Mandatory counseling for gamete

donation recipients: ethical

dilemmas
Jean Benward, M.S.
San Ramon, California

Mental health professionals have engaged in mandatory pretreatment counseling and assessment of patients seeking treatment at IVF
programs in the United States since the 1980s. At present, most recipient patients undergoing IVF with egg or embryo donation in the
United States are required to meet with a mental health professional for one pretreatment session. Mandatory counseling of gamete
recipients is fraught with ethical questions for the mental health professional. Attention to is-
sues of autonomy, confidentiality, role clarity, along with self-evaluation and openness with the
patient can help lessen the impact of these ethical challenges. (Fertil SterilÒ 2015;104:507–12. Use your smartphone
Ó2015 by American Society for Reproductive Medicine.) to scan this QR code
Key Words: Counseling, ethics, mental health professional, gamete donation recipients and connect to the
discussion forum for
this article now.*
Discuss: You can discuss this article with its authors and with other ASRM members at http://
fertstertforum.com/benwardj-mandatory-counseling-gamete-donation/ * Download a free QR code scanner by searching for “QR
scanner” in your smartphone’s app store or app marketplace.

his article examines first how

T
technology (ART) can add to the psy- gatekeeper to screen out possibly un-
mandatory or required counseling chological strain. Research has also stable patients (2). Although profes-
for gamete recipient patients rai- shown that psychological counseling sional guidelines at that time did not
ses several ethical concerns, including for patients with infertility can provide address counseling for patients under-
implications for patient autonomy, effective assistance, reduce levels of going donor insemination (DI), manda-
informed consent, confidentiality, non- anxiety and depression, increase tory pretreatment counseling for donor
maleficiance, and fairness. Second, it coping, and improve the quality of life. sperm recipients was instituted in
explores how mandatory counseling rai- Less recognized is that mental several, primarily academically based,
ses questions about autonomy for health professionals have engaged in ART programs in the early 1990s
mental health professionals, with a final mandatory pretreatment counseling (3, 4). Over time with the expansion of
look at how mental health professionals and assessment of patients in IVF pro- IVF and reassurance that patients with
can identify, address, and resolve ethical grams in the United States for more infertility presented no more evidence
conflicts. than two decades. One of the first arti- of psychopathology than any other
The value of counseling and psy- cles describing a role for the mental group, most ART programs moved
chological support in fertility care has health professional in an IVF program away from mandatory pre-IVF
been recognized for some time. A large appeared in 1984 (1). The use of counseling.
body of psychological research has mandatory counseling arose in part Since its introduction >25 years
confirmed that infertility is stressful, out of the uncertainties associated ago, IVF with oocyte donation has
constitutes multiple losses, and evokes with starting the first IVF programs in become highly successful. But its intro-
a wide range of emotional responses the United States and the unknown duction into ART programs has been
that include sadness, depression, anxi- psychological effects of IVF treatment. accompanied by questions about its
ety, grief, and isolation. Furthermore, The mental health professional could social, legal, and ethical acceptability.
the experience of assisted reproductive then serve as a safety mechanism or Thus, as with the introduction of IVF
in the 1980s, the advent of oocyte
Received May 4, 2015; revised July 20, 2015; accepted July 21, 2015; published online July 31, 2015. donation prompted concerns about
J.B. has nothing to disclose. psychosocial screening and counseling
Reprint requests: Jean Benward, M.S., 18 Crow Canyon Court, Suite 305, San Ramon, California 94583
(E-mail: jeanbward@sbcglobal.net). of patients seeking oocyte donation.
The involvement of mental health pro-
Fertility and Sterility® Vol. 104, No. 3, September 2015 0015-0282/$36.00 fessionals in mandatory counseling has
Copyright ©2015 American Society for Reproductive Medicine, Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.fertnstert.2015.07.1154 grown with both the increase in ART

VOL. 104 NO. 3 / SEPTEMBER 2015 507

VIEWS AND REVIEWS
cycles using donated gametes and with professional recom-
mendations that ‘‘patients may benefit from psychological
counseling’’ (5).
