Clinical Review ABC of subfertility

Intractable infertility

BMJ 2003; 327 doi: (Published 06 November 2003) Cite this as: BMJ 2003;327:1098
  1. Alison Bagshawe,
  2. Alison Taylor


    It is rare for any of the options available for couples with intractable infertility to be seen as a first choice. For many couples in this situation infertility is like bereavement and causes great emotional distress. However, with help, people may be able to accept their position and see the opportunity to start a new life. To embrace any of the following options and to cope with the complications and frustrations of each, psychological strength and stamina are needed, plus help from a skilled independent counsellor.

    Egg, sperm, and embryo donation

    Counselling for gamete and embryo donation

    Counselling for those receiving donor gametes or embryos encourages them to explore concerns and feelings related to their infertility before considering the social and emotional issues that may arise from non-genetic parenthood. The emotional impact and implications of donation can cause problems for recipients. Men and women often have different thoughts and feelings about the donors and about accepting donated gametes or embryos.

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    For many couples, facing the situation of intractable infertility is extremely distressing and help from a counsellor may be needed

    Short and long term implications of donation are influenced by the attitude, beliefs, and personal and social situation of the individuals concerned. Sperm, egg, and embryo donation can be from an anonymous or a known donor, and each has different implications. Counselling can be relatively straightforward or complex depending on the circumstances, and the counselling sessions will vary in length and intensity accordingly. Counselling explores the implications of a person's reasoning and challenges their assumptions and preconceptions. Issues such as openness or secrecy must be considered, as well as the questions of whether to tell the potential future child about their genetic background, and what, how, and when to tell both the child and the wider family.

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    Donor insemination

    Selection and screening of donors

    Information is given about the selection and screening of donors. Gamete donors have to give a detailed personal, medical, family, and genetic history and are screened for sexually transmitted infections including HIV, hepatitis B and C, and other viral infections, such as cytomegalovirus. Their karyotype is checked and they are offered counselling before they consent to donate their gametes. Donors are invited to write non-identifying information about themselves that can be made available to recipients.

    Options for intractable infertility

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    Quarantining donated semen

    Sperm quality is assessed and, if initial screening tests are normal, semen is frozen. Samples remain quarantined for six months, at which point an HIV test is repeated (to exclude recently acquired infection before seroconversion). If all results are negative, samples can then be released for clinical use. Egg donation is usually with fresh eggs rather than frozen eggs because it is more difficult to freeze eggs than sperm. Recipients need to be aware of the small potential risk of HIV transmission from a donor who has recently acquired the infection but not yet become seropositive.

    Issues explored in counselling for couples pursuing gamete or embryo donation

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    Legal issues

    The legal status of the donor, recipient, and future child should be discussed as part of counselling before treatment. Under the terms of the UK 1990 Human Fertilisation and Embryology Act, the woman giving birth to the child is the legal mother, and her husband or partner is the legal father (unless he can show he did not consent to treatment), irrespective of whether gametes or embryos used were their own or donated.

    As the law currently stands, donor anonymity is protected, although the child has the right to contact the Human Fertilisation and Embryology Authority at 18 years (or 16 years if wishing to marry) to ask if he or she was born as a result of gamete donation and if a prospective partner might be related. However, a revision of law is being considered that may in future allow the identity of donors to be known, and recipients should be encouraged to consider how they might feel about the right of a child to this information.


    As a result of the UK 1980 Children Act the “welfare of the child” is paramount. Most adoption agreements support “open adoption,” which encourages honesty with the child and ongoing links with the birth family. Recruitment and placing is often made with a particular child in mind, and preliminary assessments try to ensure a match between the child and the potential parents.

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    Overseas adoption can be difficult and expensive

    Adoption after infertility treatment

    A couple who have been trying to conceive their own child must change their perspective before adoption can be considered seriously. Coming to terms with infertility before embarking on this option is essential. Counselling aims to help this process and to prepare the couple for the reality of adoption.

    Overseas adoption support groups for patients

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    Adoption agencies and the assessment process

    All adoptions must be through an adoption agency, either local authority or voluntary, and each has its own criteria for adoption. Interviews take place over several months before a child is placed. Issues such as the couple's attitudes to their infertility and their motives for wanting to adopt will be explored exhaustively to assess the couple's stability and commitment to adoption. The process can be lengthy, and counsellors who do not take part in the assessment can offer support, a fresh perspective, and a safe environment in which the couple can explore their thoughts and feelings.

