Medicine and the Community|
Assisted reproduction: a reassuring picture
Many couples seek solutions to problems of infertility by using
assisted reproduction techniques. Despite very different
beginnings, children conceived after donor insemination, ovum
donation, in-vitro fertilisation or gamete intrafallopian
transfer show no adverse long term effects, either physically or
Gabor T Kovacs
MJA 1996; 164: 628-630
Donor insemination -
Ovum donation -
Issues of genetic identity -
In-vitro fertilisation -
Intracytoplasmic sperm injection (ICSI) -
Reproductive technology and the risk of cancer -
More articles on Sexual health
A 1995 report on assisted conception from the Australian Institute of
Health and Welfare showed that there were over 2300 births after
conception by in-vitro fertilisation (IVF) and gamete
intrafallopian transfer (GIFT) in 1993, and that about 1% of all
births in Australia are a result of these techniques.1 Between 1980 and
1993, more than 15 000 babies were born in Australia after conception
by IVF and GIFT.1 Since the mid-1970s,
several hundred more have been born each year after artificial
insemination with donor sperm. As more families are using assisted
reproduction techniques, the long term outcome of these children and
their families has become an important issue.
The first investigation of long term outcomes after assisted
reproduction was performed on 54 children born after conception by
donor sperm in Tokyo in 1968.2 These children, aged up to 11
years, were not inferior in measures of body weight and length or in
intelligence and development quotients when compared with a control
group of children conceived naturally. Over the next decade, the same
conclusions were reached when the study was expanded to include 133
Similar results for psychomotor development and psychological
adjustment in children born through donor insemination programs
were found in two early 1980s retrospective French studies of
30 and 75
families,4,5 and in a 1990 American
study of 362 families.6
The first assessment of families who had had children by donor
insemination in Australia was a retrospective study in 1982 that
showed no major obstetric, paediatric or emotional problems in 50
children aged between one and three years.7 Researchers at the Prince
Henry Institute in Melbourne in 1993
did the first controlled study of the psychosocial
development of children conceived by donor
insemination.8 Twenty-two children
conceived by this technique and aged from six to eight years were
compared with matched controls (20 children conceived naturally and
10 adopted children). Psychomotor scores derived from the Achenbach
Child Behaviour Checklist showed no significant difference between
the three groups of children.8
In a Sydney study by Durna et al., 76% of 276
couples thought that having had a child by donor insemination
had a positive personal effect and less than 1% had
regrets.9 Forty-seven per cent
felt their marriage had improved, which is similar to the 54% seen in an
American study.6 Marriage
breakdown was reported at 3.6%, which is less than the rate for the
general population. Durna et al. concluded that prospective couples
could be reassured that having a child by donor insemination can have
positive psychosocial effects on their relationships.
The most detailed study of families with a child conceived by assisted
reproductive technology was by Golombok et al., who studied 45
families with a child by donor insemination, 41 families with a child
by IVF, 55 families with an adopted child and 43 control
Assessments involving interviews and
questionnaires were carried out on children aged from four to eight
and their parents to determine the children's emotions, behaviour
and relationships, and the parents' psychological state and quality
of parenting. The quality of parenting for children conceived by
assisted reproductive technology appeared superior to that of
naturally conceived children. There were no significant
differences between children conceived by donor insemination and
children conceived by IVF.
A survey of donor oocyte clinics worldwide in 1991 identified just
over 200 such pregnancies.11 Thirty-six couples who
conceived children using donor oocytes in Melbourne between 1983 and
1991 unanimously agreed that they would recommend ovum
However, as the technique of ovum donation is a
more recent development, the number of studies are limited and
further studies are needed to assess long term outcome.
Issues of genetic identity
Of increasing concern is the issue of genetic identity. What are the
psychosocial effects on a child conceived from donated gametes who
knows about his or her true biological origins? The issue may not be
resolved for several years as open discussion about donor
insemination has only recently become acceptable. In the study by
Durna et al., 21% of couples were concerned about telling their child
about donor insemination.9A 1995 study by
Daniels et al. found considerable disagreement and debate about
whether to tell their child among 58 couples who had conceived a child
through donor insemination at the Dunedin Infertility Clinic (New
Zealand).13 Controlled studies are
required to compare children who know their biological origins with
children who do not.
