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Autumn 2020

Whose Sperm Is This?

Israel is one of the leaders in fertility treatment, but its rampant use of other people's genetics will have long-lasting implications.

S

tanding at 6’2”, with sparkling blue eyes and curly brown curly hair speckled with just the right amount of gray, Ari Nagel, a 45-year-old professor of mathematics, is every Jewish mother’s dream: tall, smart, handsome, and an MOT (Member of the Tribe, for the uninitiated).

He’s also many a wanna-be-mother’s dream, Jew and non-Jew alike, as evidenced by the fact that this New Yorker has fathered 69 children and counting, freely giving his sperm to most anyone who asks: sometimes in a sterile cup in a bathroom stall, other times the “traditional” way—if you can call sex with a random woman who wants you to father her child “traditional.” In 2016, when Nagel had a mere 22 children, The New York Post made his story public, dubbing him “The Sperminator.”

Three years later, Israel’s High Court ruled that Nagel’s sperm was “illegal,” denying a 43-year-old single woman the right to be impregnated by it. “It’s doubtful he [Nagel] can function as an actual father,” the court observed. According to Israel’s Ministry of Health, sperm donation in the country must be anonymous: “The donor does not know the identity of the recipients/recipients of the sperm. The sperm recipient/recipients do not know the identity of the donor.” A non-anonymous donor must assume biological rights, the guidelines state.

The court ordered that Nagel’s sperm, being held at an IVF clinic on behalf of a number of women who wanted to be impregnated with it, be destroyed. “This case threatens to render meaningless the entire institution of parenthood,” the judges decreed.

A noble ruling from the justices, yet without precedent. In fact, this may be one of the few times that Israel has formally intervened in the big business of gamete donation.

***

For the most part, Israel hardly regulates sperm and egg donation—technically, not a “donation” at all, but rather the actual purchase of sperm or eggs from a person who is not the intended parent (commonly referred to as “IPs” in the world of third-party reproduction, when intending parents are obliged to seek the assistance of an outside entity—sperm, eggs, embryos, or in the case of surrogates, a womb).

Some couples need donor sperm or donor eggs because their own cannot facilitate a successful pregnancy. When it comes to eggs, age is often a key factor: A younger woman’s eggs have a higher chance of leading to a successful pregnancy, because it’s the age of the woman providing the egg, not the age of the uterus of the woman carrying the baby, that is the most important factor “in predicting success with treatment,” according to the Journal of Human Reproductive Sciences.

Others, like gay couples and singles, can’t have a baby without this help. While some people use what is called a “known donor”—a brother, sister, or friend, or another gay couple who may or may not share in parenting responsibilities after the fact—many in Israel prefer to use an anonymous donor, to minimize emotional complications and therefore purchase gametes from an anonymous donor.

Let’s backtrack for a moment to the “regular” procedures of In Vitro Fertilization (IVF), when a man’s sperm fertilizes a woman’s eggs outside the body in a laboratory, and the resulting embryo created from the parentsown genetic material, is returned to the mother’s womb. Israel’s first IVF baby, born in 1982 was the world’s fifth such birth. (The world’s first IVF baby, Louise Brown, was born in the United Kingdom in 1978.) Israel’s early adoption of this technology of procreation signaled “the dawn of a prosperous assisted reproductive technology industry: Israeli women undergo, on average, more IVF cycles than women in any other country,” according to University of Haifa’s Professor Daphna Birenbaum-Carmeli in her 2016 study, “Thirty-five Years of Assisted Reproductive Technologies in Israel.” Most agree that Israel is a “pro-natalist” country. “Whether due to the Biblical commandment to ‘be fruitful and multiply’ or the traumas of the Holocaust and perennial wars, reproduction has been a central goal in Israel, some would say a pre-occupation, since its foundation,” Birenbaum-Carmeli wrote.

The State of Israel funds unlimited cycles of IVF treatment for all women between ages 18 and 45, for her first two children with her current partner. Fertility treatment comprises at least 2% of Israel’s health budget. IVF live births have increased from 1.7% of Israel’s total live births in 1995 to 4.3% in 2013.

The history of third-party reproduction, however, is a bit more complex.

At first, sperm donation was used to overcome male-factor infertility. But in the last two decades, following the development of technology allowing for sperm to be injected directly into the egg (known as Intracytoplasmic Sperm Injection, or ICSI), donor insemination is mostly utilized by single women and lesbians in Israel. Israel’s Ministry of Health estimates that 1,200 babies are the result of donor insemination each year.

One key factor in the procedure is the provenance of the sperm. “A substantial portion of donor sperm in Israel is now imported,” Birenbaum-Carmeli stated in her 2016 report.

