When You Come to a Fork in the Road...

Now, just as Yogi Berra implied, when you reach that fork in the road, you are expected to make a choice and make a move. It can be useful for couples experiencing fertility challenges to discuss their feelings about various family building options and develop a tentative Plan B before reaching their treatment limit to remove the pressure of feeling that you have come to the end of the road. While it can feel heartbreaking to determine, either on your own or at the suggestion of your reproductive endocrinologist, that it is time to consider an alternative to using your own gametes to build a family, it is my hope that thinking about the following factors can help you to decide on the "fork" that may fit your needs best and bolster your hopes for a future addition to your family.
(NOTE: This article will address the choice of donor egg/sperm or adoption. If you are unable to safely carry a pregnancy to term but produce usable gametes, you may consider a gestational surrogate, instead. The use of a donor embryo or deciding to remain childfree are other options one may consider, but are not addressed in this article.)

Has my body had enough?

Are you worried about your exposure to ovarian stimulant hormones? Do you react badly, either physically or emotionally, to some or all of the medications used in fertility treatment? Would it feel like a relief never to have to be poked or prodded by a reproductive endocrinologist again? If you answered yes to the above, you may be ready to consider adoption. If you can handle additional body intrusion, the use of donor gametes does reduce the amount of physical intrusion and exposure to ovarian stimulants compared to an IVF cycle with your own gametes, however it does not completely eliminate body intrusion.

How important is pregnancy and breastfeeding?

Is the experience of pregnancy, childbirth, and the opportunity to breastfeed important to you? Is it important to you to share the pregnancy experience with your partner? Would you prefer to have some control over the prenatal environment of your baby? If you answer yes to these questions, you may prefer trying donor gametes. If it would be preferable to avoid going through pregnancy and childbirth yourself, adoption may be the way to go.

How important are genes?

Do you wish to preserve a genetic connection with at least one of you? Can you tolerate genetic inequity, i.e., your child being genetically related to one of you but not the other? Can you accept the ambiguity involved in not knowing the genetic makeup of a donor and not knowing how a donor's genes will play out in combination with the genetic contributions of one of you? (It is important to remember, however, that although we all inherit a unique genetic endowment, control over the outcome of genetic assortment, even when using one's own gametes, is illusory.) Do you feel that you can love and be loved by a child that is genetically unrelated to you? Do you believe in the interaction of nature and nurture, i.e., genes, life experience, as well as personal effort, rather than the supremacy of genes in determining the evolution of each individual? If your answers to the above questions are primarily yes, the option of donor gametes may be acceptable to you. If you seek genetic parity, where neither of you has a genetic connection to your child but will be social parents together, adoption may be your choice. The importance of genetic continuity in your families or origin may also factor into your decision.

Do we need to have the highest likelihood of success?

First, you will need to define what you mean by success. Does it mean overcoming infertility, getting pregnant, or becoming a parent? Neither the use of donor gametes nor adoption overcomes infertility. If success for you means experiencing a pregnancy, however, donor gametes will be preferable to you. If success equates with becoming a parent and you prefer as close to a 100% chance of success as possible, adoption may better fit your needs. Although adoption offers the closest to a guarantee of having the opportunity to raise a child, you will need to accept the possibility of some false leads and disappointments along the journey to your child. For example, if pursuing a private domestic adoption, it is possible you will not be chosen by one or more birth parent(s); if pursuing an international adoption, you must accept that the borders of countries can often close unexpectedly and without warning. Nevertheless, if you can hang in there until an adoptive situation is finalized, you will become a parent.

Does cost count?

Least expensive is donor insemination (~$200-$600 per donor insemination), particularly if done without ovarian stimulation. Egg donation costs are higher ( ~$3,000-$10,000 fee for the donor +~$15,000 for medical and legal expenses). Adoption is not inexpensive, either (~$20,000-$35,000 for independent domestic adoption; ~$15,000-$25,000 for a domestic adoption through an agency; ~$15,000-$50,000 for an international adoption). But, whether you adopt domestically or internationally, you will likely be eligible for an adoption tax credit (~$12,000, depending upon your income) and many major U.S. companies offer some adoption assistance to their employees. Adoption from the foster care system is virtually free and, in fact, subsidies are often provided for a child's living and healthcare expenses even after the adoption is completed.

Because adoption offers the greatest likelihood of parenthood, many prospective parents wish to maintain enough of their savings to cover an adoption so that this option remains available to you should you so desire.

Do we prefer a newborn?

If yes, your options would be using donor gametes or adoption through a private domestic arrangement. If you are open to bringing a slightly older infant into your family, an agency or international adoption may be acceptable to you.

Legal issues

Adoption laws differ from state to state and knowledge about federal law is necessary, as well. Like all legislation, adoption laws are constantly undergoing changes. All states require you to complete an adoption homestudy before placement. Generally this requires a criminal background check, personal background information, medical records and a safety assessment of the home. A social worker usually provides support and information to assist you in the adoption process, as well. Before children are legally free to be adopted, their birth parents' rights must be terminated. Courts and judges make decisions about terminating parental rights based on state laws. To finalize an adoption, the court must find the adoption to be in the best interest of the child. It is important that you engage an adoption attorney knowledgeable of the state laws both of where you reside and where the birth parents reside as well as of federal adoption laws.

