Worlds apart or two sides of the same coin? Attitudes, meanings, and motives of potential oocyte and sperm donors in Austria

The research population consisted of approximately 32,000 students from three different Austrian universities. The students received an email invitation to participate in this online survey. The email included a short study description and a link leading directly to the survey. Instructions on how to fill out the questionnaire were given online after participants had read and confirmed agreement on the informed consent form. Hence, the participation was voluntary and anonymous. The questionnaire could be completed in 20 min.

Between April and June 2017, 922 students participated in the online study. Three hundred sixty-five students have not completed the questionnaire, while 555 have fully answered the questionnaire. We do not find significant gender differences for the ones who did not finish. For the analysis at hand, we decided to only use completed datasets.

All procedures performed in the study were in accordance with the ethical standards of the institutional ethics committees and with the 1964 Helsinki Declaration and its later amendments. The Board of Ethical Questions in Science of the University of Innsbruck approved the study design (Certificate of good standing 02_2017), as did the Research Committee for Scientific and Ethical Questions (RCSEQ) at UMIT – University for Health Sciences, Medical Informatics and Technology (Certificate of good standing 2060).

Two questionnaires, a female and a male version, were designed based on international literature and an internal review process of an interdisciplinary research team, consisting of reproductive physicians, jurists, psychologists, ethicists, and psychiatrists, two of each profession. Based on the outcome of a pretest among 50 students, changes were made concerning the phrasing of some vague wordings.

Both versions of the questionnaire generally consist of the same 44 items, intending to reveal respondents’ attitudes, meanings, and motives, as well as the willingness to donate. The only difference is that items in the questionnaire for female respondents exclusively refer to oocyte donation, while the items in the questionnaire for male respondents exclusively focus on sperm donation. This difference enables the analysis of gender differences. Example items measuring motives and perceptions of gamete donation, as well as meanings ascribed to gametes, are given below in connection with the scale descriptions.

If not otherwise stated, participants responded to all measures presented below on a six-point Likert rating scale (1 “not true at all”, 6 “absolutely true”). To ensure that high item scores consistently indicate a high degree of agreement, some items had to be recoded.

In detail, the first part of the questionnaires focused on the willingness to donate oocytes or sperm. In line with Svanberg et al. [10], we assessed the willingness to donate oocytes or sperm with the following items: Would you consider donating oocytes (female questionnaire)/sperm (male questionnaire) at some point in the future? This question had to be answered by choosing from the response options “yes”, “maybe”, and “no”.

Part two of the questionnaire measured the general attitudes towards oocyte/sperm donation, which were assessed with the five items formulated by Svanberg et al. [10]. Example items of this scale are “Oocytes (female questionnaire)/ Sperm (male questionnaire) donation is a good way to help childless couples” and “If you cannot have children on your own, you should not have any”. Cronbach’s alpha for this scale was α = .83. To reveal participants’ meanings of their oocytes and sperm, we formulated six items. Exploratory factor analyses revealed two separate factors, which we labelled personal vs. factual meaning of gametes. The subscale “personal meaning of gametes” consists of 4 items (α = .74), and the subscale “factual meaning” consists of 2 items (r = .34, p ≤ .00). An example item for the factual meaning factor is “I perceive my oocytes/sperm as comparable to blood or plasma”. Example items for the personal meaning factor are “I perceive my oocytes/sperm as part of myself” and “I perceive my oocytes/sperm as foundation of future life”.

In part three, our questionnaire also asked for respondents’ motives, based on the literature and previous works [6, 9, 10, 13‐17]. In detail, participants indicated the role of (1) altruism, (2) passing on one’s genes, (3) financial reimbursement, and (4) self-enhancement regarding their willingness to donate. Each motive was assessed with a single item. Participants additionally provided information on whether the type of relationship they have with the recipients would influence their willingness to donate. Only participants who were willing to make their oocytes/sperm available for assisted reproduction were asked to respond to the motive items and to those referring to the nature of the relationship with the recipients.