Counseling, screening, and educating patients about the
implications of gamete donation has become a central recom-
mendation for pretreatment counseling in guidelines issued in
the United States, United Kingdom, Australia, New Zealand,
and Germany, among other countries. Internationally, there
remains considerable variation in recipient counseling,
ranging from legislated, recommended, or minimal (6).
Currently, most recipient patients in the United States who
undergo IVF with egg or embryo donation are required to
meet with a mental health professional for one session pre-
treatment. Both the psychological literature and professional
guidelines describe multiple goals for the mental health pro-
fessional who counsels gamete donation recipients. These
include education, counseling, and assessment/evaluation
(7). Thus, since the first ART programs, mental health profes-
sionals have been positioned as potential or actual
gatekeepers.
ETHICAL CONSIDERATIONS
Although there is general agreement about the importance of
counseling for recipients, the decision whether to require it
has been left to individual programs in the United States
without a profession-wide debate about the ethical
implications.
Patient Autonomy and Harm to the Patient
Mandatory counseling can take away the recipient's self-
determination or autonomy in choosing whether to engage
in pretreatment counseling and has the potential to add
harm. For some patients, counseling becomes an obstacle to
overcome to receive treatment, requiring them to take more
time off work, drive a distance, and pay additional costs. In
addition, patients often feel that they do not need to talk to
a mental health professional. Perhaps surprisingly, many pa-
tients with infertility have never engaged in counseling
before. Associating counseling with the stigma of mental
illness, they are often nervous and resentful for being singled
out just for needing ART to become parents. For some, it is
culturally foreign and embarrassing to discuss personal feel-
ings with a stranger. Although patients report diverse opin-
ions about mandatory recipient counseling, the criticisms
typically reflect concerns about cost, loss of choice, and
paternalism (8).
Values and Utility
Despite the potential negative impacts, there are arguments in
favor of mandatory counseling based on the notion of utility:
an action that benefits the patient. The strongest evidence in
support of required pretreatment counseling comes from
research about patient attitudes. There is evidence that
patients who participate in required counseling before an
IVF cycle find it helpful and feel positive about the coun-
seling. Hammarberg et al. (9) found that most women who at-
tended mandatory pre-IVF counseling thought that it should
508
be part of the treatment. Hakim et al. (10) surveyed 69 couples
undergoing treatment who were required to attend a psycho-
social counseling session before treatment. The majority
anticipated the session would be beneficial. After the session,
views were significantly more positive. The majority (>95%)
found the session to be helpful and informative. A Swiss study
(11) reported that when a routine pre-IVF counseling session
was expected (although not required), most patients followed
through with counseling. Of those who had not planned on
attending, 86% found it helpful. Among those who had
already wanted to attend a session, 95% found it helpful.
The researchers also found that when all patients were ex-
pected to see a counselor, it was normalized and more accept-
able than if counseling was required only for some patients
(11). The study by Daniluk and Leader (12) of 43 infertile cou-
ples found that most men and women believed there was a
need for psychological services.
There is additional research on how gamete recipients
view the requirement to attend a counseling session. A 1994
study of couples planning treatment with DI found that the
majority believed psychological counseling should be manda-
tory (13). An Australian study (14) found that when gamete
recipient patients were required to attend a counseling ses-
sion, they typically found it beneficial and subsequently
had a positive attitude about the experience. A U.K, researcher
found that some patients wished the counseling was required
(15). U.S. research indicates that gamete donation recipients
typically express the need for support and wish for assistance,
especially in discussing disclosure. Shehab et al. (16) found
that most couples recognized the potential value of coun-
seling; some had not recognized a need for counseling during
treatment but in retrospect wished they had received it. Hersh-
berger et al. (17) found that women using oocyte donation
found counseling helpful.
Despite widespread agreement among professionals and
patients that infertility counseling is beneficial, the uptake
rate when offered but not required, can be very low (18). There
are many reasons, including cost, time constraints, stigma,
uncertainty about what counseling involves, protection of
privacy, and fear of what the counselor might think. Another
factor that influences uptake is how the recommendation or
referral is made. Patients are more likely to follow through
if the recommendation is made personally by their physician,
and when the benefits of counseling are explained. The
research then suggests that if not required to attend a coun-
seling session, many patients will not do so, although those
attending find it helpful (10, 18, 19).
