Document Type : Original Article
1 School of Nursing, Koc University, Istanbul, Turkey
2 School of Nursing, Gulhane Military Medical Academy, Ankara, Turkey
3 Department of Obstetrics and Gynecology, Gulhane Military Medical Academy, Ankara, Turkey
Childbearing is an important goal for marriage
and seen as a vital means of stability and satisfaction
in married life in many Islamic societies.
Thus, being unable to fulfill this primary goal, an
infertile couple is highly likely to be regarded as a
Currently, there are various treatment options
for infertility, and new techniques are also being
developed as it is an important healthcare problem
affecting approximately 15-20% of married couples (
The practice of oocyte donation involves ethical, social, religious, psychological and medical issues. Scant attention has been given to the medical risks of oocyte donation. The risks of oocyte donation mean that special scrutiny should be paid to the treatment of oocyte donors during the donation process. There are several side effects and long term risks that may be associated with being an oocyte donor, which include pain, infection, bleeding as a result of the oocyte retrieval process, premenstrual syndrome like symptoms, ovarian hyperstimulation syndrome (OHSS), and a controversial risk of ovarian cancer from the medications the donor uses. The risks of oocyte donation necessitate the inspection of the treatment of oocyte donors during the donation process (
Treatment by oocyte donation, as one of the most contentious issues surrounding assisted reproduction, elicits active debate within many societies with regard to its moral, ethical and religious aspects (
At present, there are approximately 120 fertility clinics operating in Turkey. Some of the fertility clinics are sited in public or university hospitals, but the majority of them are established in private hospitals or operate as independent centers. In March 2010, a new version of the regulations, the "Legislation Concerning Assisted Reproduction Treatment Practices and Centers", was introduced in Turkey. In the revised legislation, a number of new restrictions have been declared including limitations regarding the licensing of private IVF centers, specifications on gamete and embryo storage and restrictions on the number of embryos that can be transferred to a patient [only one for women aged under 35 in their first and second cycle of IVF, and a maximum of two embryos for women in their third or subsequent cycles or over 35 years of age (
The use of donor eggs, sperm, or embryos is more of a social or cultural problem than a medical one (
The purpose of study was to evaluate the level of information of fertile and infertile Turkish women on oocyte donation in order to understand their awareness of the legal, ethical, social and religious issues regarding this technique and to compare these two groups in terms of these variables.
The study intended to provide answers to the following questions:
What are the opinions of fertile and infertile women regarding oocyte donation and the legal arrangement in Turkey?
Would fertile and infertile women accept being an oocyte donor or recipient?
Are fertile and infertile women aware of the legal, ethical, religious and social aspects of oocyte donation?
This cross-sectional study was carried out between October 2008 and January 2009 in Ankara, Turkey. Women applying to Gulhane Military Medical Academy gynecology and infertility clinics who were willing to participate and who met the inclusion criteria were included. The inclusion criteria for fertile women were: having conceived spontaneously and having no other gynecological problems, while for infertile women, being under treatment in ART outpatient clinic and having no other additional gynecological problems.
A data collection form was developed by researchers after evaluation of the relevant literature (
In the questionnaire, women were first asked if they had previously heard about oocyte donation, and those who had heard about it were asked to define the procedure. This was done to verify the actual knowledge level of women about the subject. Later, all were informed about the oocyte donation and women then answered the rest of the questionnaire.
The prepared questionnaire was first administered to 10 fertile and 10 infertile women as a pilot study to ascertain whether the items could be easily understood. Since no problems were detected/ reported by women in the pilot stage, the questionnaire was used as is.
The women were provided information on the study in small groups at the waiting hall and those who consented to participate were taken to another room to fill in the data collection forms with face-to-face interviews. A total of 97 infertile women that attended the ART program of Gulhane Military Medical Academy,
A detailed report about the study, including the purpose, possible benefits, methods and data collection means, is presented to the Gulhane Military Medical Academy Ethical Committee. Our study was then approved by this ethical committee. All participants were informed and their oral and written consents were taken. After their consent, all participants were interviewed by the researcher for about 20 minutes each, and filled the data collection forms.
