(p. 660) Assessment of Egg and Sperm Donors
I am a licensed clinical psychologist in private practice in Portland, Oregon where I treat adolescents and adults in individual, couple, and group psychotherapy. I work predominantly with a lesbian, gay, bisexual, transgender, intersex, questioning (LGBTIQ) population and with infertility. I have been practicing psychotherapy for nearly 10 years and was licensed in California in 2012 and Oregon in 2016. I treat a variety of conditions in my practice and also provide supervision and consultation. Additionally, I perform psychological evaluations for egg and sperm donor and gestational carrier candidates and/or the intended recipients/parents. On average, I perform eight to 10 of these evaluations per year.
The Niche Practice Activity
Assisted reproductive technologies (ARTs), subfertility (often called “infertility”) treatments, and the field of reproductive endocrinology in general have made significant clinical advancements in recent years. A variety of factors have contributed to an increase in the number of individuals and couples using these services. The options are vast and often confusing and overwhelming. The subfertility process, including treatments, is physically and emotionally demanding. The experience has been described as similar to receiving a cancer diagnosis (Domar, Zuttermeister, & Friedman, 1993). Many of these individuals can benefit from receiving psychological services. In fact, stress reduction in and of itself has been cited as a major component of the success of fertility treatments (Harrison et al., 1984; Smeenk et al., 2004). In addition to psychotherapy, psychologists can play an important role in providing necessary evaluations for individuals who are using egg or sperm donors, as well as gestational carriers.
Some individuals and couples cannot conceive, even with the assistance of ARTs. Some choose to enlist the services of egg or sperm donors or gestational carriers or surrogates. Sperm donation is (p. 661) a fairly straightforward process involving the donor providing one or more sperm donations. It is not an invasive procedure. Oocyte (egg) donation is a more involved process and significantly more invasive. Being a gestational surrogate or carrier is an even greater commitment. Carriers are implanted with an embryo through in vitro fertilization that is composed of the intended parent’s egg and sperm. Surrogates donate their own egg and then subsequently carry the child. Due to the invasiveness of these procedures, as well as their commitment and the emotional ramifications to the intended parents and child, many clinics and hospitals require a psychological evaluation of any individual who provides egg donation or becomes a gestational carrier or surrogate. Evaluations for sperm donors are rare but do occur. An evaluation of the intended parent(s) is also sometimes requested.
Individuals choose to donate or become a carrier or surrogate for various reasons, although the most frequent are altruism and financial gain. A number of physical and psychological risks exist for donors and carriers or surrogates. Psychological risks exist for intended parents and the resulting children. Most individuals who donate or become carriers or surrogates report satisfaction with the process (Kenny & McGowan, 2008; Klock, Braverman, & Rausch, 1998). There is evidence, however, that when the donor is unknown to the intended parents, those “with high levels of predonation financial motivation or ambivalence should be carefully screened and counseled before oocyte donation to ensure satisfactory psychological outcome” (Kenny & McGowan, 2008, p. 229). In these cases, I am evaluating to determine if excessive financial need may be influencing the decision, or if the donor’s ambivalence is significant enough that she may regret her decision. Some ambivalence is expected and normal, but it should not be so strong that the individual is consistently wavering from one decision to the other. If the donor is primarily motivated by financial concern, the donation may be seen as coercive.
The psychological evaluation always involves an interview/assessment. It often, but not always, involves the administration, scoring, and interpretation of the Minnesota Multiphasic Personality Inventory (MMPI-2; Butcher et al., 2003). The psychological evaluation is intended to assess the candidate’s motivation for serving as a donor or carrier/surrogate; understanding and appreciation of the psychological and emotional implications involved; understanding and appreciation of the time commitment and medical aspects of treatment involved; perspectives about the future child and oneself in relation to that child now and in the future; if the donor or carrier is previously known, considerations of the impact on the existing and future relationship; personal and familial mental health history, including any background of trauma or loss; current psychological and emotional stability; preparedness for various cycle outcomes; reliability and responsibility; and lifestyle factors. The evaluation also serves as an opportunity for education and discussion about relevant topics such as preferences regarding the nature, frequency, and parameters of contact with the parents or resulting offspring; number of embryos to be transferred and potential for multiple gestation; parameters for consideration of multifetal reduction; and decisions about remaining embryos.
