A relationship between traditionally motivated patterns and gamete donation and surrogacy in urban areas of Greece

Joannes E. Chliaoutakis

Department of Social Work, Technological Educational Institute (TEI) of Crete, Stavromenos 71500, Heraklion, Greece. Email: jchlia{at}seyp.teiher.gr


    Abstract
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
BACKGROUND: Although gamete receipt or donation has become an integral part of infertility management, previous research in the field of social attitudes and intention to use medical technologies is limited. The aim of this paper was to investigate people's intentions to receive or donate sperm, oocyte or uterus (surrogacy) and to identify possible motivational patterns explaining this intention. METHODS: Personal interviews were conducted with 365 men and women of reproductive age (18–45 years). Stratified random sampling was performed to select the men and women for interview. The content of the instrument used was derived from in-depth qualitative interviews with physicians experienced in assisted reproductive technologies, as well as from people who had recourse to gamete donation and surrogacy. RESULTS: The results obtained highlighted the following major aspects: (i) approximately 50% of the survey's participants would be prepared to receive/donate sperm and oocyte; (ii) the results from multiple regression analysis suggest that the `traditional gender roles' pattern is positively associated with `intention to use gamete donation and surrogacy'. On the contrary, `confidence in emotional relationship' is negatively associated with `intention to use gamete donation and surrogacy, and (iii) men are more likely than women to report `intention to use gamete donation and surrogacy'. CONCLUSION: These data suggest that specific motivational patterns of the population need to be thoroughly analysed and taken into consideration, in order that appropriate counselling be addressed to individuals and couples.

Key words: assisted reproductive technologies/gamete donation/infertility/reproduction/surrogacy


    Introduction
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
In the last decade the increasing use of assisted reproductive technologies (ART) continue to raise moral, ethical, cultural and legal questions for scientists, authorities and the public. This is particularly true for the techniques designed to enable infertile couples to have children through gamete donation, procedures where a third party is involved. However, the demand for gamete donation continues to increase along with greater public awareness and improved reproductive techniques (Eisenberg and Schenker, 1998Go).

In Greece, infertility exists among a large number of individuals since it affects ~12–15% of all couples of reproductive age. It is estimated that ~35% of the infertility cases are due to a female factor, 30–35% to a male factor and in 20% to both genders, while the remaining 10% are referred to as `unexplained infertility'. It has been estimated that in 1998, the last year for which statistics are available, nearly 2500 pregnancies occurred from all forms of ART from the ~50 medical establishments practising ART. Pre-embryo donation was initialized in Greece in the late 1980s. More than 10 years later, the practice of pre-embryo donation is still limited. The pregnancy rate following pre-embryo donation is considered to be the same as that following oocyte donation (personal communication, B. Tarlatzis, 2001).

Reproductive biotechnology has made enormous progress in the last quarter century, raising serious concerns, more or less justified, e.g. reproductive cloning in human. Particularly if a large majority of the scientific community and society is not ready to accept it, public concern is understandable (Ménézo, 2000). Although ART poses a multitude of ethical questions, since it involves several parties with separate interests, and the decision process to use these technologies is influenced by many social factors, research in the field of social attitudes and intention of using such technology is limited.

Very recently attention has been given to the ethical and legal issues concerning ART (Dickens and Cook, 1999Go; Fonnest et al., 2000Go; Sozos et al., 2000Go); others put more emphasis on the risks and benefits of biotechnology in medicine (Macer, 1994Go; Ryan, 1996Go). Additionally, a limited number of surveys has been carried out with parents of children born after the use of ART (Cederblad et al., 1996Go; Braverman et al., 1998Go). Yet, there have been limited efforts (in Greece none at all) to determine public attitudes towards ART and intention to use such technology and to educate men and women about it (Genuis et al., 1993Go; Zegos-Hochschild, 1999; The Bertarelli Foundation Scientific Board, 2000Go).

The purpose of the present analysis was to investigate how a population living in urban areas of Greece perceives gamete donation and surrogacy (GDS), as well as its intention for potential gamete receiving or donation. This is the first time that such a research has been conducted in Greece on the topic of the attitudes and intentions towards GDS. This study, therefore, has three main objectives: (i) to determine the sociological profile of the individuals that would use GDS, i.e. would receive or donate sperm, oocyte, and uterus for managing infertility; (ii) to assess the intention to receive or donate sperm, oocyte, and uterus to or from any of the partners, family persons or others via GDS in case of a fertility problem, and (c) to explore possible motivational patterns, concerning procreation and ART that might influence public's intention to use GDS technologies.


