New Paths to Parenthood

As infertility treatment technology advances, more Americans are turning to assisted reproduction. Here, we look at some of the choices families are making.

After trying for years to have children, Mark and Lucy Johnson* acknowledged a hard fact: Even if they could determine the cause of Lucy's infertility, her eggs were probably too old to warrant their trying in-vitro fertilization (IVF). "I felt like my body had failed me," she says. They could either pursue adoption or try for a pregnancy using eggs donated by a younger woman.

"I'd heard of sperm banks, but not egg donors," Lucy remembers. "I didn't think it was something I'd ever have to do, but I decided that I wanted this child to have some of Mark. It was also important to me to be pregnant."

The Johnsons faced a few roadblocks. Their upfront expenses--$5,000 to the donor, $12,000 to the fertility clinic, $5,000 for medications, $6,000 for the egg-donation agency's program fee--were not covered by insurance. After their first donor backed out, it took them eight months to save $8,000 for a second try with a new donor.

Despite their bumpy road to parenthood, today, 45-year-old Lucy is a happy cliché of an expectant mother. Due in less than two months, she's attending showers and shopping for onesies. She can barely believe her good fortune. Science has given her and Mark something they were beginning to think they might never have.

Growing in popularity
As international adoption becomes more difficult, and the unpredictability of being "chosen" by a domestic birthmother makes some prospective parents anxious, more people are turning to assisted reproductive technologies (ART) to create their families. Some use donor sperm, a practice that's quietly been taking place for centuries. Others implant eggs from younger women or frozen embryos left over from another couple's IVF procedure. Still others employ gestational carriers (in the U.S. and, increasingly, abroad, because of reduced costs) to bear a child conceived from their egg and sperm. (Unlike a "surrogate," a gestational carrier has no genetic link to the child she is carrying.)

Reports published annually by the U.S. Centers for Disease Control and Prevention show that assisted reproduction is on the rise. In the U.S., there were 146,244 ART cycles performed in 2009, compared with 99,629 in 2000. In 2009, 60,190 infants who were conceived using ART were born, versus 35,025 in 2000. Shady Grove Fertility Center, a clinic with offices throughout the Washington, D.C., area, initiated more than 2,500 donor-egg treatment cycles from 2007 to March 2011.

Melissa Brisman, a New Jersey attorney who facilitates pregnancies through egg donation, embryo transfer, and gestational carriers, says that, in 2000, she negotiated about 20 gestational-carrier births. Now that number is between 200 and 300 annually. Diane Michelsen, a California attorney who facilitates family-building through ART, estimates that in 2000 her practice was 40 percent ART and 60 percent adoption. Those figures have now flipped.

Choosing assisted reproduction
While the considerations of raising a child who is not genetically related to either or both parents are similar to those faced by adoptive families, reproductive technologies are so new that there is currently no consensus about best practices. "This is pioneer territory," says Joni Mantell, LCSW, CSW, director of the New Jersey-based Infertility and Adoption Counseling Center. "In adoption, we think in terms of the child's best interests. With ART, the starting point is the desire and need of the parents."

Many prospective parents who choose to get pregnant with donated sperm, eggs, or embryos have spent years coping with infertility, or have lived through the heartbreak of a failed adoption. "They want control back," says Mantell. "Women may want to carry the baby, eat the right food, and plan for the child's birth. Men may want to nurture a pregnant wife."

Practical considerations were a big plus for Carol Jean Feth, the mother of an 11-year-old biological son, a six-year-old son conceived from a donor egg, and a 14-month-old daughter who was adopted from Guatemala. "With egg donation, you experience a pregnancy and all the joys that brings," she says. "Another big ‘pro' is that you know when your new bundle is going to arrive, and can gear your preparation toward that date. In adoption, you have very little time to prepare after getting ‘the call.'"

Some parents, like the Johnsons, want the genetic connection to one partner, as well as the emotional experience of carrying a baby. Although Lucy admits to moments when she thinks, "This isn't my kid I'm carrying," being pregnant is cementing her attachment. "I feel very connected to the baby," she says. "Our bond is growing every day."

Maintaining contact
Just as adoptive families wonder about the kind of relationship they will have with their children's birthparents, parents using ART have to decide whether or not they will maintain contact with the people who helped them create their families.

Although most ART procedures, with the exception of gestational carriers, are based in anonymity, donors may agree to some level of identification or contact, and many parents write thank-you notes, send gifts, or meet their donors. In Everything Conceivable (Anchor Books), an engaging analysis of the cultural implications of ART, author Liza Mundy describes a baptism ceremony for triplets, where the guest of honor was the children's egg donor.

Tamara and Joseph Bove enjoy a close bond with one of their two gestational carriers. The relationship with their first carrier faded after a few years, and they are no longer in contact. But their bond with the second carrier grew as the pregnancy progressed.  "From the beginning, we were hoping to develop a friendship," says Tamara. "But we didn't know whether we would. You don't have the opportunity to get to know the person before you start working with her." Over time, they discovered many shared values. The Boves named their only daughter after her carrier.

The reality of those potential relationships has yet to be worked out on a larger scale. "There's a schism here, and people go to either end of the spectrum," says Michelsen. "Some parents are grateful for someone else's efforts [on their behalf]. Others think of ART as a business transaction. They think, ‘I want this baby to be delivered to me safely. I don't need a connection with you.'"