The data were analyzed using the "Statistical Package for Social Sciences" (SPSS) version 15.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics, such as frequency, percentages, means and standard deviations were used to describe the sample and main variables. The appropriateness of the variables (age, duration of marriage and monthly income) was checked by a single sample Kolmogorov-Smirnov test and found to have normal distribution. Chi square test and indepent-samples t test were used to compare infertile and fertile women. Values of p less than 0.05 were considered statistically significant.
The socio-demographic characteristics of the women are presented in table 1. In table 2, it can be seen that the subject of oocyte donation had previously been heard by 54.6% of the infertile and 41.9% of the fertile women. However, only 40.2% of the infertile women and 18.1% of the fertile women could correctly define "oocyte donation". There was a statistically significant difference between the two groups (p=0.000, χ2=12.04).
The fact that oocyte donation is illegal in Turkey was known by 70.1% of the infertile women and 50.5% of the fertile women. There was a statistically significant difference between the infertile and fertile women regarding their knowledge on illegality of oocyte donation in Turkey (p=0.003, χ2=8.08,
The percentage of women who did not want oocyte donation to be legal in Turkey under any circumstances were 50.5 and 44.3% for the infertile and fertile women, respectively (
The women were asked whether they would use the oocytes of another woman if necessary to have a child. About 67.6% of the fertile women said they would never want to use this method, while 63.9% of the infertile women stated that they may want to use this method under certain conditions (such as from a close relative or from someone they do not know at all). The difference between the fertile and infertile women was significant (p=0.000, χ2=20.10,
The women were then asked whether they would donate oocytes for someone else if necessary. About 58.1% of the fertile women said they would never want to make a donation, while 55.7% of the infertile women said they may donate their oocytes under certain conditions. The difference between the fertile and infertile women was significant (p=0.03, χ2=3.82,
The sociodemographic characteristics of the women
|Fertile women N=105 X̅ ± SD||Infertile women N=97 X̅ ± SD||P||t|
|32.41 ± 6.19||30.62 ± 3.88||0.016||2.43|
|9.25 ± 6.29||6.44 ± 3.37||0.000||3.91|
|2768.47 ± 1141.80||1982.29 ± 687.07||0.000||5.87|
|University- or higher||60||57.1||27||27.8|
*; Independ-samples t test and **; Chi Square test were used.
Fertile and infertile women’s knowledge about oocyte donation and its practicabilty in Turkey
|Fertile women N=105||Infertile women N=97|
|Can not define||86||81.9||58||59.8|
|Thinks oocyte donation is legal||-||-||-||-||0.003||8.08|
|Thinks oocyte donation is illegal||53||50.5||68||70.1|
|Oocyte donation must bekept illegal||75||71.4||56||57.7||0.29||4.15|
|Rules and legislation on oocytedonation must be revised||30||28.6||41||42.3|
|Under some circumstances(Oocytes of a closerelative or from a personwhom she does not know)||34||32.4||62||63.9|
|Under some circumstances (For a close relative or a person whom she does not know)||44||41.9||54||55.7|
Chi Square test was used.
In table 3, it can be observed that, both fertile and infertile women stated that oocyte donation may be accompanied by legal, ethical, social and religious problems. The most common (64.8% of the fertile and 41.2% of the infertile women) concern regarding these problems was the emergence of the donor in the following years for financial or emotional demands from the family or the child. The other concerns were the fear of a consanguineous marriage later in life since the biological mother is not known (51.4% of the fertile and 39.2% of the infertile women), the genetic features of the biological mother remaining unknown for both the couple and the child to be born (43.8% of the fertile and 35.1% of the infertile women), and the possibility of elderly couples having children with this method (33% of the fertile and 12.4% of the infertile women).
The percentage of women who stated they would choose adoption in case they could never have a child at all were 81.0% of the fertile and 60.8% of the infertile women in our study. However, 20.6% of the infertile women indicated that they would choose oocyte donation as a second option, even if they knew that it was illegal. The difference between the fertile and infertile women was significant (p=0.00; χ2=19.26,
Fertile and infertile women’s opinions on the advantages and possible problems that oocyte donation may bring
|Fertile women N=105||Infertile women N=97|
Chi square test was used.