Although mandatory counseling impacts patient auton-
omy and intrudes on confidentiality, there is reason to believe
that counseling can be beneficial. Arguably, the paternalism
implicit in mandated counseling is limited in scope and serves
ultimately to maximize the patient's autonomy and decision-
making about family building with donated gametes.
Egg Donation Recipients versus Sperm Donation
Recipients
The notion of justice requires us to give equal consideration
to and provide equal opportunities for counseling.
VOL. 104 NO. 3 / SEPTEMBER 2015

Historically, counseling guidelines for sperm donation recip-
ients and oocyte donation recipients have not been equiva-
lent. The American Society for Reproductive Medicine 1997
guidelines for sperm donation recipients stated, ‘‘Patients
may benefit from psychologic counseling to aid in this deci-
sion.’’ In contrast, for oocyte recipients, guidelines recom-
mended ‘‘psychological screening of the recipient and
partner’’ (20). In the 2002 revision of the Practice Guidelines,
the recommendations for counseling were similar. However,
guidelines for donor sperm recipients were listed under
Recipient Guidelines, whereas the recommendations for
oocyte recipients started in a separate section called Psycho-
logical Evaluation (21).
Although the guidelines subsequently became equivalent,
other factors surrounding the use of donor gametes continue
to lead to differential referrals for counseling. The cultural el-
ements that make sperm donation different begin with the
much longer history of secrecy and stigma compared with
egg donation. Widening the difference is that male factor
infertility is hidden, less acknowledged, and less discussed
in society. Both historically and currently, it would appear
there has been an implicit, if not actual, hierarchy in how re-
ferrals for counseling have been made (personal communica-
tion, Ethics Committee, IVF Program; (15)). At present, the
recipients of donated oocytes and embryos are more
frequently referred for mandatory counseling before treat-
ment than sperm donor recipients within the same program
(personal communication, Ethics Committee, IVF Program).
In a study of 142 couples in northern California who had
used either sperm or egg donation, researchers found that
DI couples tended to receive no counseling at all before treat-
ment, whereas most oocyte recipients received a counseling
session mandated by their clinic (16).
The referral for counseling is further influenced by the
type of assisted conception and by the institutional context.
There are significant differences between IVF programs and
sperm banks, for example. Most sperm banks will provide
resource information and referral to mental health profes-
sionals for those intended parents who request it. No sperm
bank in the United States, however, requires recipient coun-
seling before the use of donor sperm. The inconsistency un-
dermines the counseling needs of donor sperm recipients.
This is especially concerning as heterosexual couples express
greater discomfort and negative expectations about using
donor sperm than donor oocytes (22). Although the difference
in IVF clinic and sperm bank practices is not likely to change,
a greater effort can be made to equalize the treatment of
sperm donor recipients and egg and embryo donor recipients
within programs.
ETHICAL CHALLENGES IN DISCLOSURE
COUNSELING
In recent years, in the United States and other developed
countries, disclosure of donor conception to the offspring
has been supported by professional recommendations (23).
Concomitantly, several associations of fertility counselors in
the United States, United Kingdom, Canada, Australia, New
Zealand, and Germany have recommended counseling
VOL. 104 NO. 3 / SEPTEMBER 2015
Fertility and Sterility®
patients about disclosing donor conception to their children
(23). In keeping with this, discussion of disclosure has become
a central piece of pretreatment counseling.
Counseling patients about disclosure presents the mental
health professional with an ethical dilemma. Although pro-
fessional guidelines promote an ethical obligation to discuss
and even recommend disclosure, can a counselor do this
without imposing professional and personal values on the pa-
tient? It is axiomatic that fertility counselors avoid harm by
not imposing their beliefs and values, but in reality disclosure
is not a topic about which most mental health professionals
are neutral. Furthermore, mental health professionals
approach disclosure counseling in multiple ways, from the
nondirective to the prescriptive.