Developing an Interest and Training in this Niche Activity
My education, training, and licensure as a psychologist has prepared and enabled me to perform these types of evaluations. A thorough knowledge and understanding of the field of subfertility (p. 662) and ART is also exceptionally important. Candidates should be aware that you have expertise in this area, which includes the physical and medical procedures and processes and the psychological/emotional ramifications of those processes. As stated above, the subfertility experience is immensely challenging for individuals. Possessing a strong familiarity with this field not only provides you with the ability to provide emotional support to candidates, but it also enables you to be able to perform competent evaluations.
This expertise can be acquired in a number of different ways. I have attended numerous conferences related to the field. I strongly encourage the establishment of a network of disparate clinicians and practitioners. At these conferences, as well as other training events like workshops and seminars, you will encounter acupuncturists, herbalists, nutritionists, functional medicine experts, chiropractors, nurses and nurse practitioners, physicians of various types, and others. It is important to build a relationship with these individuals as they have expertise in various areas of the field, all of which can be helpful to your own growth and knowledge. Additionally, there is a wealth of literature related to subfertility and infertility. It is important to be familiar with this literature, ranging from significant foundational articles that are older to more current studies and discussions.
Joys and Challenges Related to this Niche Activity
Although the process of subfertility treatments is arduous, when I perform these evaluations I am often encountering individuals during a hopeful and encouraging phase of their experience. Carriers, surrogates, and donors are generally excited to be able to support the individual(s) trying to have a child and feel good about the opportunity. There is often a warm and eager feeling among all those involved. It is a pleasure to be a part of this complicated process. Donors, carriers, surrogates, and prospective parents can be confused, however, about what is necessary from an evaluation.
The donation that a donor is making may have significant emotional and physical impacts in his or her life. During an assessment, I am looking for evidence that he or she is informed and aware of the implications of the donation. Does the donor appear likely to be able to endure any challenges—physical, psychological, or interpersonal—related to the process? I am further attempting to determine if the donor is approaching the opportunity with a clear mind, hope and excitement, and realistic expectations, as well as openness to other strategies should the donation be unsuccessful. Finally, I am looking for any other information that may provide me with reservations about the donor’s suitability. These may include significant mental illness, significant substance abuse issues, or physical or medical hardships.
A challenge to be aware of is that donors, carriers, and intended parents may not reside in state. I am licensed only in California and Oregon. If you are providing services in another state or via telehealth, the issue of where the client resides is key, and you must be aware of that state’s laws and limitations. Some states have guest licensure provisions for such practices, but these provisions have specified conditions. See your licensing board and consult with the American (p. 663) Psychological Association (www.apa.org) for more information. The Association of State and Provincial Psychology Boards (www.asppb.net) can also provide support.
The number of individuals undergoing all forms of ART is increasing steadily. It can be a complicated process to perform the evaluations that assist individuals in egg/sperm donations and gestational surrogacy/carrying, but it is also a tremendously rewarding process. I play a small but important role in the process. The ultimate reward for parents is the birth of a child, often at the end of a very long and stressful journey. It is an awesome thing to be a part of the joy they experience.
Business Aspects of this Niche Activity
One of my initial steps is to clarify what the evaluation must include (e.g., psychological interview only or interview and MMPI-2). This is always done through the intended parents, since they are the primary individuals coordinating the treatments. Unfortunately, there is often confusion on their part regarding the details of what the evaluation must cover. In some circumstances, the fertility specialists that the intended parents are working with articulate only that “an evaluation” is required, without stipulating what must be included in the evaluation. This can delay the process, although usually only minimally. This is resolved by the intended parents speaking with their fertility specialist. The determining factor leading to the decision to include an MMPI-2 or not appears to be individual to the clinic, hospital, or physician rather than the specific referral. My experience is that a particular organization has a standard that is maintained for all referrals.