Part four included twelve items focussing on different aspects of the donation procedure itself that could positively influence the willingness to donate. These items were formulated with reference to Svanberg et al. [10]. Examples for such factors and thus for the response options provided are “you could talk to a woman/man who has already donated oocytes/sperm” and “you would know the recipients, you would already have own children, or you would have been asked to donate at a medical check-up”.

Finally, participants had the option to add their own comments as free text in a qualitative response section.

The questionnaire ended with questions about socio-demographic features of the students (age, relationship status, sexual orientation, religious beliefs, etc.).

Based on the item concerning participants’ willingness to donate oocytes/sperm at some point in the future, the study sample was subdivided into three groups: potential donors (n = 133; 24%; women: 48.1%, men: 51.9%) who could imagine donating oocytes/sperm at some point in the future; doubtful donors (n = 207; 37.3%; women: 75.8%, man: 24.2%) who were unsure in this regard; and non-donors (n = 215; 38.7%; women: 68.3%, man: 31.7%) who would not donate oocytes/sperm.

All statistical analyses were performed with IBM SPSS (v22.0).

Of the participating students (n = 555), 68% were female and 32% were male. More than half of the students (58.5%) lived in a stable relationship, while the rest were single (41.5%) at the time of the survey. The vast majority considered themselves heterosexual (90.1%) and had no children yet (92.2%). A total of 61.7% belonged to a religious community, whereas 23.3% were without confession. The sample included students from a wide variety of fields of study, namely, humanities (4.1%), natural sciences (5.6%), economic sciences (4.3%), educational sciences (4.7%), engineering sciences (1.3%), medicine (62.2%), social sciences (12.2%), and law (5.5%). For absolute numbers of all socio-demographic variables, see Table 1.

The distribution of male and female students over the three donor groups (potential/ doubtful/ and non-donors) showed that the group of female potential donors (16.9%) was significantly smaller than that of male potential donors (39.2%), while the groups of female non- (41.4%) and doubtful donors (41.7%) were significantly larger than the groups of male non- (28.4%) and doubtful donors (32.4%) (chi² = 33.13; df = 2; p < .00).

Individuals with religious affiliation (21.3% potential donors, 38.6% non-donors, 40.1% doubtful donors) were less willing to donate oocytes/sperm than those without religious affiliation (32% potential donors, 30.5% non-donors, 37.5%) (chi² = 6.23; df = 2, p = .04).

Relationship status had no influence on the willingness to donate (chi² = 1.07; df = 2, p = .56).

To analyse sex differences and differences between the three donor groups regarding general attitudes towards oocyte and sperm donation, respectively, two-way analyses of variance were conducted. While findings demonstrate differences among the three donor groups (F (2,549) = 68.08, p < .00), they reveal no sex differences (F(1,549) = 1.13, p = .29) and no interaction effects (F(2,549) = 1.97, p = .14). Post hoc tests (Scheffé) show that non-donors differ significantly from potential donors and doubtful donors. Mean differences in Table 2 imply that non-donors attitudes towards gamete donation are significantly less positive than those of potential and doubtful donors. In detail, non-donors express lower agreements to statements like “Oocyte/Sperm donation is a good way to help a childless couple” and higher agreements to statements like “If you cannot have children of your own, you should not have any”.

Differences between the three donor groups and sex differences were again tested with analyses of variance and subsequent post hoc tests (Scheffé). Mean values and results of the post hoc tests are summarized in Table 2.

For both dimensions, personal and factual meaning of gametes, we identified highly significant differences among the three donor groups (dimension personal meaning: F_(2,549) = 4.55, p = .01; dimension factual meaning: F_(2,549) = 17.43, p = .00) and highly significant sex differences (dimension personal meaning: F_(1,549) = 15.59, p = .009; dimension factual meaning: F_(1,549) = 14.43, p = .00) (Table 2). In addition, analyses of variance demonstrate highly significant interaction effects between sex and the affiliation to one of the three donor groups (dimension personal meaning: F_(2,549) = 6.92, p = .00; dimension factual meaning: F_(2,549) = 6.66, p = .00).

