” rather than a payment. Egg agencies tend to encourage this way of thinking by using the terminology of gift-giving, by emphasizing the donors’ relationship with the women who will receive the eggs rather than with babies who may follow, and by encouraging the recipients of donated eggs to send at least a thank-you note, or some gift or other token, at the end of the cycle.

The ability of egg donors to look past the remuneration and think about their activity as a gift to help others is, Almeling persuasively argues, linked to egg donors’ psychological work of separating genetic parenthood from motherhood:

[W]omen who do not nurture are censured as bad mothers…. For this reason, egg agencies and egg donors both have a powerful incentive to define egg donors as not-mothers. If egg donors were categorized as mothers, then, culturally speaking, they would be the worst kind of mothers. Not only are they not nurturing their children, they are selling them for $5,000 and never looking back.

“In effect,” Almeling argues, “the market for sex cells collapses the distinction between the public sphere of the market and the private sphere of the home, because it is the family that is for sale.” The language of donations and gifts serves “to manage the cultural tension of women being paid for eggs that become children and create families.”

The striking counterpart to this analysis is Almeling’s observation that, while egg donors almost uniformly insist that they are not the mothers of the offspring conceived with their eggs, most sperm donors willingly describe themselves as the fathers of the offspring conceived with their sperm. In fact, some men even reported being pleased by the thought that they may have genetic offspring; these men get to spread their seed without bearing financial and other responsibilities for offspring.

It seems rather amazing that sperm donors can describe themselves as fathers and yet be comfortable walking away entirely from their children, while egg donors must vigorously insist that they are not the mothers of their children in order to make their participation in conception but not in child-rearing acceptable to them. Almeling describes this disparity as arising in part from a belief that parenthood means more to women than it does to men and requires greater obligations from them: “men who do not nurture are still fathers.” Thus egg donors emphasize that they are giving “just an egg,” which is still subject to the contingencies of fertilization, implantation, pregnancy, and childbirth before there is a child; the donors assert that the child’s only true mother will be the one who raises the child. Notably, egg donors largely seem to agree that they could not bear to be surrogate mothers because they foresaw they would feel great difficulty at surrendering the children they would bear.

Indeed, it is likely that women not only need reassurance in violating a cultural norm about maternity but also that it is genuinely harder for them psychologically to give up their gametes than it is for men. The fact that egg agencies require a psychological evaluation of egg donors — a requirement not made by sperm agencies — further suggests that clinical practitioners have found that women more than men may have a hard time coping with their role in producing genetic offspring they will not raise.

Whatever the reasons for it, the greater difficulty of reassuring women that it is legitimate not to feel a connection to their genetic offspring may be part of why the fees for egg donation are so much greater than those for sperm donation (even remembering, again, that the gametes are retrieved very differently). Almeling notes the apparent paradox of “egg donors who describe what they are giving as a ‘huge’ gift and then say in the very next breath that it is ‘just an egg.’” Perhaps the large fees work to support this seeming contradiction: How could the act be such a “huge gift” if it were reciprocated with something marginal?

The language of sale and purchase in sperm donation keeps a potentially fraught transaction simple, and the small fees suggest a lack of moral significance to the transaction. By contrast, the large fees for egg donors underscore the physical and psychological burdens on the donor and the value to the recipient. These fees allow the inevitable feelings of emotional and moral significance experienced by both donor and recipient to be acknowledged but treated as surmountable. Substantial payment soothes the feelings of both the donor and the recipient in the egg-donation transaction: a woman who accepts such a large fee is saying to herself that even while she is “just” giving away her eggs, she is also giving away something of intangible value — and, reciprocally, by paying such a large fee, the woman who purchases the eggs for use to conceive a baby asserts herself as the real mother of the baby who may result. The language of donation, gift, sale, and purchase artfully channels and simplifies the potentially fraught nature of gamete transactions.

Almeling seems convinced that most women and some men are ultimately in gamete donation for more than the money, but she does not consider the useful question of what happens when money is removed from the equation. It turns out that U.S. stem cell scientists have found it nearly impossible to get women to donate eggs for research purposes. Harvard scientists, for example, reported in 2011 that they had been able to recruit only one woman to donate without compensation her eggs for an earlier stem cell research project. (New York is currently the only state that allows egg donors to be paid when donating to research programs — up to $10,000 per egg retrieval cycle.)

One kind of research that stem cell scientists would like to pursue with donated eggs is known as somatic cell nuclear transfer (SCNT) — better known colloquially as “therapeutic cloning,” in which a cloned embryo is created by removing the nucleus from a donated egg and replacing it with the nucleus of an adult cell taken from a patient. If the procedure were successful, the embryo could be used to generate a stem cell line that would be nearly genetically identical to the patient, potentially allowing for the regeneration of damaged or diseased tissues in the patient.

For a woman contemplating egg donation, donation to a stem cell research program might be attractive for the altruistic purpose of helping develop new therapies, although the prospect of creating cloned embryos only to destroy them for scientific research may strike some women as ethically problematic. Furthermore, many egg donors are drawn to the prospect of giving the gift of a baby to another, particular woman; they may find that good, which can be realized in nine months, more compelling than giving to a research program that might or might not yield new medical therapies years in the future.