    Materials and methods
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
Statistical design
Between November and December 2000 a representative sample of 365 adults, 18–45 years old, residents of Crete, were interviewed personally. A probabilistic, stratified random sampling was performed to select men and women participants, using information from the National Statistics Department. A two-stage conglomerate sampling was made, with sub-sampling and stratification of the first units that were the censual sections in which Crete is divided. Once the censual sections used for sampling had been selected, all households existing in these sections were counted, and the list of homes selected for the sample (two per censual section) was drawn by simple random sampling, without replacement, from the total list of homes. If, in the same household, several men or women of reproductive age (18–45 years old) were eligible to be interviewed, one of them was randomly selected on a number table. This sampling design ensured the adequate socio-demographic representation of the sample. The variables used to stratify the sample to be selected were: sex, age, marital status, educational level and occupation.

Methods for collecting information
It was decided to perform personal interviews and interviewers were controlled for at each stage of the fieldwork in order to prevent potential errors occurring during data collection. For that purpose the following measures were taken: (i) use of a team of social workers who had received appropriate training, and who were supervised by the researcher; (ii) design of an easy-to-use questionnaire; (iii) consent requested and received by all subjects prior to the completion of the questionnaire and after informing them of the aims of the study; (iv) general instructions given on how to complete the questionnaire; (v) protection of subjects' rights to anonymity and confidentiality and (vi) quality control by the validation of 10% of the completed questionnaires randomly selected. The response rate was 95%.

Questionnaire and measures
A pilot study with a sample of 30 individuals preceded the present study. For the purposes of the pilot study, the interviewers used a questionnaire with open-ended questions referring to motivations and attitudes towards GDS. This instrument was evaluated by several physicians experienced in ART, as well as by people who had recourse to GDS. The final questionnaire, used in the study, was the result of a combination of an already existing questionnaire (Genuis et al., 1993Go) and the conclusions of the pilot study. Therefore, a new questionnaire has been developed, with 50 different items and divided in two sections:

The first section referred to the socio-demographic background of the sample including gender, age, marital status, educational level, profession, number of children, voting preferences and church attendance.

The second section was subdivided into two parts. The first part included six items assessing the intention of men and women to use GDS, or encourage another person to act in a similar way, i.e. receiving/donating sperm, oocyte, and uterus from–to brother/sister/close relative, friend, unrelated healthy person, and/or the refusal of these medical technologies. The composite score of these six items formed the scale of the `intention to use GDS'. Responses to the six items were averaged to obtain the score on the scale. Its internal consistency, as measured by Cronbach's {alpha}, was 0.88. The second part comprised a question with 15 items, resulting from the pilot study and measuring the motivational patterns that lead a person to have recourse or not to medical technology in order to manage infertility. Each item was formulated as a statement. The interviewees were asked, `to state the significant reasons that would motivate or inhibit a man or a woman to use GDS, as a solution to his or her infertility'. Examples of statements were: `I wish to fulfil my male/female role by giving birth to a child...', or `pregnancy is the best proof of femininity/masculinity', or `I want to have the physical and emotional experience of pregnancy', or `gestation is the result of emotional relations and not of technological substitutes', or `we trust in God and not in biomedical science for having a child' etc. The respondents were asked to rate each statement on a four point Likert-type scale that ranged from 1 (disagree) to 4 (agree).

Statistical analysis
The initial statistical process used was principal components analysis (PCA) and the data modelling was constructed through multiple linear regression. PCA with varimax rotation was used in one initial run for the 15 items measuring the motivational patterns. The PCA was chosen for two main reasons: first, in order to reveal the `latent' variables (factors) and second, in an effort to reduce the large number of the variables.

Table IGo presents the results of the PCA analysis. The final factor solutions for the analyses met four criteria: (i) each one was based on factors with an eigenvalue >2.0; (ii) each individual item was correlated with the factor concerned at the 0.40 level or above; (iii) each item included had no significant correlation with another factor, and (iv) only items with a communality of >0.50 were selected.


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Table I. Principal components analysis of the fifteen items (in bold) referred to the motivations of using/not using GDS following varimax rotation
 
Two factors emerged, describing the motivations to use GDS, accounting for 55% of the total variance. Labels for the two factors were derived from the items with higher loadings. The first factor, accounting for 38% of the variance, consisted of nine items related to traditional patterns towards societal expectations of gender role, fulfilment of masculine and feminine role, maintenance of a genetic link (even from one side) with the descendant, lineage and name perpetuation to offspring, etc. This factor has been labelled `traditional gender roles'. Also, the label of the second factor, accounting for 17% of the variance, was `confidence in emotional relationship', since it reflects a subject's confidence in the emotional relationship with the partner (e.g. `maintenance of the emotional relationship even without having a child', `confidence in the relationship and the partner and not in the new medical technologies', `gestation is the result of beloved relations and not of technological substitutes' etc. The two factors, of the analysis, were internally consistent and well defined by the relevant items (Cronbach's {alpha} were 0.88 and 0.79 respectively for each factor).