The MMPI-2 is time intensive to administer, score, and interpret. I use Q Local for scoring, but it can also be used for interpretation (http://www.pearsonclinical.co.uk/Q-Local/Q-Local-Scoring-and-Software.aspx). This service can be used to administer the test on a computer, or you can have the client take the test on paper and then you can enter the results into the system. I have found it far more efficient to have clients take the test directly on the computer. Q Local charges an annual membership fee and a small fee for each test scored. Unless you have extensive experience scoring an MMPI-2, I strongly suggest using a service and not scoring it by hand. These services can also provide test interpretation for an additional fee. However, there are significant limitations to computer-generated interpretations. Should you use that service, those interpretations should be treated as broad hypotheses. It is up to you as the clinician to consider the entire clinical picture, including all data you have derived from the evaluation. To simply take the provided interpretations without question and without synthesizing it with other information is unethical and clinically unsound. With increased practice, though, comes expertise, speed, and efficiency.
The same may be said about the final report. The first few reports can be challenging to write. After completing perhaps the first dozen or so reports, I found that I can perform the interview and complete the MMPI-2 and report in a brief amount of time. Many reports use boilerplate language that minimizes the amount of writing I need to do. The reports are structured in the format of traditional psychological evaluations. They include the client’s name and demographic information, along with the following sections: Reason for Referral, Tests Administered, Background Information, Behavioral Observations, Assessment Results, Diagnostic Information (p. 664) (usually completed as “not applicable”), and Conclusions. I choose “Conclusions” rather than “Recommendations,” as is often seen in psychological reports, because it seems more appropriate. Reports are often two to three pages in length. If only an interview is required by the referral source, I can produce the completed report within 30 to 45 minutes, if not more quickly. Scoring and interpreting an MMPI-2 may require an additional 45 to 60 minutes, or more.
Fees are based upon my hourly rate of service. The following are the approximate number of hours that an evaluation would require, including in-person contact and report writing:
• Gestational carrier candidates—3 to 5 hours
• Donor candidates not previously known to recipients—2 to 3 hours
• Donor candidates previously known to recipients—1 to 2 hours
The number of hours required for an evaluation will vary based on a number of different variables relevant to the evaluation. The fees apply regardless of the recommendations of the psychological evaluation. Unfortunately, insurance cannot be used to pay for the psychological evaluation. Given the nature of the service, the evaluation is focused on the candidate’s understanding of and suitability to fulfill a certain role rather than on diagnosing or treating a mental health condition. Insurance companies typically require a billing code that reflects the diagnosis or treatment of a mental health disorder to reimburse for services, which is not applicable in this case. The billing always goes to the intended parent. Cash or check can clearly work for payment; however, because you may not actually meet with the intended parent (e.g., when assessing a surrogate only), it is particularly effective to be able to accept an alternative form of payment, like credit cards.
It is important to disclose payment procedures and information from the outset so that all parties are very clear on how much will be charged and how. My initial paperwork includes an intake form for the donor or carrier, covering necessary medical and mental health information, not unlike what one would use for psychotherapy. Additionally, I have a consent form written specifically for a psychological evaluation. I also have a credit card authorization form for the payer, as well as a release of information form for the donor or carrier, which includes both the payment as well as the report.