One-way analyses of variance reveal that the personal meaning men ascribe to their sperm is comparable in all three male donor groups (F_(2,173) = .30, p = .75). In contrast, the personal meaning that women ascribe to their oocytes is significantly different among the three female donor groups (F_(2,376) = 20.49, p = .00). In detail, compared with female doubtful- and female non-donors, female potential donors ascribe the lowest personal meaning to their oocytes. The results further demonstrate that for men, the factual meaning of their own sperm is comparable among all three male donor groups (F_(2,173) = 1.05, p = .35). In contrast one-way ANOVA tests show for all three female donor groups highly significant differences (F_(2,376) = 36.46, p = .00) regarding the factual meaning of their own gametes. Significant mean differences in Table 2 demonstrate that the factual meaning of their own gametes is lower in the female non-donor group than in female potential donors and female doubtful donors. Moreover, potential donors also perceive their oocytes significantly more factual than doubtful donors. Female non-donors can be said to view their oocytes more strongly than any other female or male donor group as “part of themselves”, “a basis for future life”, or “part of their body”. This conclusion is based on their lowest mean value in the dimension factual meaning and their highest mean value in the dimension personal meaning, together with the significant differences observed between the three female donor groups (see Table 2). At the same time, their agreement to statements like “I consider my oocytes as comparable with blood/ plasma” is lowest.

Because motives were assessed solely among study participants falling into the group of doubtful and potential donors, only the motives of these two donor groups were compared.

Mean values of potential and doubtful donors and separate mean values for male and female potential and doubtful donors, together with the significant mean differences, are shown in Table 3.

Results of two-way analyses of variance provide evidence for sex differences and/or differences between doubtful and potential donors in motives for gamete donation, but not for interaction effects.

Doubtful donors differ significantly from potential donors in the role that altruism (F_(1,289) = 5.04, p = .03), passing on one’s genes (F_(1,289) = 5.72, p = .02), and enhancing one’s self-worth (F_(1,289) = 4.5, p = .04) play with respect to the willingness to donate (Table 3). Altruism is more important to doubtful than to potential donors, while passing on one’s genes and enhancing one’s self-worth are more important to potential than to doubtful donors. Beyond that, altruism (F_(1,289) = 4.74, p = .03) and the motive of passing on one’s genes (F_(1,289) = 14.32, p = .00) are more relevant to men than to women. For the self-enhancement motive, we found no significant sex differences (F_(1,289) = 3.31, p = .07).

In regard to the closeness of the recipient, it seems more important to doubtful than to potential donors that donor recipients are either family members (F_(1,289) = 5.60, p = .02) or loved ones (F_(1,289) = 4.23, p = .041). Doubtful and potential donors assess donations to unknown persons equally, based on our non-significant results (F_(1,289) = .19, p = .66). The results additionally reveal that it is more important to women than to men that recipients of their donation are family members F_(1,289) = 11.661, p = .001). Regarding a donation only to loved ones (F_(1,289) = .93, p = .34) or only to unknown persons (F_(1,289) = .40, p = .53), no sex differences were observed.

Finally, we were also interested in relevant circumstances of the donation procedure making gamete donation more likely. Again, two-way analyses of variance with subsequent Scheffé tests were conducted. Results of the Scheffé tests together with the relevant means and standard deviations are presented in Table 4.

The three donor groups evaluate precise circumstances of the donation procedure significantly differently with regard to their positive influence on the willingness to donate. Non-donors turn out as least likely to be positively influenced by specific circumstances of the donation procedure. This applies to all circumstances of the donation procedure for which significant group differences were identified (see Table 4). Doubtful donors seem more likely to donate if they already have children on their own, but this is not the case for potential donors and non-donors (F_(2,549) = 3.77; p = .03). Female non-donors are the least likely to be positively influenced by a short treatment period before oocyte retrieval.