Issues surrounding whether and how to disclose the use of
donor gametes are among the most complex and emotionally
charged issues for both the patient and the mental health pro-
fessional. It is with regard to disclosure counseling that
patients most often express dissatisfaction. Patients have ex-
pressed a desire for counseling that is more individualized,
rather than being directed to disclose (15, 24). They do not
like counseling where they feel pressured to disclose (16).
Hershberger et al. (17) report that although the women in
their study found counseling helpful, several ‘‘openly
questioned the disclosure recommendations made by mental
health professionals.’’ Adair and Purdie (25) suggest that
even when couples are encouraged to disclose, they may
not do so.
The research findings suggest that disclosure counseling
is most helpful when patients/parents have an interest in
learning more (26). There is no clear evidence that counselor
recommendations influence patient behaviors when recipi-
ents do not plan to disclose (27).
Impact of Mandatory Counseling on the Mental
Health Professional
There is a relative lack of practice-based research on how
mental health professionals manage and experience the com-
plex nature of their helping roles, and specifically how they
promote patient autonomy while working with patients
mandated for counseling. A 2013 study of the role of coun-
selors in UK treatment programs described the counselors'
experience of role tension. Counselors were expected to pro-
vide implications counseling and assessment counseling. One
reflected, ‘‘This [assessment] is completely away from my
counseling side.the patient considers you to be a judge.’’
(28). Mental health professionals describe the tension stem-
ming from a role that is defined in different and sometimes
competing ways—not only by other members of the treatment
team—but also among mental health professionals them-
selves. The work of mental health counselors with gamete
donation recipients has been described in the literature and
in discussion as pretreatment counseling, evaluation for suit-
ability/stability, assessment of psychological readiness, psy-
choeducation, and assessment of psychopathology (7).
A related concern focuses on the potential role conflict
when serving several stakeholders at once: the patient, the
IVF program, and the needs of the treatment team. Given
509
VIEWS AND REVIEWS
how variously the role of the mental health professional has
been defined, the treatment team may have specific expecta-
tions of the mental health professional that may or may not
coincide with the mental health professional's view of his or
her own ‘‘job description.’’ The role strain or conflict is further
shaped by the context within which the mental health profes-
sional's power or influence can vary considerably.
Another concern noted by counselors in the United States
and in the United Kingdom centers on how the counseling is
framed for the patients. Often the potential benefits of coun-
seling are not made clear to patients, nor is the counseling
necessarily presented by the clinic staff as helpful and appro-
priate (15). Instead, patients are frequently given a checklist of
pretreatment requirements and reminded to see a counselor
for ‘‘psych clearance’’ or ‘‘psych eval.’’ The resulting lack of
clarity exacerbates the patients' wariness about counseling
and their fear that they might be found unsuitable. Many
patients during the years have ended a session with the ques-
tion, ‘‘So, did I pass?’’
PRACTICE IMPLICATIONS AND
RECOMMENDATIONS
Patient Autonomy and Informed Consent
Much of the writing about health care ethics has addressed
issues in the relationship between health care providers and
patients, where informed consent is an essential part of pa-
tient autonomy and a bioethics cornerstone. What does
informed consent mean in the context of mandatory coun-
seling? It helps to think of the patient as an active partici-
pant in the decision-making. As we have seen, mandated
counseling interferes with the patient's autonomy and
choice about whether to meet with a mental health profes-
sional, with implications for the patient and the mental
health professional.
One remedy is to acknowledge to the patient the lim-
itations placed on his or her autonomy to choose coun-
seling (or not) and then begin a process of negotiated
consent that allows the patient to be an active participant
in the consent process. For instance, a consent form with
a list of what information may be shared with whom pro-
vides the patient with an opportunity to withhold consent
to sharing some types of information. The counselor also
needs to acknowledge that because the patient is required
to attend, he or she may have some concerns about what
is shared. In keeping with this, the mental health profes-
sional should clearly communicate his or her intent with
explicit discussion of the limits of confidentiality. This
means explaining what type of information the mental
health professional will share and with whom before the
counseling begins. Furthermore, it means explaining the
implications of the information and what impact, if any,
it might have on the patient's treatment plan. Finally,
the mental health professional must be clear about his
or her dual role, one with responsibilities to the patient
and the referring program.