The multiple regression method was used to assess the relationship among several independent/predictor variables and the outcome/dependent variable. Multiple regression was selected because the outcome variable was continuous, i.e. a composite score of the rates of the intention to use or not GDS. The following variables entered in the regression analysis as independent variables: (i) socio-demographic characteristics (gender, age in years, number of children); (ii) Socio-economic characteristics (educational level, in years of education, and six professional categories: scientists and self-employed, traders, shop assistants and officers, etc., blue collar workers, housewives, students and unemployed etc.). (iii) Voting preferences (socialist, liberal, and other) and church attendance (ranged from 0 = never to 5 = every Sunday) and (iv) the two motivational indicators (the factors were extracted by the PCA).


    Results
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
Information concerning the sociological profile and some other characteristics of the 180 (49.3%) men and 185 (50.7%) women are presented in Table IIGo.


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Table II. Distribution of study subjects according to socio-demographic characteristics, voting preference and church attendance
 
Intention to use gamete donation and surrogacy (acceptability of sperm, oocyte, uterus receiving/donation)
Interviewees were asked to hypothesize that they were unable to become a parent through the usual route of intercourse, conception, pregnancy and childbirth and their physician suggested they should use the convenient medical technology of assisted reproduction; or advise other persons who face the same problem. In which case would they intend to act according to their physician's advice or encourage a family member to act similarly? Percentages of receiving or donating sperm and oocyte (or encourage a family member to do so) are almost equally distributed between those who would use GDS and those who would use none of these procedures (Table IIIGo). More specifically, 53.1% of the participants were in favour of receiving sperm from a relative, a friend or a stranger. Intention to donate sperm was reported by 48.9% of them. Additionally, data have shown an almost equal acceptability rate in receiving or donating oocytes (48.6 and 50.7% respectively). The refusal of a woman to `borrow another uterus from/or lend her own uterus to' was high (69.5 and 73.1% respectively). Moreover, willingness to receive or donate sperm, oocyte and uterus increased for a healthy stranger and decreased for a family person or a friend (Table IIIGo).


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Table III. Intention to use gamete donation and surrogacy: percentage of respondents who would receive/donate sperm, oocyte and uterus
 
With regard to the gender differences between each of the above categories, male's acceptability of GDS was significantly higher compared with that of females, only for sperm donation (59%, {chi}2 = 12.4, P = 0.006).

Multiple regression analysis
Table IVGo presents the regression coefficients and the associated level of significance for the two factors, describing the motivational indicators of the participants, and the socio-demographic characteristics on the composite score of the `intention to use GDS'. Results from this model suggest that the factor of `traditional gender roles' is associated with `intention to use GDS'. These data suggest that participants who reported traditional motivated patterns are more in favour of using GDS. Also, the factor of `confidence in emotional relationships' is negatively associated with `intention to use GDS', suggesting that men and women who strongly expressed their confidence to the emotional relationship with their partner are less likely to use GDS (regression coefficients 0.58 and –1.49 respectively).


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Table VI. Linear regression derived coefficients (b) and their standard errors (SEM) for the model summarizing the association between the socio-demographic variables, the motivational indicators and the composite score of the intention to use GDS
 
With respect to the socio-demographic variables, only gender has a significant effect on the intention to use GDS (P < 0.0001). In particular men tend to be more willing than women to use GDS techniques. Also, among the other socio-demographic variables, those who vote liberal and the professional category of traders, shop-assistants, officers, etc. are negatively associated with `Intention to use GDS' (P = 0.055 and 0.030 respectively).


    Discussion
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
The purpose of the present analysis was to elicit information on how men and women at the reproductive age, living in urban areas of Greece, perceive eventual recourse to medical assisted technologies for solving infertility problems. The conduct of this work aims, also, for a better understanding of motivational patterns explaining intention to use GDS. If confronted with hypothetical inability to have a child through the natural route of intercourse, approximately half of the respondents reported they would pursue or encourage a familial person to pursue alternative ways of having a child. In particular, these results (Table IIIGo) indicate similar intentions towards the refusal of sperm receipt/donation (47 and 51% respectively) and oocyte receipt/donation (51 and 49% respectively). Refusal of `borrowing or lending a uterus' is reported in higher percentages (69.5 and 73% respectively). Although, in Greece the debate over bio-medical assistance and technologies has started only during the last decade, the results of the present paper suggest that this study's participants tend to accept reproductive technologies. Yet intention to use GDS procedures is differentiated according to the relation with the recipient/donor. Participants prefer to receive sperm and oocyte from a stranger than a relative or a friend. This finding leads to the conclusion that the Greek population accepting ART, trusts medical services and practitioners' discretion and at the same time is less willing to discuss reproductive problems within its micro-environment.

