Intended for healthcare professionals
Original research•

Perceptions and reflections of embryo donation recipients: a qualitative follow-up study

Abstract

Objective Cross-sectional quantitative data from donor embryo recipients suggest children conceived through embryo donation are psychosocially well adjusted with healthy parent–child relationships. This study delves deeper into this topic using a qualitative grounded theory approach to capture recipients’ experiences and perceptions regarding family-building through embryo donation.

Methods This was a national qualitative study conducted via semistructured phone interviews. Interviews were self-nominated and composed of 25 open-ended questions. Interviews were transcribed using Temi software and coding was conducted in accordance with grounded theory methodology by five independent researchers to identify themes.Participants came from three embryo donation programmes across the USA. 28 participants, with an average age of 48 years (range: 34–69), volunteered to participate in interviews from a larger subject group. This previous group was a cross-sectional, survey-based study of psychosocial outcomes of children born via embryo donation. The majority of patients (92%) identified as Christian/Catholic.Themes were identified in participants’ responses to questions regarding general perceptions of embryo donation, decision-making process, disclosure and children’s psychosocial adjustment.

Results Of the 118 participants from the quantitative survey-based study who volunteered for this qualitative study, 28 individuals (24%) participated in the phone interview before thematic saturation was reached. The main themes identified include a desire to use existing embryos efficiently; religious frameworks encouraging maximal embryo use; satisfaction with and enthusiasm for embryo donation; lack of concern regarding child social adjustment and willingness to disclose donor embryo use to others.

Conclusion This qualitative study’s findings affirm that participants find conceiving a child through embryo donation highly satisfying and rewarding, experiencing minimal adverse events or regrets. As respondents identified largely as Christian/Catholic, further studies are warranted to assess the perceptions of a more diverse and generalisable population of recipients and children born via embryo donation.

What is already known on this topic

  • Although more individuals are using donor embryos for family-building, there is a large knowledge gap concerning this process’s effects on family functioning. Existing literature focuses primarily on embryo donors’ perceptions rather than on recipients’ experiences, as such, a previous cross-sectional quantitative analysis assessed embryo donation recipients’ perceptions of their child(ren) which suggests that the process results in healthy parent–child relationships and psychosocial well adjustment for both parties.

What this study adds

  • This study aims to deeply investigate embryo donor recipients’ experiences and perceptions via semistructured telephone interviews and a qualitative grounded theory approach.

How this study might affect research, practice or policy

  • Results of this study lay the groundwork for future research to further explore the experience of using donor embryos. Having better insight into the experience of donor embryo recipients will provide guidance to providers on how to more effectively counsel patients considering this form of third-party reproduction.

Introduction

The field of assisted reproductive technology (ART) has witnessed remarkable advancements since the first live birth via in vitro fertilisation (IVF) in 1978. Today, up to 2% of infants in the USA are born via IVF annually.1 Once patients’ family-building goals have been achieved, patients are often left with excess cryopreserved embryos for which they must make difficult disposition decisions. Patients can elect to donate embryos for research, discard them or donate them to other individuals for use. Of these embryo disposition options, embryo donation is often the least commonly made decision.2 Embryo donation is not ubiquitously offered in all countries and regions. However, it has become more common in the USA since it was first reported in 1983. The number of embryo transfers performed annually with donated embryos has steadily increased—up to 1.5% as of 2019.3 Despite increased utilisation, embryo donation remains an understudied area of ART. Most studies published have investigated the embryo donors’ motivations and perspectives, which range from the desire to help others struggling with infertility to desiring alternatives to discarding embryos for personal, moral or religious reasons.4 5

Prior research on the impact of third-party reproduction on family dynamics has primarily examined donated gametes: sperm or oocytes. This research indicates that both parents and children of families created via donated gametes have good psychological and social adjustment compared with families created via unassisted conception.6 However, unlike donated gametes in which half of the children’s genetics are from a donor (ie, sperm) and a half from an intended parent (ie, oocyte), donor embryos result in children that are not at all genetically related to the intended parent(s). A limited number of studies from the UK have reported on the resulting effects of embryo donation on recipient families, assessing parents’ perceptions of children through early adolescence (up to age 14). These studies concluded that, although parents tended to be more private about their children’s conception through donor embryos, the children were not at increased risk of psychological issues.7–9

Despite embryo donation’s growing popularity, there is a paucity of comprehensive data on embryo recipients, including how embryo donation affects family functioning and the parent–child relationship. Our research team conducted a quantitative survey-based, cross-sectional study on psychosocial outcomes of children born via embryo donation in the USA that included 185 participants ranging from age 27 to 67 years old (at the time of the survey) with results that were overwhelmingly positive; based on parental reports, embryo donation resulted in psychosocially well-adjusted children with healthy parent–child relationships.10 We sought to explore various aspects of embryo donation such as perceptions, treatment experiences, disclosure processes and child adjustment.