Gamete donors generally give up all legal and other rights over the biological children produced from their gametes. A legal contract is recommended, however, particularly when using a known donor, as this can clarify each party's expectations of the other, presently and in the future, by defining the rights and obligations of both donor and recipients and thereby enhancing informed consent of all parties involved. Here, too, using a lawyer familiar with this area of law and the laws in your own state is very important. The known donor should also be counseled by a lawyer independent of yours.

Are we comfortable with the childrearing/disclosure issues involved?
All children face problems of one sort or another growing up, including learning or peer problems, adolescent issues of breaking away, etc. If you decide to grow your family through the use of donor gametes or adoption, you will have many of these same issues plus a few additional ones to face.

While using donor gametes does offer parents the possibility of maintaining privacy about their method of conception, the American Society for Reproductive Medicine and most mental health professionals now encourage parents to disclose to their child their use of donor gametes. Be aware, also, that high school students will soon be able to take a cheek swab and compare theirs to their parents for a biology assignment, thus exposing that it is not possible that a donor-conceived offspring is genetically related to one of his/her parents. If one wishes to maintain privacy around this issue or chooses to wait until the child is older to disclose, it is advisable that you not share this information with family or friends either, as this increases the risk that this information may be revealed inadvertently to your child by someone other than yourself. This information is significant to the child's medical history, however, and should be shared with your child's pediatrician.

Many parents find disclosure issues complicated when donor gametes have been used, as you have to decide if, when, and how to share this information with your child as well as others in your social circles. Since this is not a one-time telling to your child, you will need to re-address this as your child matures and is better able to understand reproduction, and remain available to your child to answer his or her increasingly complex questions. Research thus far, although still rather meager, suggests that offspring react most favorably if informed by their parents when they are young, and react most negatively if informed when they are already late adolescents or adults or are not informed by their parents but find out from others in an unplanned disclosure.

Since adoption has been a family building option for far longer than using donor gametes, more information is available to assist those considering adoption. The vast majority of parents inform their child of their adoption. Thus, whether or not to tell no longer seems to be an issue for adoptive parents. Since having been relinquished by one's birth parents can be experienced as a loss by offspring, parents will need to be available to answer questions and empathize with these feelings. Attachment issues, however, remain for some children who have been adopted, particularly for those children who were adopted after they spent much of their first year of life in a situation where they did not receive consistent care from a sensitive caretaker.

Do we want maximum social support?

Although your fertility journey has resulted in you being very familiar with the use of donor gametes, their use is still foreign to many throughout the United States. Many parents worry about whether their donor-conceived child will be accepted into their families and communities as readily as a fully genetically related child. Currently there are far fewer resources or supports available for couples choosing the donor gamete option than for those choosing adoption.

Although adoption appears to be more socially accepted, partly because adoption has been a family-building option for many more years and partly because adoption has been viewed as an altruistic choice, family and friends may, nevertheless, not be as welcoming to your child as you had expected. Adoptive parents may be either seen as saints or pitied, neither of which feels comfortable to most who want to be considered a family like all others. Especially if you have built a family that is "conspicuous", i.e., wherein your child/ren looks different from you, you must be prepared for friends or even strangers, at times, asking intrusive questions about your child, some of which feel insensitive such as, "Do you know who the real mother is?" or "What did it cost?" In reality, building your family using alternative methods to spontaneous conception often does require that you educate others and advocate for your child.

If you are feeling emotionally and/or physically exhausted by treatment, can no longer tolerate the wait to become a parent, feel you are missing out on years of your life, and wish to re-gain a sex life that is no longer focused solely on procreating, you may be at the fork in the road leading you to alternative family building options. Your response to the above issues, weighted in their order of importance to you, can help you make a decision. Many people grapple for a prolonged period of time in attempting to make the "right" choice for themselves, forgetting that we human beings have an amazing ability to make our choices "right" for us once we make them. Selecting a path to parenthood that is different from what we had originally envisioned requires the ability to hold the ambiguities of what genetic surprises might be in store: What will this child look like? Will this child look like he/she fits in our family? What will the child's personality, likes and dislikes be? Will I be able to love a child to whom I am not genetically related as much as a biological one? Will I feel like a "real" parent? What will we do if relatives don't embrace this child? The ultimate goal for you in determining which fork to take is to feel a sense of pride and comfort in your family-building choice and to feel entitled to parent and deserving of the children that come to you as a result of your choices. After all, bonding to future children can actually begin to occur as you go through this challenging process of decision-making and planning together.

Joann Paley Galst, Ph.D., is Co-director of Support Services and Chair of the Mental Health Advisory Council of tPath2Parenthood. She is a psychologist in New York City specializing in reproductive health issues including infertility and pregnancy loss and a past chair of the Mental Health Professional Group of the American Society for Reproductive Medicine. She has written extensively in the fertility field and is a co-author with Judith Horowitz and Nanette Elster of the recently published book entitled, Ethical Dilemmas in Fertility Counseling.