These considerations aside, the absence of altruistic donors of eggs for research in the United States may be for mostly financial reasons. By way of contrast, the United Kingdom has sharply limited compensation for gamete donation: compensation for egg donors is limited to £750 for each cycle and for sperm donors to £35 per visit (about $1,200 and $55 respectively) — and rather than offering a financial incentive, it is meant to cover only the expenses incurred in the process of donation. Yet, in spite of the very limited compensation, there have been sperm and egg donors who donate gametes to fertility programs and research programs. This suggests that the issue in the United States may be that men and women are not willing to give their gametes away to a research clinic when they could choose to be paid by a fertility clinic.

A fuller understanding of gamete donors would require comparison between compensated and uncompensated donors. In particular, a useful follow-up to Almeling’s study would scrutinize the motivations of unpaid gamete donors — which, for now, would mean looking outside the United States. There might also be value in learning from experiences with other areas of tissue donation. For instance, switching from paid blood donation to entirely voluntary blood donation in the United States apparently improved the safety and reliability of the supply of blood; might that experience hold lessons for gamete donation?

Almeling raises but does not answer the question of whether it is ethical, good, or otherwise desirable for doctors and infertile couples to pay men and women for their gametes. What she finds in her interviews suggests that both men and women have a lasting thought of connection to those conceived with their gametes, and that it is not as easy as most donors try to make it seem to sell their gametes and let go of that genetic connection. For many, a clean sale just isn’t possible.

Consider another of Almeling’s findings — that even those who acknowledge that they are donating gametes for the sake of money, or who treat it as a form of employment, do not treat the money they receive as unremarkable. The large majority of the donors Almeling interviewed treated the money as “‘special money,’ in that it is earmarked for particular purposes.” For younger donors, especially women, that purpose tended to be paying down debts or paying for education; for older donors with children, that purpose tended to be special family treats. One man mentioned season passes to an amusement park for his children.

Other donors seemed to feel that the money from the sale of their sex cells was somehow tainted, and must be redeemed by being dedicated to some especially important purpose. One man gives away all the money he receives to his brother, a postdoctoral researcher with a wife and children. Another young man expressed something like this feeling as he fumblingly described his attempt to deal properly with the money:

I cash the checks, don’t put them in the bank, and I just put them in this thing [fund or container]…. I’m just kind of saving it right now. I’ve thought about different things. Well whenever I get married or get engaged, I’ll use that money to buy an engagement ring. So it’s kind of like — I don’t want to say turning the bad to good — but kind of like using something that wasn’t, that was for something else.

Moreover, although the donors had given up only their gametes, and in spite of the common rhetoric among women about having made a gift of what was “just an egg,” when asked about their genetic offspring, many donors were unable to maintain their emotional remove. Some said they were curious to learn how the children “turned out.” A few donors even said that they would help offspring conceived with their gametes “if the child needed financial assistance or a place to live,” indicating some sense of obligations or legitimate claims on the genetic parents by the children, similar to those of acknowledged parents or other family members.

Many of the long-term sperm donors Almeling interviewed described their feelings about sperm donation changing over time, particularly when they reached the stage of wanting to begin their own families. One sperm donor contacted Almeling for a follow-up interview when he learned that he and his wife were expecting a baby, and he questioned for the first time his decision to become an identity-release donor. Another long-term identity-release sperm donor who had no children of his own — but had met several of his genetic offspring — described the challenge of how to be friendly but not too intrusive upon the lesbian couples whose children were conceived with his sperm. However, this donor reported that the challenge of navigating these relationships was less stressful than not having them at all, saying, “It kills me to know that there are more out there that I’ll probably never meet, because I want to see them when they grow up.” Another sperm donor described how, after he had married and discovered his new wife was infertile, he experienced resentment toward those who had borne children conceived with his sperm.

For many of these people, the amount of money that they’re paid — which can seem large sums, especially in early adulthood — may ultimately end up not being worth the ambivalent feelings or outright regret that ultimately develop as they enter, or fail to enter, stable relationships and become parents. One wonders whether sperm and egg banks have taken advantage of the youth of many donors in encouraging them to make decisions whose full implications they failed to weigh because they were not near planning their own families. Almeling cautions her readers not to assume that commercialization of body parts is simply bad — but it is hard to escape the sense that selling gametes is, in the end, a bad deal for many on the donation side of such contracts.

While Almeling at least raises the question of whether the sale of gametes is in fact a good practice for those who enter into contracts to sell their sperm or eggs, she does not ask how selling gametes affects the most vulnerable parties in these transactions: the children who are created from them. As Elizabeth Marquardt, Norval D. Glenn, and Karen Clark describe in their report My Daddy’s Name is Donor (2010) and Jennifer Lahl shows in her documentary Anonymous Father’s Day (2012), children who are conceived with donated gametes often wrestle with the sense of loss of connection with their genetic parent and express pain that part of what makes up their identity was sold for money. Those who were conceived by anonymous donation also can suffer anxiety about inadvertently entering an incestuous relationship with a genetic half-sibling. And for those who know only half of their medical history, there are difficulties of diagnosis and prevention. In fact, a Canadian case, likely to reach the Canadian Supreme Court, brought by a woman conceived with donated sperm may end anonymous gamete donation in Canada precisely on the grounds that she and others conceived by anonymous gamete donation suffer from not knowing their genetic origins.

Almeling’s sociological study is a valuable starting point in understanding the vendors in the large market for gametes. A fuller understanding of this market will require study of the buyers and answers to questions like why women often report having different feelings about buying sperm from men than about buying eggs from other women. And a sociological account should be only the beginning: if we are committed to the wisdom and ethicality of selling sex cells, we must face honestly not only the great blessings but also the difficult issues these markets raise for sellers and buyers alike — and most especially for the children whom these markets create but who have no say in entering into them.