There are no reports that have followed up children conceived by GIFT.
The first cohort of IVF children were born in Australia. In an initial
follow-up report from Melbourne in 1985, 52 children conceived by IVF
were assessed developmentally at birth and at 10 months, and 33 had a
psychosocial assessment between one and three years of
The principal findings were the caesarean
section rate was much higher (37%); the rate of premature births was
four times the expected rate; and the number of very low birthweight
children and twins were 10 times more than that expected for children
conceived naturally. Scores on the Bayley Scales of Infant
Development fell within normal range. Although this was an
uncontrolled study and there was an increased rate of obstetric
intervention, the authors concluded that these families did not have
an increased rate of psychosocial or developmental problems.
Similar results were found in a Perth study in 1986 in which 20 children
conceived by IVF were reviewed a year after birth.15 |
In a controlled American study of 83 children conceived by IVF and 93
controls, physical examination, neurological and developmental
examination, echocardiography, electrocardiography and
abdominal and cranial ultrasound examination were performed on each
child.16 There was no significant
difference in mental or psychomotor development. However, in a small
but controlled French study, there was a significant difference in
the relationship between mothers and their children conceived
through IVF compared with infertile women having ovulation
induction and a control group of mothers who had conceived
The largest controlled study on outcomes after IVF was based on 314
children conceived through IVF and 150 matched controls in
Families were assessed when the children were two
years of age and underwent tests such as the Short Temperament
Questionnaire for Toddlers, Family Environment Scale, General
Health Questionnaire, Dyadic Adjustment Scale, Interview Schedule
for Social Interaction and the Monash Family Interview. The authors
found that both the cognitive and motor development of children
conceived through IVF fell within the normal range, and that there was
no difference in parental concerns or child care patterns between the
IVF parents and the control parents, and no difference in neonatal
problems or physical outcomes (including disabilities or
congenital malformations). However, there was a high caesarean
Intracytoplasmic sperm injection (ICSI)
In ICSI , a single sperm is injected into the cytoplasm of the ovum,
under microscopic control. It is used in cases of severe male
subfertility. A recent Dutch study reported five cases of sex
chromosomal anomalies among 15 fetuses conceived after ICSI and
tested by chorionic villus sampling.19 However, this sample size
was too small to draw any clinically relevant conclusions. In
contrast, the Brussels group who developed the ICSI
technique in 1991 reported on 669 children born by mid-1995 who had
been conceived by this method.20 Of the 491 who had had
prenatal karyotyping, 479 (97.6%) had a normal karyotype and 12
(2.5%) had an abnormal karyotype (half of these were benign
structural aberrations). Major congenital malformations were
reported in 18 (2.7%) of the 669 children born following ICSI.
A review of Australian and New Zealand microinsemination data up to
1993 found nine major abnormalities among 220 fetuses but no
The National Perinatal Statistics Unit is
assessing a larger cohort by collecting data for all ICSI pregnancies
in Australia in 1994 and 1995 (P Lancaster, Director, AIHW National
Perinatal Statistics Unit, Sydney, NSW, personal communication).
Reproductive technology and the risk of cancer
A recent retrospective study found no increased incidence of breast
or ovarian cancer in 5564 women who had had ovarian stimulation as part
of their infertility treatment compared with 4794 infertile
In 1992, the National Health and Medical Research Council of
Australia established a Working Party to examine the long term health
effects on families who have had a child by assisted
conception.22 After reviewing the
literature, this Working Party asked more questions than it answered
and recommended the continuation of long term studies of these
families. No deleterious long term effects of reproductive
technology have been shown in either the offspring or their families.
It appears that families with a child conceived by donor
insemination, IVF or GIFT do not have an increased risk of
psychosocial or developmental problems compared with children
- Lancaster P, Shafir E, Huang J. Assisted conception in Australia
and New Zealand 1992 and 1993. Australian Institute of Health and
Welfare and the Fertility Society of Australia. Sydney: AIHW, 1995.
Iizuka R, Sawada Y, Nishina OM. The physical and mental development
of children born following artificial insemination. Int J Fertil
1968; 13: 24-32.
