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Postmortem non-directed sperm donation: quality matters
  1. Joshua Parker1,
  2. Nathan Hodson2
  1. 1 Department of Medicine, Wythenshawe Hospital Education and Research Centre, Manchester, UK
  2. 2 Division of Health Policy and Management, Harvard TH Chan School of Public Health, Boston Massachusetts, MA, USA
  1. Correspondence to Dr Joshua Parker, Medicine, Wythenshawe Hospital Education and Research Centre, Manchester M23 9LT, UK; joshua.parker{at}doctors.org.uk

Abstract

In our paper ‘The ethical case for non-directed postmortem sperm donation’ we argued that it would be ethical for men to donate sperm after death for use by strangers. In their thoughtful response Fredrick and Ben Kroon lay out practical concerns regarding our proposal. They raise issues regarding the quality of sperm collected postmortem based on empirical studies. Second, they claim that concerns about quality would make women unlikely to use sperm collected after death. In this response we explore issues of sperm quality in both living and dead donors. We consider whether there might be ways to ensure quality in both. Finally, we question whether quality should be a barrier to women choosing to use sperm donated after death.

  • artificial insemination and surrogacy
  • cryobanking of sperm
  • ova or embryos
  • donation/procurement of organs/tissues
  • reproductive medicine

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We are grateful to Fredrick and Ben Kroon for their thoughtful reply to our paper ‘The ethical case for non-directed postmortem sperm donation’.1 Our paper argued that there was no ethical barrier to voluntary postmortem sperm donation outside of a known relationship.2 In their response they outline practical issues regarding our proposal, raising cogent empirical concerns that at best there is uncertainty regarding the quality of sperm collected after death. The Kroons are concerned that difficulty guaranteeing the quality of sperm obtained postmortem means that these donations would not be used. In turn this makes our arguments for increasing quantity and heterogeneity of sperm redundant. Second, they believe that even if deceased men’s sperm was available to those who require donor sperm to reproduce, intended parents would be reluctant to use it because of its uncertain quality.

There is no doubt that the sperm of dead men can be used to reproduce; it has been done numerous times before. The Kroons’ concern lies not over the possibility but the probability that postmortem sperm donation could be scaled up to meet demand and exist in anything other than known relationships. We note, as the Kroons do, that sperm quality is an ongoing challenge in live donation. In a large UK-based study, nearly 65% of potential sperm donors were rejected, overwhelmingly (around 85%) due to concerns about quality.3 This is especially concerning in light of an overall decline in semen quality in the UK.4 Sperm quality is therefore an issue for all forms of human reproduction. There were 5651 donor insemination cycles in the UK in 2018, and approximately 500 semen donors are required for every 4000 treatment cycles annually.5 Currently the number of donors falls short of this. With a severe mismatch between supply and demand of donor sperm it is important to consider the role that sperm quality plays in this.

We do not question the Kroons’ empirical arguments; given general concerns about sperm quality in both live and dead donors, the Kroons are right to raise this. Here we discuss the implications of the issue of sperm quality.

Recruiting more donors

The most obvious solution to having a small number of donors is to recruit more. In the experience of one fertility clinic, less than 5% of initial enquiries lead to completed donations.2 If recruitment can be increased, the absolute numbers of semen samples for donation can be increased even if the proportion of successful donations following checks and quality analysis remains low. This ensures quality while also increasing quantity. Indeed, if the recruiting pool can be broadened as well as extended this may also have implications for heterogeneity of desirable characteristics.

Recruitment of sperm donors has been a consistent problem in the UK since at least 2005 when the law around anonymity changed.6 Payment, changing anonymity rules, benefits in kind and restructuring of services to offset disincentives have all been considered as routes to increase donors.7 None of these have come to fruition. In 2014 a national sperm bank was instituted, funded by a start-up grant from the Department of Health.8 After just 2 years the sperm bank had closed having recruited only eight donors. In the absence of a viable recruitment policy, the donor shortage means the UK continues to import sperm from other countries where donors are paid thus undermining their own policies on payment. With demand continuing to outstrip supply, individuals have looked to the internet for help. So-called ‘connection sites’ are legal but unregulated and have facilitated greater access to donor sperm but with all the accompanying risks of unregulated transactions.9 While increasing living donors would be preferable there is little evidence of meaningful or successful change, leading us to posit more radical methods of increasing donor sperm.