Previous publications regarding embryo donation in the USA have largely reflected the perspectives of participants from a single faith-based embryo donation agency. This agency approaches the process as embryo ‘adoption’ and follows procedures similar to live-birth adoption.11 In approaching this study, we sought to contextualise responses within the religious and social frameworks of the respondents.

Materials and methods

Subjects

Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research. During our prior cross-sectional survey-based study, for which informed consent was obtained, participants indicated if they would agree to consider participating in a future qualitative study; willing participants were asked to provide a personal email address.10 Participants who were self-selected to participate in the qualitative interview were later contacted directly via email. Researchers sent each a personal email containing an invitation to participate in a semistructured phone interview. Each individual was contacted up to three times to schedule an interview. Interviews were conducted from August 2022 to March 2023.

Semistructured interview

Interviews were developed using a qualitative grounded theory approach to capture participants’ experiences and perceptions regarding family-building through embryo donation. Researchers solicited input from an interdisciplinary group of healthcare professionals, including fertility specialists, psychologists and bioethicists to compose an interview guide containing 25 comprehensive questions (online supplemental file 1). Questions were open-ended to facilitate participant discussion and covered a range of topics, including the decision-making process regarding using donor embryos, perceptions and process of procuring donor embryos, disclosure of donor-conceived status and children’s psychosocial adjustment. Prior to the start of the interview, researchers asked participants for permission to audio record the interviews and informed them that they could decline to answer any questions and could end the interview early for any reason.

Data analysis

Data were analysed according to grounded theory, a qualitative research methodology that uses participant narratives to construct theoretical frameworks to explore participants’ psychosocial responses to various experiences or issues.12 Superficial data analysis occurred simultaneously with data collection until thematic saturation was achieved. Interviews were transcribed using the online website, Temi; the original interviewer then compared the transcript to the audio and edited it for accuracy. Researchers completed an initial coding round based on a predetermined codebook that aligned with the study’s target broad themes: decision-making regarding the use of donor embryos, procurement of donor embryos and perceptions after the use of donor embryos (table 1). To increase rigour and promote analytic insights, the data were independently coded by five separate researchers who thoroughly reviewed each interview and identified key responses to the interview questions. The results from each researcher were then compared in a group meeting. Researchers discussed coding discrepancies and reached a consensus that was then applied to the assessment of similar subthemes.

Table 1
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Interview question domains and subthemes discussed with participants

Results

Of the 118 participants from the quantitative survey-based study who were willing to be contacted for this qualitative interview, 28 individuals (24%) agreed to schedule an interview and subsequently completed that interview before thematic saturation was reached. It was determined that saturation was obtained at this point in time given that the themes arising from interview questions were overlapping without other novel concepts emerging. Study participants had undergone embryo donation through three different embryo donation programmes: National Embryo Donation Center (32%, n=9), Embryo Donation International (18%, n=5) and Snowflake/Nightlight Christian Adoptions (50%, n=14). Both the National Embryo Donation Center and Snowflake/Nightlight include stated religious affiliation/content in their mission statements. Interviews lasted 32–124 min (average=49 min).

Of note, 2 of these 28 participants did not fully complete the initial quantitative survey and their demographic information is incomplete. Participants’ average age at the time of interview was 48 years (range: 34–69). Most participants were non-Hispanic white, Catholic/Christian, married, heterosexual and had a college degree or higher (table 2). A total of 85% (n=22) of participants had informed their children that they were conceived through embryo donation. The remaining 15% (n=4) had not yet disclosed that fact to their children but planned to do so eventually.

Table 2
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Most common demographics of participants

Deciding to use donor embryos

Participants’ religious beliefs most strongly informed their decision to pursue embryo donation in the first place. Several themes were prevalent in participants’ responses to interview questions about using donor embryos, including the desire to use existing embryos’ reproductive potential, a belief that using existing embryos would be more efficient and save time and money, and the perception that using donor embryos more closely aligned with their religious beliefs.

Many study participants expressed a belief in embryos’ reproductive potential, which motivated them to choose faith-based embryo programmes, as one participant remarked, “[The embryo donation program’s] mission…seeing these embryos as life and wanting to have an opportunity for these embryos to have more of a life than that…aligned with our belief system. [It] seemed like a perfect fit.”