In regard to sex differences in the evaluation of specific circumstances of the donation procedure, the results suggest that receiving financial compensation (F_(1,289) = 6.996, p = .01) and carrying out the procedure in an anonymous setting (F_(1,289) = 28.37, p = .00) would make men more likely to donate. In contrast, women would be more likely to donate if they received in-depth counselling (F_(1,289) = 8.779, p = .003), if they could talk to actual female donors (F_(1,289) = 85.11, p = .00), if they knew the couple to whom they donated their oocytes (F_(1,289) = 14.55, p = .00), and if they already had children of their own (F_(1,289) = 13.7, p = .00).

In our cohort, 24% were willing to donate: 39% of the male participants and 17% of the female participants. Interestingly, comparably the same percentage of potential female donors was identified by Svanberg et al. [10, 11] shortly after the legalization of oocyte donation in Sweden in 2003.

Our study reveals that doubtful donors differ significantly from potential donors in the role that altruism, passing on one’s genes, and enhancing one’s self-esteem play with respect to the willingness to donate. Hence, altruism is more important to doubtful than to potential donors, while passing on one’s genes and enhancing one’s self-worth are more important to potential than to doubtful donors. Beyond that, our results show that altruism and the motive of passing on one’s genes seem more relevant to men than to women. Although we are not aware of studies dealing with these specific gender discrepancies with respect to motives for gamete donation, our findings are in line with reported results for sperm donation. Cook and Golombok [13] concluded that altruistic motives were important in the decision to donate sperm, and studies performed in Sweden and Australia pointed at the relevance of altruistic motivation for male donors [14, 15]. Additionally, the importance of the motive of passing on one’s genes, meaning the desire to procreate, was also revealed by Riggs and Russell [16] who studied the motivation of sperm donors in four different countries.

In our study, donation was seen as a way to help others, indicating a positive attitude towards gamete donation and not favouring adoption or remaining childless instead. In an epidemiological study in 11 countries, purely altruistic motives were found in 47.8% of oocyte donors [1]. Altruistic oocyte donors are influenced by their personal and emotional relationship to the recipient, their own motherhood, and their empathy [17]. In Austria, financial compensation and recruitment of donors are not legal. Therefore, recipients may depend on relatives or friends as oocyte donors. A close relationship has been identified as the main motive, especially between sisters [18]. However, restricting donations between family members has been discussed before [19]. This close relationship between the recipient and donor implies a high risk of personal emotional involvement and even higher pressure to have a successful outcome. A failure can have a significant negative impact on both parties [17]. Donors might feel an obligation to repeat the procedure if the outcome is unsuccessful [20]. On the other hand, positive changes in the relationship between recipient and known donor have also been found in previous studies [17, 21, 22]. In our setting, a psychological state of dependence can develop, similar to the state described after transplantation of a kidney or liver between relatives [23, 24].

In our cohort and in accordance with previous research [17], no association between the willingness to donate and religious beliefs was found.

We found that participants were more likely to donate if they were offered financial reimbursement. We suppose that this aspect plays a major role in our cohort, as we questioned students who were not yet earning money. Obviously, it is easier to have purely altruistic motivations when one’s own income is secure. In a previous study analysing socio-demographic characteristics of oocyte donors, it was found that the higher the level of education, the more altruistic the donor was [1]. Previous research showed that a combination of altruistic and financial motives is very common in donors [1, 3]. The presence of financial reimbursement did not mean that these donors were mainly motivated by money. Nevertheless, it was shown that the financial motivation of oocyte donors was greater when more money was offered [25]. Donor characteristics with regard to age, education, and psychological profile remained the same regardless of the amount of compensation [26]. The appeal of financial reimbursement may not lead to ignoring the health risks of oocyte donation. Although our results point at the impact of financial reimbursement, it is necessary to state that the Austrian law on artificial procreation does not allow any provision of gametes in return for payments. Therefore, thorough counselling is of major importance.

Health risks play a minor role in sperm donation; additionally, the effort of donation is less than for oocyte donation. Consequently, one could assume that women would be more likely than men to expect a financial reimbursement for their donation. In contrast, in the present study, significantly more men favour financial compensation than women. In a previous study, 62% of sperm donors would not have donated if they had not received payment [13].