Towards higher quality postmortem sperm

The Kroons point to a number of issues with the quality of sperm taken after death. If these can be overcome this would be significant for sperm donation for it not only supports the possibility of non-directed postmortem sperm donation but may have implications for donation in life, which we know is also of poor quality. One issue raised by the Kroons is difficulty of grading sperm collected postmortem, owing in part to differences in methods of collection but also because there is no objective grading measure as there is for semen. Others, however, have noted difficulties in defining objective thresholds for normal sperm in men generally.10 These problems are not exclusive to postmortem donation and work on grading of sperm could have benefits for both dead and living donations.

A second issue is determining a method most likely to be successful. In a study cited by the Kroons, in four men undergoing large testicular biopsies postmortem, ‘plentiful numbers of motile sperm’ were collected and in some cases enough for multiple treatment cycles.11 A further case study had similar findings.12 It is true, as the Kroons point out, that these methods are not widely practised. But this study is at least promising that such methods could hold success. Ultimately the solution to this is research to determine the methods that are most promising and to ensure training of practitioners. Nevertheless, as the Kroons note, barriers to this also exist.

Quality and choice

It has been suggested with regard to sperm donated in life that we should be willing to lower the standards of acceptable quality to increase the donor pool.7 This is a Goldilocks problem: if the quality is too low then the chance of conception is so adversely affected as to be futile, if the quality required is too high the donor pool will be minuscule. If, however, we can set the quality threshold just right and achieve a balance of diminishing quality that still provides a reasonable chance of conception, the donor pool can be extended. While shortages persist this might be considered. If this is acceptable for live donors, it might also be extended to postmortem non-directed sperm donation.

The Kroons’ view on this is that, ‘women put considerable time, emotional energy and money into procuring sperm, and being unable to give them any reassurance about the quality of the sperm is likely to make them reluctant to use it’. Therefore, even if we were willing to tolerate lower quality of sperm, it makes no difference because women would reject it. This is an empirical claim which would be interesting to test. We imagine the response would be: ‘how much lower?’. The answer is that we do not know and this makes pursuing further research in this area more pressing. The second question would be what is the potential benefit gained by reducing the chance of conception?

As we originally argued, people care about more than conception. Live birth rates matter and people take extraordinary steps by pursuing interventions that are invasive, complex and expensive to maximise their chance of having children. Indeed, some are vulnerable to abuse in attempting to achieve reproductive fulfilment.13 Nevertheless, the value that people place on reproduction goes beyond simply conceiving and involves, among other things, having certain kind of child with desirable characteristics and a certain relationship to that individual. It would have serious implications for procreative liberty if all that mattered was successful conception. For example, the Human Fertilisation and Embryology Authority recently reported that donor eggs increase the birth rate in older women.14 While some women might choose therefore to use donor eggs to increase their rate of conception, it would hardly be ethical to force them to use donor eggs. Some women may believe that a genetic connection to their offspring, or the sharing of characteristics means they would rather risk a lower chance of conception using their own eggs. The point, however, is that the centrality of procreative liberty means women should be afforded choice. Again, while poor quality donor sperm might put some women off, what is important is that they are able to discuss their options transparently and, should they value certain donor characteristics, they should not be forced away from this in favour of maximising the chance of conception. The choice should be theirs.

Conclusion

The Kroons have drawn attention to the issue of quality in deceased donor sperm and argued that it threatens our ability to obtain large numbers of sperm. We have built on this showing that quality is a problem across sperm donation making the discussion of these issues ever more pressing. Alternative approaches to the shortage of donor sperm should be considered, whether these involve postmortem donation or other arrangements. Where we diverge from the Kroons is in being more willing to allow intended parents more power to determine how far an issue of sperm quality should limit their ability to fulfil their reproductive desires.

References

Footnotes

  • Twitter @joshp_j, @nathanhodson

  • Contributors Both authors contributed equally to the planning, writing and revising of this manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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