Which is a good thing, since a 2006 investigation by the State Comptroller found that local Israeli sperm banks were not complying with recommendations to limit sperm donations at their discretion. Some donors, it transpired, may have fathered up to 25 children.

Similar scandals have also beset egg donation in Israel. In 2000, Israeli police opened the “Egg Affair” case, investigating two prominent Israeli doctors accused of over-stimulating patients in order to create extra eggs—which they then sold on to other patients, unbeknownst to the ova owners.

Since then, a cottage industry of foreign egg donation has sprung up, with Israeli doctors procuring eggs from women in Eastern Europe. In 2005, the Ministry of Health approved six foreign clinics, working in conjunction with Israeli hospitals and medical centers, to provide egg donation services—retrieving the ova, combining them with provided sperm, then transferring the resultant embryos into their Israeli patients.

The Hadassah Medical Center in Jerusalem, for example, takes Israeli women to Reprofit Clinic in the Czech Republic. L.B. IVF, a private clinic opened in Tel Aviv in 2003, works with the Isida Clinic in Ukraine. “I would say we have about 20 donors and 200 women a month,” says Professor Jacob Levron, who notes that even though a new egg donation law enacted in Israel in 2010 allows Israeli women to donate eggs up to three times, “the regulations on egg donation makes it nearly impossible to implement.” For example, in 2013 and 2014 only 16 and 19 Israeli women donated eggs, respectively, according to the Ministry of Health. By 2018, this number had only increased to 50, noted  IVF specialist Dr. Itay Gal in a 2018 article for Israeli daily Yediot Aharonot. Gal has a two-year waiting list of clients hoping to receive an Israeli egg donor.

”Not many donors are coming forward,” Professor Levron notes.

The State appears to monitor donors within Israel, with laws concerning who can donate, how they are screened, and how many times a donor can donate their genetic material to prospective parents. The law still leaves it to the clinics to self-regulate the number of times that a man can donate sperm. Some clinics, like the Sheba Medical Center in Tel Aviv, recommend that a man donate only 7-10 times; others limit it to ten families. But there is no guarantee that a donor won’t go to a different sperm bank and donate again after reaching the limit in one bank, receiving a few hundred dollars each time. (A 2017 proposed donation law is yet to have a reading in the Knesset, Israel’s parliament.)

And donors may not be who they say they are. Although donor information disclosed to the Intended Parent is minimal—age, height, weight, profession, at the very least—the donor is supposed to give the clinic a full health and psychological history. But a 2018 undercover investigation by Yedioth Aharonot revealed that Israeli egg donors included women with a history of psychiatric problems, drug and alcohol addicts, and sex workers; and that the so-called “strict” screening process that the government touts did not rule out carriers of genetic diseases. In some cases, not even a complete medical record was required before donation.

The clinics procuring gametes (eggs and sperm) outside Israel for Israeli intended parents are subjected to even less oversight by the government (or even the media), who cannot investigate these foreign donors, all of whom remain anonymous.

To be fair, this is not Israel’s problem alone. Many donors around the world self-report their medical and psychiatric history, although clinics allegedly perform their own genetic tests and psychiatric evaluations.

In any case, it is not so much the donors’ health, medical, and psychiatric history that concerns me. It is, rather, the unregulated use of anonymous genetic material to produce children—without due consideration for the wellbeing of the resulting offspring.

Take Israel’s law for sperm donors. “The donor signs that he is prevented from receiving information about pregnancies and live births, and that the sperm bank undertakes to maintain the donor’s confidentiality forever.”

This is far from an academic topic for me. I started writing about my own IVF journey, for The New York Times, back in 2013—a time when hardly anyone outside the medical profession was speaking about the topic in a public forum.

Because I kept getting pregnant—first naturally, then through IVF, then losing these pregnancies—I was sure that it would eventually work out for me and my husband, both Israeli citizens (him by birth, me naturalized.) I never, ever, imagined that I would have to use donor eggs—even though I was 41 when I started trying to conceive.

After two years of IVF and miscarriages in America, we decided to come to Israel to take advantage of the free fertility treatment for citizens. Another eight months of treatment in Jerusalem, this time with pre-implantation genetic testing (PGT) of my embryos, to determine if my miscarriages were the result of chromosomal abnormalities, revealed that my eggs were abnormal.

“I’m not saying you have zero percent chance of having a baby with your own eggs,” my lovely doctor in Jerusalem told me, as she pushed the box of tissues across her desk. ”I’m just saying you have less than a 1% chance.”