Mochimaru F, Sato H, Kobayaski T, Iizuka R. Physical and mental
development of children born through AID. In: David G, Price WS,
editors. Human artificial insemination and semen preservation. New
York: Plenum Press, 1980: 277-282.
Semenov G, Mises R, Bissery J. Attempt at follow-up of children born
through AID. In: David G, Price WS, editors. Human artificial
insemination and semen preservation. New York: Plenum Press, 1980:
Manuel C, Czyba J. Follow-up study on children born through AID. In:
David G, Price WS, editors. Human artificial insemination and semen
preservation. New York: Plenum Press, 1980: 467-474.
Amuzu B, Laxova R, Sander S. Pregnancy outcome, health of children,
and family adjustment after donor insemination. Obstet Gynecol
1990; 75: 899-905.
Clayton CE, Kovacs GT. AID offspring. Initial follow-up study of 50
couples. Med J Aust 1982; 1: 338-339.
Kovacs GT, Mushin D, Kane H, Baker HWG. A controlled study of the
psychosocial development of children conceived following
insemination with donor semen. Hum Reprod 1993; 8: 788-790.
Durna EM, Bebe J, Leader LR, et al. Donor insemination: effects on
parents. Med J Aust 1995; 163: 248-251.
Golombok S, Cook R, Bish A, Murray C. Families created by the new
reproductive technologies: quality of parenting and social and
emotional development of the children. Child Dev 1995; 64:
King CM, Kovacs GT. Oocyte donation: survey of results. In: Oocyte
Donation. Reprod Fertil Dev 1992; 4: 119-124.
Munro J, Leeton J, Horsfall T. Psychosocial follow-up of families
from a donor oocyte programme: an exploratory study. In: Oocyte
Donation. Reprod Fertil Dev 1992; 4: 125-130.
Daniels KR, Lewis GM, Gillett W. Telling donor insemination
offspring about their conception: the nature of couples decision
making. Soc Sci Med 1995; 40: 1213-1220.
Mushin DN, Spensley J, Barreda-Hanson M. Children of invitro
fertilization. Clin Obstet Gynecol 1985; 12: 865-876.
Yovich JL, Parry TS, French NP, Grauaug AA. Development
assessment of twenty in vitro fertilization (IVF) infants at their
first birthday. J InVitro Fertil Embryo Transfer 1986; 4:
Marin N, Wirth F, Johnson DH, et al. Congenital malformations and
psychosocial development in children conceived by in vitro
fertilization. J Pediatr 1989; 115: 222-227.
Raoul-Duval A, Bertrand-Servais, Frydman R. Comparative
prospective study of the psychological development of children born
by in vitro fertilization and their mothers. J Psychosom Obstet
Gynaecol 1993; 14: 117-126.
Halasz G, Munro J, Saunders K, et al. The growth and development of
children conceived by IVF. Report to the Commonwealth Department of
Health, Housing, Local Government and Community Services; Research
and Development Grants Advisory Committee (RADGAC); and Victorian
Health Promotion Foundation. Melbourne, Monash University
Department of Psychological Medicine, 1993.
Veld P, Brandenburg H, Verhoeff A, et al. Sex chromosomal
abnormalities and intracytoplasmic sperm injection. Lancet
1995; 346: 773.
Liebaers I, Bonduelle M, Legein J, et al. Follow-up of children
born after intracytoplasmic sperm injection. In: Hedon B, Bringer J,
Mares P, editors. Fertility and sterility: a current overview. New
York: Parthenon, 1985: 409-412.
Venn A, Watson L, Lumley J, et al. Breast and ovarian cancer
incidence after infertility and invitro fertilisation. Lancet
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on women from assisted conception. Consultation document.
Canberra: NHMRC, 1995.
This article is based on a lecture presented at the 15th World Congress
on Fertility and Sterility, Montpellier, France, 17-22 September
Department of Obstetrics and Gynaecology, Monash Medical School,
Box Hill Hospital, Box Hill, VIC.
Gabor T Kovacs, MD, FRACOG, Director. Chairman, IVF Directors Group,
Fertility Society of Australia.
No reprints will be available from the author.