Most participants’ Christian religious beliefs played a substantial role in shaping their decision-making processes, including which embryo donation programme to use. Some participants mentioned that the embryo donation process reinforced a live-birth adoption framework because the embryo donation programme required them to obtain a home study and other evaluations that would also be required before live-birth adoption. As one participant describes, “The system was…robust…in terms of really screening our family and making sure that we were prepared as parents and as a family unit…helping to match us with a corresponding biological family…and then also going through the process of having a legally binding contract.”

Many participants felt it was imperative to use embryos that were already in existence to not ‘waste’ resources and streamline family-building processes. These participants valued a family-building method that optimised resources such as time, money, and reproductive assets. As one explained, “All the [embryos] were…wanted by both sets of parents. The family that created the embryos went through a lot of time and money and trouble just so they could have children. And so did we.”

Of course, participants were sensitive to the fact that cryopreserved embryos already had genetic and relational ties to their progenitors and wished to honour and recognise those ties. Although no participants obtained embryos from direct (identified) donors, many were agreeable to future communication with their donor/donor families after delivering their child(ren). This may correlate with being transparent about conceiving through embryo donation. As one female participant explained,

Sometimes my daughter will say things like ‘I don’t want to hurt your feelings.’ If [she] has a desire to meet [her] genetic family, it doesn’t hurt my feelings. It doesn’t make me believe that [she] thinks less of me as [her] mother… This is a choice that my husband and I made that ultimately impacts [my children] …and I want them to be able to speak openly about it.

Several participants discussed the relationships they had already established with their embryo donors and described the process of building these connections with the donor or donor family as an ongoing process:

Early in the process, we didn’t think we [would want contact with the donors], we planned to… keep it separate…but after everything was done and I was pregnant with my first child… we contacted our agency and said we were open to meeting this family if they’re open to meeting us… I got to meet [my daughter’s] two fully genetic siblings. It was wild…and it ended up being the best thing because now we keep in touch regularly. We’ve stayed with them for a week on vacation.

Procurement of donor embryos

All participants reported that their programmes shared similar donor profile characteristics with them, including progenitors’ age, physical characteristics (height, weight and hair/eye colour) and family medical history. They also received information on how long the embryos had been in cryopreservation and the embryos’ stage/grade at cryopreservation. Participants were divided on how best to choose among potential donors and embryos using a range of factors, including donor demographic characteristics and embryo stage/grade at the time of cryopreservation.

Most participants (78%) stated that they did not prioritise being genetically related to their offspring. Approximately 50% of participants perceived that using donor embryos was significantly different from using donor gametes (oocytes or sperm) because embryos were a ‘complete genetic package’ and had the potential to develop into a separate human being. One participant stated, “I wouldn’t opt to use egg donation and sperm donation…because I feel like that is…bringing something into the relationship or the marriage, creating something outside of it. Where with [donor embryos], these have already been created.”

However, the other 50% of participants perceived that using donor embryos was very similar to using donor gametes. One participant explained that although she felt that these two resources were similar, she did not bother to compare donor embryos to gametes while she was undergoing the embryo donation process as she and her partner were simply focused on streamlining the process of conceiving a child.

While many participants were unsure of what happened to other embryos from the same donor cohort that had been allocated to other recipients, some were aware of the outcomes of these other donation processes. Whether or not they knew these details, all participants affirmed that they realised that their children born via donor embryos could or did have genetic siblings in other families and did not find this fact problematic.

Perceptions after the use of donor embryos

All participants demonstrated satisfaction with and enthusiasm for the embryo donation process. Few participants (14%) stated that they had concerns regarding their future child(ren)’s psychosocial adjustment or their bond to their child before giving birth. After their child(ren)’s birth, all participants affirmed that their concerns were resolved and denied having any other ongoing concerns regarding their child(ren)’s social adaptation. One participant explained, “I had some wonders…Can I love this child? Will I bond with this child? …But it’s different [from domestic adoption]. You’re bonded with them through the whole pregnancy. No regrets.” Another remarked, “Once he was born, there was no doubt he was my son. I wasn’t even thinking, or I forgot, that he wasn’t biologically mine. I was just completely in awe by his presence.”

Participants overwhelmingly were or intended to be open about using embryo donation. In total, 85% (n=22) of participants disclosed to their children that they were conceived using embryo donation. The remaining 15% (n=4) planned to do so later. Of those who had already disclosed these circumstances to their child(ren), none cited concerns regarding their child(ren)’s adjustment after learning of their genetic origin. Many participants discussed the importance of explaining the concept of third-party reproduction to their children at a very young age to normalise the origin stories. As one participant elucidated, “We started exposing her to the idea very young, three or four years old. We did it through reading this really great book…that exposes these ideas in general…about penguins at the zoo who are given an egg [with a baby in it] from another family.”