Long story short: we decided to move onto donor eggs. Truthfully, I wasn’t in the best frame of mind at the time. I’d just completed four rounds of high-dosage dizzying IVF stimulation medication, I was depressed that a last-ditch effort to have a child with my own genetic material had not worked, and I was desperate to have a baby already. So I wasn’t my usual inquisitive journalistic self, keen to fully understand the subject of donor eggs and the potential implications of the procedure.

“Can the donor have curly hair?” I asked the nurse while filling out a donor preference form. It had a few straightforward questions, like, “What color eyes do you want the donor to have?” and “What color hair?” Most agencies try to match the donor’s physical characteristics to those of the intended parents. She laughed. “Why does it matter what kind of hair the donor has? All that’s important is that she’s physically and psychologically healthy!” she said. “It’s just like an organ donor.”

I believed her. I wanted to believe her. So I joined a cohort of eight other women and hopped on board a flight to Ukraine, filled with a cohort of singing religious women on a pilgrimage to Uman and the grave of the venerated Rabbi Na-Na-Nachman of Breslov. Some of the other intended parents on the trip had tried egg donation five or six times, in different countries. A few looked old enough to be grandmothers (Israel allows fertilization by means of egg donation until the prospective mother is 54), although I shouldn’t have judged since I was almost 44, at the end of my natural fertility, and technically old enough to be a grandmother, too.

The next morning, we were driven to the spotless, empty clinic, closed to the Ukrainian public, for our embryo transfers. My husband’s sperm had been sent in advance to fertilize the donor’s eggs; after three days, the doctor was going transfer the resulting embryos to my womb.

Because egg donation is anonymous in both Israel and Ukraine, I did not know much about the donor. I had purchased six eggs, from a cohort that was ostensibly shared with other women. (It is possible to buy an “exclusive” batch of eggs, but this only applies for one donor cycle. In Israel, donors are allowed to donate for three cycles, and abroad the limit is similar, but when it comes to egg and sperm donation, no one can really monitor whether a donor goes to another clinic.)

While I sat in the stirrups, legs spread, waiting for my transfer, the doctor entered the room and showed me a Post-It note—a Post-it!—with the donor’s stats: her age, height, weight, profession, hair color, and eye color.

And guess what? Our daughter does have curly hair. Knotty, unruly, curly brown hair, just like me and her father. The nurse was right. It doesn’t matter what she looks like, beautiful, but not really like us; it does matter that she’s super healthy, not to mention super smart, funny and artistic—just like us.

But, as she grows up (she’s five), I can’t help but think that the nurse—and everyone else engaged in anonymous donation—is also wrong. It does matter who the donor was. My daughter might want to know her genetic origins, that family’s history of disease, and whether the donor’s eggs resulted in any more children. Who might be my daughter’s half-siblings, or as they’re called in the industry, “Diblings.”

She also might want to know the donor herself. This is a thought that terrifies me and threatens my very identity as a mother—something I hadn’t really thought about when I so desperately decided on using donor eggs.

***

When sperm and egg donation became de rigueur techniques in the world of fertility treatment, no one probably considered the ready—and affordable—availability of DNA testing today. Today, companies like 23&Me and Ancestry.com can provide genetic clues, and even the identity, of the donor or diblings. The Donor Sibling Registry (DSR), a website and non-profit founded in 2000, has to date helped to connect almost 20,000 people.

“There is no such thing as anonymity,” Fredrik Andreasson, a top executive at the Seattle Sperm Bank told The Huffington Post in 2019, noting that many clinics are revising their contracts: rather than promising anonymity, they only promise not to share information.

”People are doing DNA testing just for kicks, and getting the shock of their lives. There was such a culture of secrecy. Sometimes the mother tells after the father has died. Other times, there’s a letter left in a safe-deposit box,” DSR founder Wendy Kramer told Dani Shapiro in Shapiro’s best-selling Inheritance: A Memoir of Genealogy, Paternity and Love, a memoir relating how Shapiro discovered in her fifties that she was donor-conceived.

Even in Israel, stories abound of donor-conceived (DC) kids seeking out their half-siblings from sperm donors: a man discovering his twin brothers from the same donor, sisters reunited after 20 years thanks to a DNA test. “Stop Looking for Your Anonymous Donor,” one fertility doctor even admonished single women, as if Israel were not aware of the availability of DNA tests. But that is patently untrue. Just this year, Israel’s High Court upheld a ruling that the Rabbinate can use DNA tests to determine the Jewishness—or otherwise—of an individual. As halachic Jewishness is matrilineal, the Rabbinate is fixated on genealogy. As a consequence, most discussions in Israel around third-party reproduction, egg- and sperm-donation and surrogacy focus on who should be considered as the halachic mother of a child (and whether the child needs to be converted). Without going into the nuances here (I wrote a feature about this for Hadassah magazine earlier this year), I really have only one question: In a pro-natal country obsessed with a child’s genealogy, why are they not concerned about a child’s genetic material?