In similar studies coming from countries with more developed medical systems and with a wider dissemination of relevant campaigns (e.g. USA and Canada), acceptability of GDS is much higher (~89%) compared with that reported in the present study (Kazen et al., 1995Go; Ravin et al., 1997Go). Furthermore, support for sperm and oocyte donation decreases with increasing distance between the donor and the recipient (Genuis et al., 1993Go). On the contrary, our results suggest that maintenance of anonymity in Greece constitutes a very important concern, because the likelihood of donor's contact with the resulting children is significant, endangering family stability.

Health promotion services in Greece should focus their efforts on the general population and specifically on couples with infertility problems, reinforcing acceptability and trust in reproductive technologies. As noted above, it is often difficult for such couples to address openly their infertility problem and this lack of openness diminishes their chances of seeking a solution (The Bertarelli Foundation Scientific Board, 2000Go). Our data point out that health promotion services should seriously take into consideration that such couples may see themselves as defective, because they have internalized the social norms expressed in gender roles (Whiteford et al., 1995). Therefore, physicians and social scientists should put more emphasis on helping such couples reconcile with medical reproductive technologies and especially women, who are more reluctant than men to have recourse to gamete donation.

The positive relationship between the `traditional gender roles' and the `intention to use GDS' adds a new dimension to the debate over infertility and its treatment. This survey is a first attempt to offer the necessary tools for designing interventional campaigns, based not only on socio-demographic factors or information on ART, but also on people's motivations to use GDS. People with serious fertility problems, reluctant to undergo ART even if they are adequately informed, could be further encouraged by appropriate health campaigns. The aim of these campaigns should be not only to reinforce their trust in medical reproductive technologies, but also to convince couples with fertility problems that gamete receiving would increase their chances of fulfilling their social roles by giving new members to the society or another meaning to their life. Similarly to the present results, previous research has emphasized the emotional needs of infertile couples and the importance of the ingrained societal expectations concerning human reproduction (Robinson and Stewart, 1989Go; Tarlatzis et al., 1993Go; Papaligoura and Papagounos, 1996Go; Ravin et al., 1997Go).

Our data show also a strong negative association between the motivational pattern of `confidence in emotional relationship' and the `intention to use GDS'. It appears that motives derive from the emotional relationship between the partners and their belief in God. It is possible that these couples experience the latent fear that natural reproductive behaviour is replaced by an artificial medicalized method of reproduction. Thus, they prefer tightening their emotional relationship with their partner and trusting in God, firmly avoiding the use of GDS. However, it should be noted that fear towards the new reproductive technologies could be attributed, at least in part, to lack of trust towards such technologies. Besides, it seems that the family environment and the relationship of the partners provide a feeling of security that inhibits them from using new methods for solving their infertility problems. It is evident that the socio-cultural context in which these technologies are implemented is a vital factor for people's perceptions. Therefore physicians and health promoting professionals, in consultation with the public, should have the primary responsibility for clarifying the limits and the meaning of these very useful treatments.

Finally, the sociological characteristics of the investigated population did not have a significant effect on the `intention to use GDS'. However, similar to other studies (Genuis et al., 1993Go; Kazen et al., 1995Go; Ravin et al., 1997Go), men are better supporters than women of gamete receiving and donation. It is possible that this attitude is mainly due to men's minor physical involvement in the GDS procedure and, simultaneously, to their stronger desire for having descendants.

In conclusion, urban Greek men's and women's intention to use GDS varies, depending on the type of reproductive material used and their relationship with the donor/recipient. The acceptability of receiving or donating sperm and oocytes is relatively high, taking into consideration that the implementation of such technologies in Greece is recent. Specific motivational patterns contribute to encourage or discourage couples from claiming recourse to ART as a solution to their fertility problems.


    Acknowledgements
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
The author is particularly grateful to Sofia Koukouli and Gareth Owens who kindly devoted their precious time in revising the English of this article.


    References
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
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Submitted on October 18, 2001; resubmitted on March 8, 2002; accepted on April 24, 2002.





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