Most IVF programs that require a pretreatment meeting
ask for feedback from the mental health professional, either
in a short note that verifies attendance or in a longer docu-
510
ment. Such feedback raises issues of confidentiality and the
patients' comfort level in discussing their feelings and
thoughts. To the extent possible the mental health profes-
sional's communication with the donor program should be
transparent, and the patients should be offered a copy of
any report. If the mental health professional is not expected
to write a lengthy report, then a brief statement of the topics
discussed and the patients' desire to go forward should be suf-
ficient to document the counseling and preserve confidenti-
ality. When deciding what to record and report back, the
mental health professional should imagine all the people or
agencies, including the patient, who might eventually have
access to the patient's record.
Focus of Counseling
Although experienced professionals have described their
work with gamete donation recipients in a variety of ways,
from assessment to counseling, increasingly mental health
professionals (including the author) see this meeting as an op-
portunity for psycho-educational or implications counseling:
an opportunity for patients to consider the many issues that
could potentially arise from the use of donated gametes.
Nonetheless, many mental health professionals continue to
describe their work with recipients as ‘‘assessment,’’ although
the purpose of the assessment is defined variously. One of the
results has been the conflation of counseling with assessment,
as can be seen in current guidelines (5).
It can be argued that there is no ethical justification for
requiring an assessment of those who are receiving donor
gametes from anonymous donors, in the absence of a specific
concern about a patient's psychosocial functioning and sta-
bility. This seems especially sound, as studies have shown
gamete donation recipients to be psychologically healthy
(29). We should assume that gamete recipients have the ca-
pacity to make decisions about their treatment. Some would
argue that the dual role of counselor/evaluator is necessary
and appropriate in these mandated referrals. Although coun-
selors often reference the need to consider the welfare of the
child in assessing patients, it is doubtful that a 60- to 90-
minute session will provide the information needed. Adoption
evaluations and home studies or custody evaluations typi-
cally take hours and may include psychological testing.
Furthermore, we simply have no tested and reliable tools for
determining ‘‘fitness to parent.’’ We serve patients the best
when we can figure out what kind of help the patient seeks
and how to provide it, including information about resources,
books, groups, and internet sites. To the extent that the ses-
sion revolves around assessment, opportunities to help may
be lost. It is well recognized that there are times when a pa-
tient's behavior or history can raise serious concerns about
his or her childrearing ability. In these cases, which appear
to be infrequent, the patient's behavior or history is more
likely to surface in the midst of counseling or interactions
with other team members, than in any specific evaluation
or assessment (30). Although the disturbed or unstable patient
would understandably compel the mental health professional
to switch roles from counselor to evaluator, there is still
debate about how this is best carried out.
VOL. 104 NO. 3 / SEPTEMBER 2015

Disclosure Counseling
Before counseling patients about disclosure, counselors have
an ethical duty to examine their feelings about disclosure and
‘‘secrets.’’ What are their personal feelings about secrecy and
the keeping of secrets? How have secrets operated in their
family? And what about the counselor's potentially negative
feelings toward a patient who opts not to disclose? As dis-
cussed in Evan Imber-Black's book, Secrets in Families and
Family Therapy, we all have a position about secrets, and
we all have a position about our position—namely that ours
is the correct one (31). The best aid for discussing disclosure
is the counselor's awareness of his or her feelings, ideas,
biases, and reactions to the presence of secrets. Without this
self-awareness, one's work will be less effective.
In the end, neither a strictly nondirective approach nor a
purely prescriptive one seems ideal. The counseling is a bit
like doing a dance where the infertility counselor may lead
or follow. Some patients will want to disclose and seek help
with how to do it. Others will be less certain but would like
to discuss it. A third group will have firmly decided that
they will not disclose.