Developing this Niche Activity into a Practice Strategy
At this stage in my practice, referrals largely come on their own as a result of the network and reputation I have established. That referral network, however, took years to nurture and develop. This practice is relatively rare, which means that I am sometimes located by clients through an Internet search. Initially, my referrals came through a variety of sources. It is essential to build a broad network. This should include other psychologists and psychotherapists, particularly those who work with not only infertility specifically, but also with couples generally. My predoctoral internship at a local hospital had a women’s mental health and wellness program that I participated in (p. 665) through classes and patient work. In addition, it is important to build relationships with obstetricians, gynecologists, urologists, and reproductive endocrinologists in your area, as well as with any area fertility clinics and hospitals. When I began this practice, I cold-called and then invited and treated to lunch as many obstetricians and reproductive endocrinologists in the area as I could. I also contacted acupuncturists because the area I live in has many acupuncturists who specialize in fertility. Contacting and meeting these practitioners provided an opportunity for me to introduce my services and discuss how we may be mutually beneficial to one another and, most importantly, to our shared clientele. Attending conferences, conventions, and workshops is also essential to building a broad network. Finally, advertising through related associations and joining relevant listservs increases your exposure to individuals in need of this service. These listservs are often available through hospitals or fertility organizations.
For More Information
If you are interested in becoming involved in providing these evaluations, I encourage you first to be sure you feel comfortable performing brief evaluations and administering, scoring, and interpreting the MMPI-2. In addition, I strongly recommend that you begin to attend workshops, trainings, seminars, and conferences related to subfertility and treatments. I recommend the annual Integrative Fertility Symposium (https://ifsymposium.com/).
Explore becoming a member of any of the following organizations: RESOLVE: The National Infertility Association (http://www.resolve.org/), the American Society for Reproductive Medicine (https://www.asrm.org/splash/splash.aspx), the Society for Reproductive Technology (http://www.sart.org/), Childlessness Overcome Through Surrogacy (COTS; http://www.surrogacy.org.uk/), the National Infertility Network Exchange (NINE; http://www.nine-infertility.org/), and the Society for Reproductive Endocrinology and Infertility (SREI; http://www.socrei.org/). These organizations’ websites provide an array of resources.
The International Journal of Infertility and Fetal Medicine (http://www.ijifm.com/) is well known, but there are other leading journals in the discipline, including Journal of Women’s Health (http://www.liebertpub.com/jwh), Journal of Psychosomatic Obstetrics & Gynecology (http://www.tandfonline.com/loi/ipob20), Human Reproduction (http://humrep.oxfordjournals.org/), British Journal of Medical Psychology, and more.
Determine which clinics and hospitals in your area perform ART and connect with them. These organizations may keep a registry of individuals who provide psychological services. Further, they often offer workshops and trainings on a variety of related topics. Also familiarize yourself with the leading national clinics, including the Colorado Center for Reproductive Medicine in Englewood (https://www.ccrmivf.com/colorado/); the Center for Reproductive Medicine and Infertility at New York-Presbyterian Hospital/Weill-Cornell Medical Center (http://www.ivf.org/); University Fertility Consultants at Oregon Health & Science University in Portland (http://www.ohsu.edu/xd/health/services/women/services/fertility/index.cfm? ref=home); and the Infertility Center of St. Louis at St. Luke’s Hospital in Missouri (http://www.infertile.com/).
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Domar, A. D., Zuttermeister, P. C., Friedman, R. (1993). The psychological impact of infertility: A comparison with patients with other medical conditions. Journal of Psychosomatic Obstetrics & Gynecology, 14, 45–52.Find this resource:
Harrison, R. F., O’Moore, R. R., & O’Moore, A. M. (1984). Stress and fertility: Some modalities of investigation and treatment in couples with unexplained infertility in Dublin. International Journal of Infertility, 31(2), 153–159.Find this resource:
Kenny, N. J., & McGowan, M. L. (2008). Looking back: Egg donors’ retrospective evaluations of their motivations, expectations, and experiences during their first donation cycle. Fertility and Sterility, 93(2), 455–466. doi:10.1016/j.fertnstert.2008.09.081.Find this resource:
Klock, S. C., Braverman, A. M., & Rausch, D. T. (1998). Predicting anonymous egg donor satisfaction egg donor satisfaction: A preliminary study. Journal of Women’s Health, 7(2), 229–237. doi:10.1089/jwh.1998.7.229.Find this resource:
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