    Types of surrogacy arrangement

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    Overseas adoption

    Adoption from overseas can be complex and expensive, although some countries have reciprocal arrangements with the United Kingdom. However, political or legal idiosyncrasies and differing attitudes to adoption can make this a difficult course to follow. A “home study” report carried out through an adoption agency is needed, and applications to adopt a child must be approved by the Home Office and local social services.


    In surrogacy, one woman (the surrogate or host mother) carries a child for another as the result of an agreement (before conception) that the child should be handed over after birth. The couple wishing to bring up the child after the birth is the commissioning couple.

    Legal issues

    In the United Kingdom, surrogacy agreements between the surrogate and commissioning couple are not enforceable legally. The law allows parents of children born after gamete donation to be the legal parents of the resulting child or children at birth. This means the surrogate mother can be regarded as having received donated gametes to conceive. She is therefore the legal mother of the resulting child at birth. The commissioning couple have to apply through the courts to become the legal parents of the child or children. Hence, there is difficulty enforcing a surrogacy arrangement if the surrogate changes her mind and feels unable to give up the child to the commissioning couple.

    Donors do not have any parental rights or responsibilities towards any children born after treatment and can withdraw consent to the use of gametes or embryos up to the point of transfer to a recipient

    Counselling for surrogacy

    Counselling for surrogacy is lengthy and comprehensive. Home visits and several appointments are often needed. All concerned must understand the implications of what is intended and they must be committed to the proposed arrangements. The underlying focus of counselling should be to protect any existing and future child or children, as well as any adults who are involved, from possible distress and complications that could result from an ill informed or ill considered decision.

    Accepting a child-free lifestyle

    For some couples, letting go and moving on from treatment is a relief, whereas for others it is a traumatic experience. Acceptance of a child-free lifestyle only comes over time, and often after great psychological and emotional adjustment. Choosing a child-free life is totally different from being forced into childlessness through circumstance. Those facing this possibility often ask how others come to accept it, but there is no simple answer.

    Issues explored in counselling for surrogacy

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    Experiences from childhood of what parenting is, and how positive or negative it is seen to be, can build or destroy an individual's sense of self. Infertility and subsequent treatment can erode a person's confidence. Positive experiences from childhood therefore help people to cope more constructively with childlessness.

    Surrogacy support groups for patients

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    Support from partners, friends, and family is vital for couples coming to terms with infertility and accepting a child-free lifestyle. Cultural, religious, and social factors that determine a couple's attitudes to the value of children and their importance to family life can either help or hinder. It is easier for those whose family and wider social group accept childlessness to live with and adapt to a life without children than it is for those whose culture places more importance on the need for children in family life.


    Counselling for people who are trying to accept a childless future varies in frequency and intensity, and, if offered appropriately, it can be therapeutic and supportive. A person trying to accept a child-free lifestyle may visit their general practitioner with symptoms such as repetitive minor ailments, minor gynaecological problems, depression, loss of appetite, sleeplessness, and conflict in relationships. Recognising the underlying reasons for their symptoms and offering appropriate intervention at this stage can help and lead to the beginning of acceptance. Feelings of depression, being “stuck,” and hopelessness are common, and, until these are dealt with adequately, they will impede a person's ability to see any point to the future. Looking ahead to other changes and recognising that a future can exist without children gives a focus for counselling that mobilises the coping strategies of each person.

    Before a child-free life is accepted, the grief and loss experienced may cause a person to visit their general practitioner with repetitive minor health problems, depression, and conflict in relationships


    Alison Bagshawe is a counsellor at the Guy's and St Thomas's assisted conception unit, London

    The ABC of subfertility is edited by Peter Braude, professor and head of department of women's health, Guy's, King's, and St Thomas's School of Medicine, London, and Alison Taylor, consultant in reproductive medicine and director of the Guy's and St Thomas's assisted conception unit. The series will be published as a book in the winter.

    The photograph of a family with adopted children is reproduced with permission of Nancy Palmieri/AP.


    • Competing interests None declared.


    Further reading

    Blythe E, Crawshaw M, Spiers J, eds. Truth and the child 10 years on: information exchange in donor assisted conception. Birmingham: British Association of Social Workers, 1998

    Snowden R, Snowden EM. The gift of a child. Exeter: Exeter University Press, 1993

    Stanton AL, Dunkel-Scheffer C. Infertility perspectives from stress and coping research. New York: Plenum Press, 1991

    Mason MC. Male infertility–men talking. London: Routledge, 1993

    Humphrey M, Humphrey H. Families with a difference–varieties of surrogate parenthood. London: Routledge, 1998

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