Total anonymity, however, can lead to medical complications down the line. The story of a California girl who was born with Tay-Sachs disease, which she inherited from both her father and the egg donor, has led some leaders in the fertility industry to advocate for a national registry to track donors and birth outcomes. In a report released in early February, the Evan B. Donaldson Adoption Institute called for a national database to facilitate access to birth and medical information for donor-conceived offspring.

Sorting through the ethics
While it's true that many donors and gestational carriers are motivated by a desire to help infertile couples, others see ART as a way to make money. The average payment to a gestational carrier is $30,000. Egg donors usually receive $5,000 to $10,000, or more. A 2010 article in The Wall Street Journal reports that inquiries about selling eggs or becoming a gestational carrier have surged during this tough economic time.

Embryos are generally donated by genetic parents after they've had a successful round of IVF. That can be a tricky proposition, as some parents retain an emotional connection to their embryos. "Many people get cold feet about donating an embryo anonymously," says Michelsen. "They have second thoughts about their child having a full sibling they may never meet."

Embryo transfer has also sparked controversy along the pro-choice/pro-life divide. Those who consider embryos to be more than human tissue, because they have the potential to become human life, may refer to the practice as "embryo adoption." Such "adoptions" include homestudies, and allow the genetic parents to choose who receives their embryos, but do not involve a legally recognized adoption process.

Parents considering an embryo transfer must weigh additional factors into their decision-making. "Clinics use the best embryos first," says Michelsen. "Embryos that are frozen tend to be of a lower quality, and IVF cycles are expensive." Another ethical issue arises from the fact that embryos are usually frozen in groups. To defrost one, you have to defrost them all. If there are three embryos in a group, is it acceptable to implant only one or two and destroy the rest? "Are you looking at the possibilities of triplets?" Michelsen asks. "Or are you looking at selective reduction?" These issues have to be negotiated by donor and recipient.

Explaining ART to children
Another question that prospective parents face is how to handle talking with their children about the way they entered the world. In adoptive families, a child's adoption is usually talked about from the time she enters her family, but sperm and egg donation and embryo transfers often allow non-genetic parents to "pass" as genetic parents.

The American Society for Reproductive Medicine advises parents to be honest with their children. While the group's reasoning is grounded in medical practicality--complete health histories help people get better health care--adoption research has shown that people have an inherent and healthy interest in their biological origins. "Secrets are not good for families," says Mantell. "If someone tells a child that he looks just like his mom, and he sees his mom [who used a donor egg] cringe, he will know that she's hiding something."

When to tell, how to tell, and what to share? Do you go into the science of assisted reproduction? Do you say that you paid your donor or gestational carrier? Parents must deal with all these questions.

Some experts recommend starting these conversations as early as possible. When Janice Grimes worked as a nurse in an IVF clinic, she asked her colleagues how they advised parents to talk with their children about the way they were conceived. When she saw there was nothing written on the topic, she took matters into her own hands and published the Before You Were Born… book series (xyandme.com). Geared toward children between the ages of three and five, the books cover a range of scenarios, from a single dad who uses a donor egg and a gestational carrier to a mother and father who use a frozen embryo.

Grimes presents the concepts in easy-to-understand nuggets. In her book explaining donor eggs, she writes: "A special cell from Mommy and a special cell from Daddy must join together to make a baby. The baby then grows in a safe place inside Mommy. Sometimes a Mommy might not have the special cell she needs. The doctor said there was a nice lady called a donor. She would give us one of her cells to help us make a baby."

"It's important to us that each child know his or her special story," says Lisa Norton, who adopted two children from China, and conceived one child biologically and another with a donor egg. "But I hadn't anticipated how difficult it would be to introduce the concept of donor eggs." Norton "plunged in" with an explanation when her daughter was eight, but knows that more talks are in store. "On the eve of my daughter's tenth birthday, she asked whether a particular trait came from me or my husband. I reminded her that I couldn't have passed it on because she doesn't have my genes. In a typically preteen way, she replied, ‘Oh, yeah, I knew that.' Whew! We are not finished with this conversation, but at least we have begun."

Plunging in and following your child's lead may be the best way to talk about it, as there are no longitudinal studies or tried-and-tested talking points. "The answers to these questions are just beginning to be developed, and will be refined over time, with the same kind of trial and error that adoptive parents have been through, and with the same need for feedback from kids who have lived it," says Mantell.
 
While finding the right words can be hard, Mantell believes that children are usually less conflicted by the topic than their parents are. She worked with a family who had two biological kids, as well as twins conceived using donor eggs. The mother felt they had to tell their kids, but her husband didn't agree. After counseling, they agreed to tell their children, and the parents are now glad they did. "One of the children conceived from donor eggs had an intuitive sense that something was off," Mantell says. "She didn't look like her sisters."

Tamara Bove feels that her triplets benefited greatly from watching the process of her twins being carried by and born to a gestational carrier. "My kids know that most people have babies in their belly, but that my belly is broken," she says. "For my kids, this is just the way we did it in our family. It feels perfectly fine and natural."

Brisman says that the parents she has worked with in her practice have come to similar conclusions. "However you get your children, you love them," she says. "At the end of the day, you don't think about how hard it was to get them."

Elizabeth Larsen is a freelance writer who specializes in adoption. Her work has appeared in Utne Reader and Mother Jones.

*names have been changed to preserve privacy.

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