Research supports the view that many patients are inter-
ested in counseling about disclosure (26). At the same time,
perhaps the goal of counseling should not be to convince pa-
tients that they should disclose. Research suggests that pa-
tients do not want to feel pressured to do so. Gamete
recipients have typically had a long history of loss and failed
treatment. The loss of the genetic tie to their child looms
large as one more loss. Counselors can help explore patients'
fears, which are usually plentiful. In advocating disclosure,
counselors need to guard against glossing over the difficult
aspects of disclosure. It is in fact for many an emotionally
risky decision and not nearly as easy for some to execute
as it sounds. The counselor can provide realistic information
to patients: Yes, your child might be interested in learning
more about the donor; or Most donor offspring do not reject
their nongenetic parents; or Your child might tell others,
leaving you feeling vulnerable. And finally, the counselor
can share the experiences of other parents and donor fam-
ilies. Regardless of whether they plan to disclose, we can
hope that patients leave a session with less fear of the
unknown.
Team Relationships
One of the challenges in this work is dealing with the percep-
tions and expectations that others have of us. Some relief
from role strain can occur when the mental health profes-
sional and the team agree on the purpose of the referral, use
the same language in explaining it to patients, and frame
the referral with positive language. Patients need to receive
a consistent message about the purpose of the counseling,
namely that it is an exploration of the emotional implications
of gamete donation. If a patient is referred to a mental health
professional for an ‘‘assessment,’’ then the counselor needs to
have a direct conversation with members of the treatment
team about what exactly they hope the mental health profes-
sional will do, and whether realistically the mental health pro-
fessional can meet the expectation.
VOL. 104 NO. 3 / SEPTEMBER 2015
Fertility and Sterility®
In conclusion, although arguably paternalistic, manda-
tory counseling is premised on the belief that patients and
their future families will benefit from the intervention and
that acquiring information will foster choices. Although
circumstances might compel a mental health professional
to assume the role of counselor and evaluator at the
same time, the surrounding problems argue for its avoid-
ance whenever possible. However, rigorous separation of
the counselor/evaluator role is difficult, if not impossible,
in working with mandated clients. Each mental health pro-
fessional will need to navigate this terrain. Although there
is value in mandatory counseling of gamete recipients, it is
fraught with ethical landmines for the mental health pro-
fessional. Attention to issues of autonomy, confidentiality,
role clarity, along with self-evaluation and honesty with
the patient can help minimize the impact of these ethical
challenges.
REFERENCES
1. Greenfeld D, Mazure C, Haseltine F, Decherney A. The role of the social
worker in the in-vitro fertilization program. Soc Work Health Care 1984;
10:71–9.
2. Greenfeld D. Two decades as an infertility therapist. In: Rosen A, Rosen J, ed-
itors. Frozen dreams: psychodynamic dimensions of infertility and assisted
reproduction. Hillsdale, NJ: The Analytic Press; 2005:265–79.
3. Klock S. Psychological aspects of donor insemination. In: Diamond M,
DeCherney A, Greenfeld D, editors. In fertility and reproductive medicine
clinics of North America: psychological issues in infertility. Philadelphia:
WB Saunders; 1993:455–70.
4. Seibel M. Therapeutic donor insemination. In: Seibel M, Crockin S, editors.
Family building through egg and sperm donation: medical, legal and ethical
issues. Sudbury, Massachusetts: Jones and Bartlett Publishers; 1996:33–45.
5. Practice Committee of American Society for Reproductive Medicine. Recom-
mendations for gamete and embryo donation: a committee opinion. Fertil
Steril 2013;99:47–62.
6. Blyth E. Guidelines for infertility counseling in different countries: is there an
emerging trend? Hum Reprod 2012;7:2046–57.
7. Greenfeld D. Recipient counseling for gamete donation. In: Burns HB,
Covington S, editors. Infertility counseling: a comprehensive handbook for
clinicians. New York: Parthenon; 1999:345–56.
8. Levitan S. Ask the Lawyer. Legal requirement for counseling. December 16,
2011. Available at: http://ivf.ca/forums/topic/26588-legal-requirement-for-
counseling. Accessed May 1, 2015.
9. Hammarberg K, Astbury J, Baker HWG. Women's experiences of IVF: a
follow- up study. Hum Reprod 2001;16:372–83.
10. Hakim L, Newton C, Maclean-Brine D, Feyles V. Evaluation of preparatory
psychosocial counseling for medically assisted reproduction. Hum Reprod
2012;27:2058–66.