Comparison of fertile and infertile women’s future plans regarding the use of oocyte donation in case they do not have any other choice
|Fertile women N=105||Infertile women N=97|
Chi square test was used.
This study evaluated the knowledge level and opinions of both fertile and infertile Turkish women on oocyte donation. There have been published studies investigating public opinions about oocyte donation (
Both the fertile and infertile women in our study were aware that oocyte donation is illegal in Turkey. They were all approving the illegality of oocyte donation. However, 6 of every 10 infertile women reported that they could donate their oocytes for another woman under certain conditions (the donor is a close relative, never knowing the donor, etc.), and more than half said they could take oocytes from another woman if necessary. The attitude of community towards oocyte donation in different societies is still a controversial issue (
donation and the majority of Iranian public supported oocyte donation as an alternative way of overcoming infertility.
These results indicate that the percentage of Turkish infertile women with a positive attitude towards oocyte donation is constantly increasing and the method is today deemed to be more acceptable both in Turkey and in other countries.
Fertile women have a more unfavorable approach both to oocyte donation and acceptance compared to infertile women. Fertile women wanted oocyte donation to be kept illegal in the future and stated they would not use it even if necessary. However, although infertile women wanted it to be kept illegal in the future, they felt they could use it if necessary. This result is important as it indicates that infertile women feel a conflict between oocyte donation and the desire to have a child. Fertile women have a more negative attitude towards oocyte donation probably because they are not faced with infertility (
Approximately half of fertile and infertile women stated that oocyte donation would enable infertile couples to have children, and therefore provide physical and psychological comfort for them. Svanberg et al. (
The percentage of women who believed oocyte donation would harm religious values or the family structure was quite low in our study. Isikoglu et al. (
Infertile women in the current study mentioned they could use illegal routes if necessary to have a child at much higher rates than fertile women. This shows that desire to have a child is a strong motivation in Turkey. To conclude, it is demonstrated that there are infertile couples who try to find and willing to use third-party assisted reproduction techniques, although illegal in this country. It is possible (and known) that some couples travel abroad to certain countries where oocyte donation is legal to make use of the method.
However, employing these techniques without vast information could harm both the couple- the family and the child born as a result. The infertility nurse also has a responsibility to inform the infertile couple about all procedures, whether legal or illegal. The nurse needs to know the characteristics of the group, he/she, is communicating with, so that information can be provided properly. These characteristics would encompass the cultural values that could influence the final decision.
This study has been conducted in an infertility outpatient center in the capital city of Turkey, Ankara. Therefore, as a limitation, the results deriven should not be generalized.
The religious beliefs of the subjects could have influenced the answers given to the questionnaire. We would suggest "larger and possibly multi centered researches" on the topic, including subjects from various religious and cultural societies. Since the majority of the population believes Islam in our country, and since other religious societies are rather concentrated in small groups in various cities, it was not possible for us as a small group of researchers to reach a larger pool of data from different religions. Our results, therefore, reflects the opinions of a Turkish population who all believe Islam.
Finally only fertile and infertile women were included in this study. But the treatment process and the choice of therapeutic options necessitates the husbands’ opinion in the decision making. Therefore, it would be interesting to search husbands knowledge and approach to oocyte donation in future studies. Missing the male counterpart’s opinions may, therefore, be considered another limitation of this study.
This study shows that approximately half of respondents had heard of oocyte donation; however, only a very small percentage of fertile women and approximately half of infertile women could correctly define it. The majority of both the fertile and infertile women were aware that oocyte donation is illegal in Turkey. Infertile women have a more favorable approach and support oocyte donation as an alternative route for childless couples, compared to fertile women. Infertile women also mentioned that they could use illegal routes if necessary to have a child at much higher rates than stated by fertile women. This shows that the desire to have a child is a strong source of motivation in Turkey. Health care professionals need to be aware of the emotional and psychosocial impact of being childless in Turkish society.
The explanation of the current legal status in Turkey and the advantages and disadvantages of donation regarding the couple and the child to be born should be included in this presentation. The healthcare staff should provide the necessary guidance after checking the motivation of the couple.