According to our results, thorough counselling about the procedure, its consequences, and the psychological impact on the infertile couple would encourage potential donors to donate. This finding is supported by a previous study showing that over 75% of donors were motivated by their personal knowledge of the psychological burden of childless couples [17]. This motivation also applies to sperm donors [7]. The need for counselling and informed consent should be self-evident in medical practice, especially in the context of procedures with more than one party involved and of sensitive issues such as reproduction. A post-donation questionnaire study showed limited knowledge about possible side effects and long-term consequences of oocyte donation [27]. Furthermore, the relationship between the donor and healthcare provider remains a challenge [28]. Donors seem to be afraid that they are not sufficiently informed about health risks and psychological consequences, as they might be seen only as egg producers, especially if they have signed a contract and received reimbursement [28]. Positive donation experiences are reported by donors who felt that they were treated with respect and that their contribution was appreciated [18].

According to a recent meta-analysis, known oocyte donors tend to be over 30 years old, married, heterosexual, and usually a sister or close friend of the recipient [5, 9]. Participants stated that they would be more likely to donate if they had own children. In our student cohort, the percentage of men and women with children was very low. Thus, it seems that participants want to already have their own offspring before they donate to others. For sperm donors, this finding is in contrast to the literature, as the typical sperm donor is single, childless, and highly educated [20].

In our study, non-donors stated that the genetic link to the offspring was of major importance to them. Non-donors also regard children as one purpose of life. From an altruistic point of view, one could assume that these participants would be especially inclined to help others by giving them the chance to have children. In contrast, the meaning of having a child of one’s own is valued so highly that the own genetic heritage is only linked to the own self. In our study, many participants stated that they would feel responsible for the child and would want to know about its well-being. This finding is in contrast to a post-donation study reporting that the oocyte donors felt no sense of responsibility towards the off- spring [21]. It has been shown that known donors tend to treat the child as any other child [17]. The absence of a genetic link has no negative impact on the well-being of the mother, father, or children at the age of three: An interview study showed even better interactions between parents and children in families after donor conception than in families with a naturally conceived child, implying the normal psychological development of the child [29].

Interestingly, the main concern of participants about gamete donation pertains to the genetic link. The majority of comments in the additional qualitative response section of our questionnaire refer to the meaning of genetic heritage and the well-being of the offspring. In our opinion, this issue shows that the population in Austria is not yet very familiar with gamete donation. Ethical concerns that play a minor role in countries with established gamete donation arise in our setting. We consider the concerns in our study to be fundamental, as they seem to question the meaning of gamete donation itself. In particular, women regard their oocytes “as part of myself” and “something very personal” and consider this child “to be my child forever”. Most comments do not take a limited view of the oocyte as a means to an end but as the basis for a child who needs its own biological mother to take care of him/her.

A post-donation study of gamete donors showed that female donors are more interested in the outcome of their donation and more altruistically motivated [20]. Interestingly, we found that more men than women were guided by altruistic motives.

The study focused on students at three Austrian universities, a non-representative study sample. We decided for a student population since the socio-demographic characteristics (education, age, relationship status, sexuality) of this cohort are comparable to donor features examined in other studies (e.g. [1, 7, 16, 30, 31]. Furthermore it is important to underline that the Austrian law on artificial procreation only allows women between 18 and 30 years to donate their oocytes for the sake of reproductive medicine. Male donors do not face this legal restriction.

Additionally, the majority of the study population was medical students. We assume that the topic of this study generated interest among these students because it is closely related to their field of study.

The main goal of the study was to analyse the willingness to donate gametes. As men and women can only donate their own gametes, we decided to compare sperm and oocyte donation by asking gender-specific questions about oocyte donation and sperm donation. We are well aware that the health consequences, time aspects, and effort related to the procedure of gamete donation present constraints in terms of comparability. However, as we lack empirical studies addressing the differences between women and men in regard to the willingness to donate gametes, it was a central concern of our study to scrutinize this comparison.