11. Emery M, B
eran MD, Darwiche J, Oppizzi L, Joris V, Capel R, et al. Results
from a prospective randomized, controlled study evaluating the accept-
ability and effects of routine pre-IVF counseling. Hum Reprod 2003;18:
2647–53.
12. Daniluk J, Leader A. Psychological and relationship changes of couples un-
dergoing an infertility investigation: some implications for counsellors. Br
J Guid Counc 1987;15:29–36.
13. Klock SC, Jacob MC, Maier D. A prospective study of donor insemina-
tion recipients: secrecy, privacy and disclosure. Fertil Steril 1994;62:
477–84.
14. Hammarberg K, Carmichael M, Tinney L, Mulder A. Gamete donors' and re-
cipients' evaluation of donor counselling: A prospective longitudinal cohort
study. Aust N Z J Obstet Gynaecol 2008;48:601–6.
15. Machin L. A hierarchy of needs? Embryo donation, in vitro fertilization
and the provision of infertility counseling. Patient Educ Couns 2011;
85:264–8.
511
VIEWS AND REVIEWS
16. Shehab D, Duff J, Pasch L, MacDougall K, Scheib J, Nachtigall R. How parents
whose children have been conceived with donor gametes make their disclo-
sure decision: contexts, influences and couple dynamics. Fertil Steril 2008;
89:179–87.
17. Hershberger P, Klock S, Barnes R. Disclosure decisions among pregnant
women who received donor oocytes: a phenomenological study. Fertil Steril
2007;87:288–96.
18. Boivin J, Scanlan LC, Walker SM. Why are infertile patients not using psycho-
social counseling? Hum Reprod 1999;14:1384–91.
19. Boivin J. Is there too much emphasis on psychosocial counseling for infertile
patients? J Assist Reprod Genet 1997;14:184–6.
20. Practice Committee of the American Society for Reproductive Medicine.
Guidelines for gamete and embryo donation. Fertil Steril 1998;70:S1–6.
21. The American Society for Reproductive Medicine. 2002 Guidelines for
gamete and embryo donation; A Practice Committee Report. Fertil Steril
2004;82(Suppl 1):S9–17.
22. Eisenberg ML, Smith J, Millstein SG, Walsh TJ, Breyer BN, Katz P, The Infer-
tility Outcomes Program Project Group. Perceived negative consequences of
donor gametes from male and female members of infertile couples. Fertil
Steril 2010;94:921–6.
23. Benward J. Disclosure: helping families talk about assisted reproduction. In:
Covington S, editor. Fertility counseling: case studies and clinical guide.
Cambridge: Cambridge University Press; 2015:252–64.
512
24. So€derstro €m-Anttila V, Sa€levaara M, Suikkari AM. Increasing openness in
oocyte donation families regarding disclosure over 15 years. Hum Reprod
2010;25:2535–42.
25. Adair VA, Purdie A. Donor insemination programmes with personal donors:
issues of secrecy. Hum Reprod 1996;11:2558–63.
26. Crawshaw M. Prospective parents' intentions regarding disclosure following
the removal of donor anonymity. Hum Fertil 2008;11:95–100.
27. Daniels K, Gillett W, Grace V. Parental information sharing with donor
insemination conceived offspring: a follow-up study. Hum Reprod 2009;
24:1099–105.
28. Lee E, Macvarish J, Sheldon S. The role of counselors in infertility
clinics. Bionews. London: Progress Educational Trust. 2013. Available
at: http://www.bionews.org.uk/page_249841.asp. Accessed May 1,
2015.
29. Hershberger P. Recipients of oocyte donation: an integrative review. J Obstet
Gynecol Neonatal Nurs 2004;33:610–21.
30. Josephs L. Therapist anxiety about motivation for parenthood. In:
Rosen A, Rosen J, editors. Frozen dreams psychodynamic dimensions of
infertility and assisted reproduction. Hillsdale, NJ: The Analytic Press;
2005:33–49.
31. Weingarten K. On lies, secrets, and not telling the truth: a training curricu-
lum. In: Imber-Black, editor. Secrets in families and family therapy. New
York: WW Norton; 1993:373–410.
VOL. 104 NO. 3 / SEPTEMBER 2015