Additionally, the majority of participants were comfortable with being open to others, including family and friends, about the fact that they had used donor embryos to conceive their child(ren) and reported that these disclosures had gone well. As one participant summarised, “Overwhelmingly the response has been very positive. People have questions…but once they understand the process…they see the need and understand the opportunity. They can understand the joy that it provides.”

Of note, every participant indicated they would enthusiastically recommend embryo donation to others as a family-building method. Many described themselves as ‘advocates’ for this process. As one participant enthused, “I think it’s such a positive [process]. It’s the best thing that happened to me in my life and I wish the medical community was able to promote it more.”

Discussion

Increasing numbers of patients are turning to embryo donation as a method of third-party ART in the USA. While there is literature reporting favourable family functioning outcomes from sperm and oocyte donation, there are relatively few publications on the outcomes of embryo donation.6 We have previously conducted a study in the USA on child outcomes and family function following conception through donor embryos.10 While the study population is homogeneous and represents a voluntary subset of largely religious patients who elected to use donated embryos, the identified themes and participants’ remarks reinforce the results of that initial quantitative survey-based study: recipients’ experiences are overwhelmingly positive, their resulting children are psychologically well adjusted, and parent–child relationships are healthy and functional.

Our findings confirm that embryo recipients endorsed embryo donation as a highly satisfying and rewarding process. Furthermore, this study delivered valuable insights into recipients’ motivations to use this family-building method. Researchers identified several major themes including recipients’ desire to harness embryos’ human reproductive potential; being efficient and not allowing previously created embryos to be wasted; perceived differences between gamete donation and embryo donation; parallels between the process of embryo donation with a faith-based programme and conventional adoption and high satisfaction/low regret with the donation and treatment process, with no long-term adverse reported effects on family functioning or child development.

Participants’ high comfort level with disclosing their children’s donor embryo-conceived status indicates this family-building method is generally not stigmatised. Their positive embryo donation experiences facilitate transparency with both immediate and extended social circles, which likely contributes to healthy family dynamics and fosters greater openness. Additionally, participants’ consistently positive experiences and high levels of satisfaction contribute to an enthusiasm for recommending this process to others. Participants’ openness and eager endorsement of embryo donation both contribute substantially to the normalisation and acceptance of this process within communities considering third-party reproduction.

This study is one of very few that focus on the perceptions of donor embryo recipients rather than donors. Among its strengths is the fact that it is part of the first and largest US-based study on embryo donation recipients and family functioning. Furthermore, this study’s qualitative nature allowed researchers to better understand the nuances of this complex embryo donation experience while also reinforcing prior findings.10 This study’s main limitation is the generalisability of its data. Though all programmes registered in the Society for Assisted Reproductive Technology database were contacted, most participants were recruited from private embryo donation programmes which had similar patient demographics. Study participants were recruited from three different embryo donation programmes, two of which have religious verbiage in their mission statements. Therefore, the overall homogeneity of this study’s population limits generalisability specifically to non-secular recipient perspectives, an important context within which to interpret our findings.

Participants’ beliefs may not be reflective of general beliefs surrounding embryos and/or embryo donation. As stated by the American Society for Reproductive Medicine’s Ethics Committee Opinion on embryo donation, while embryos have the potential to become persons, they should not be offered equal legal status to that of a living person.13 This notion is also supported by the American College of Obstetricians and Gynecologists and the Human Fertilisation and Embryology Authority in the UK.14 15 As such, while some of the results of this study relate to the reproductive potential of embryos, it is important to note that the views reflected here do not necessarily reflect the viewpoint of all donor embryo recipients, the clinics offering embryo donation, or the authors of this study. Another limitation of this study is the fact that participants from our prior quantitative study were self-selected to participate in this qualitative study. As such, selection bias may skew the results. However, given that these findings corroborate our prior findings, the results of this study likely do accurately reflect embryo donation recipients’ perceptions.10 Of note, separate from existing studies on embryo donation recipients, future studies assessing the perceptions of children born via embryo donation can shed further light on family dynamics. Despite the stated limitations, the results of this study remain noteworthy and help to add to the overall paucity of research on embryo donation. Future investigations focusing on secular embryo donation programmes and a more diverse recipient population can explore these study outcomes across a broader spectrum.

Embryo donation has proven to be an effective method for expanding families. This research provides insight into recipient parents’ experiences and highlights the satisfaction associated with embryo donation, suggesting its potential for broader use within more diverse recipient populations.