“It is very surprising,” concedes Professor Ya’arat Bokek-Cohen, a lecturer at the Academic College of Tel Aviv-Jaffa, who specializes in family relations and fertility technologies.  “The system is not organized very well.” She is clear that fundamental reform of the existing regulation—such as it is—concerning donor-conceived kids is urgently required. “There needs to be regulation and a centralized registry,” she says about all donor-conceived kids.

While there is a new population registry in Israel which notes the use of a donor, this information is only relevant if one used a donor in the country. Clinics that procure donations outside of Israel keep their own registries.

“There are many economic interests,” Bokek-Cohen says. “They [the clinics] don’t want regulation or oversight because they get a lot of money.”

According to the current law, donor-conceived children do not have the right to request the identity of their donor; but at the age of 18, they are allowed to apply to the registrar to find out if they were donor-conceived.  A donor-conceived couple may also determine in this way if they’re related.

My Wife Is My Sister” was the headline of a 2013 “Dear Prudence” advice column in the American publication Slate. The man in question had already had three children with his spouse when he discovered that they were half-siblings—both born to lesbian moms with the same sperm donor. Keeping it In the Family, a sensationalist 2019 headline in UK tabloid The Sun, refers to a man’s discovery that his pregnant wife was his dibling (with a sidebar discussing the greater propensity for genetic diseases when siblings procreate with each other).

Professor Levron estimates that egg donor births add up to only 1% of Israel’s estimated 180,000 births per year. (He doesn’t know for sure how many of his patients gave birth, as they go back to their regular Ob/Gyn for pregnancy and delivery.) ”The chance is very low,” he opines, in relation to diblings meeting and falling in love. Besides, he notes, this is lower than what he calls  “the rate of promiscuity,” referring to women who have children with someone other than their husbands (and may not know the child’s true paternity.) “Look, I can’t tell you it’s impossible:  Half siblings do meet and get married,” he says. But while the concern over consanguinity, i.e., being descended from the same ancestor, makes for great headlines, what should be most important, in Israel and around the world, are the donor-conceived children. When will they have access to their genetic information—to their medical records, siblings, and donors?

***

These investigations into donor conception leave me uneasy. These days, I wish I could go back to those halcyon days in the Tel Aviv clinic, when I unquestioningly accepted the nurse’s assertion that the donor wasn’t important “as long as she was healthy.” I wish that I could un-know what I now know: that some donor-conceived children are bitter about their origins, especially if they find out later in life, or accidentally; more so if their parents didn’t know themselves, as in the alarming cases of doctors substituting their own sperm for that of a non-existent donor. Take, for instance, Donald Cline, a fertility doctor in Indianapolis, who inseminated at least 50 mothers with his own sperm, resulting in at least 50 children. This is not as uncommon as one would think—or hope. A 1987 survey of US fertility doctors reported that 2% acknowledged using their own sperm with patients.

It also makes me wonder about Ari Nagel, whose sperm was deemed illegal in Israel, but who keeps donating around the world: with some 12 women currently pregnant, by year’s end he will have fathered some 80 children. “I can’t decide whether you’re a force for good or whether you’re the world’s biggest creep,” Piers Morgan said to him in a 2017 Good Morning America interview. “No one calls it creepy if you do it as an anonymous donation,” Nagel replied.

When I spoke to Nagel on the phone in August, he was racing to the bris (circumcision) of his new twins—babies #68 and 69. I asked him what he made of the Israel High Court ruling against his sperm. “I think it doesn’t make sense,” he replied. Nagel said that he felt terrible for the women denied his sperm. “They ended up purchasing frozen anonymous sperm—how are they going to be a father?” he asked, referring to the anonymous donors. “But thats completely allowed and acceptable.”

Nagel says that he keeps in touch with his offspring as much as the moms allow. His oldest child is now is 16.

He did acknowledge that the Israeli court ruling was not completely at odds with his reality. “I can’t be a full-time dad to all these children.” Still, no matter what I think about his choices, I did agree with this: “I think whatever role I play is better than an anonymous sperm donor.”

 

 

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Amy Klein

Amy Klein wrote the Fertility Diary column for The New York Times's Motherlode blog for three years. She writes frequently about health and fertility for publications such as Newsweek, Slate, The Washington Post, and others. She is the author of The Trying Game: Get Through Fertility Treatment and Get Pregnant Without Losing Your Mind.

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Silence is Golden