Hey, good afternoon. How's it going? I'm Lieutenant Commander Andy Baldwin. I'm a Navy physician and just back from a very incredible trip to Kenya over in Africa where I spent about a month's time and Then came back here and I ran a marathon yesterday and then scooted down here to DC to be part of a really innovative social media experiment if you will and I want to Welcome everybody who's following along live stream today and welcome your question. So Just before we get to that though. I want to give an overview of what Navy medicine is Why I joined the Navy and why you should care so if you might not know this but 70% of the earth's surface is water and 80% of the world's population Lives near the water and then 90% of all the cargo and the Commerce that goes around the world happens through the water. So if that waterway isn't safe then Then we're not safe then you're not safe then you're not getting What you need and that's what the Navy does what it's why it's really important that we keep those secure waterways throughout the world So that's that one of the Navy's main missions is being out there forward presence deterrence so that people like pirates aren't interrupting the flow of commerce if there's a wartime that you're Not gonna take on the United States because we have a forward presence over there Navy medicine is Actually a six billion dollar enterprise I don't think many people realize that six billion dollars. There's 63,000 healthcare members as part of the Navy medicine team and we take care over one million Eligible beneficiaries that's all sailors marines And their families and then also veterans who've served our country so gallantly so I Made the decision when I was a high school student to go to ROTC at Duke to get my Commission as a naval officer and then also I got a scholarship to medical school to become a Navy physician and Subsequently went on to become a Navy diver a diving medical specialist and developed a true love for doing humanitarian assistance mission and Taking care of our sailors and Marines So I hope that gives you a somewhat of an umbrella Understanding of what Navy medicine does now how to how the heck did I end up in Kenya? He probably are wondering that well back in 2004 Tsunami occurred in Southeast Asia and We hadn't been very proactive before we had been responding to some disaster relief as the Navy But in this case the US hospital ship mercy went and responded and what we saw was the impact that this had on People's hearts and minds and how they viewed the United States Navy and How they viewed the United States and so one of the key parts of our maritime Doctrine for the Navy and the Marine Corps team and the Coast Guard became What we call manning training and equipping our force do not just respond when there is a disaster, but to train to provide humanitarian assistance throughout the world so I'm a third-year resident in family medicine at Naval Hospital Camp Pendleton and It's wonderful because one of our months that we're there. We have the option to do a full-out rotation Somewhere in the world and I chose to go to Kenya to a very remote and rural area there where I operated in austere environments and trained for just the type of humanitarian assistance or disaster relief mission that is a core part of our Navy medicine mission as part of taking care of our sailors and Marines and and their families and really Going after that key mission of humanitarian assistance and disaster relief if you don't train for it, then when it happens you're not ready to do it so that's what I was doing in Kenya and It's been an incredible experience and I'm happy to take your questions. We have an incredible team here right now That's going to be providing them to me. So Ask away and anything that you want to know about the Navy Navy medicine Dr. Andy Baldwin It's cool to be here and I and I hope you continue to stay with us So Paula is wondering What the Kenyans taught me I went over there and provided a lot of medical care and education, but you know the one thing that I really took away from Kenya Paula is the level of respect that those people have over there and How they operate as a true community and taking care of each other they have very little resources and A lot of them have suffered from HIV AIDS and passed away have suffered from malaria and They don't if you pass away you die and you can't eat That's just the kind of the way it goes. It's not life is valued in a different type of way over there Just based on the resources you have so in order to really Solve that I believe The area at least where I was you know the sense of community there was tremendous and I went and I spoke to groups of students and These high school students just sat there completely poised and That would never would have happened in the United States and every everywhere I went passing by cows and goats and sheep you're expected to shake a stranger's hand and if you pass by somebody without greeting them it's seen as a sign of disrespect so They really taught me a lot about the sense of community and frankly it brought me back to The days when when I grew up in Pennsylvania in farmland there, so thanks for a question Susan asks whether it's possible for others to do rotations like I did and Navy medicine absolutely. That's why I Join Navy medicine and that's Why I'm talking with you today to tell you how you can do these rotations in remote areas as part of other medical school training programs sure it could be possible, but I've Been to over 40 countries now throughout the world providing medical care Serving the United States Navy as a Navy physician and if you wanted to stay in one place and not move around and not have these international experiences Don't join Navy medicine if you want to have those opportunities absolutely come our way and You'll be glad you did question about whether I had spent any time on our Navy medicine hospital ships and indeed I have I Deployed with the US hospital ship comfort in 2009 to Haiti Central America and South America Actually just prior to when the comfort responded to the crisis in Haiti after the earthquake So it's exactly why we do these type of missions the fact that we were able to go and respond so quickly To the crisis in Haiti was due to the mission that I was part of in 2009 And then let me tell you why it's so crucial and it helps us back here in the United States as well from a public health standpoint When I was down in Nicaragua and Columbia and El Salvador the types of diseases that I was seeing Down there are things that I just read about in textbooks that you very rarely see here in the United States and so as Healthcare providers being exposed to that and having that experience and treating that and bringing that knowledge back to the United States is crucial and in further Crises that come up us as Navy healthcare providers Having that knowledge base now. We're more adept at treating these type of illnesses and I know nowhere did I see that more than in Kenya this past month the number of malaria cases that I treated the HIV AIDS The parasites that so many of the patients that I saw had a lot of kids didn't have any shoes and the route that Certain infections can penetrate Animal-borne illnesses rabies and brucellosis that you get from cows all these things were very eye-opening to me to see and It's why I love Navy medicine so much that you get such a breath of experience. It's not the same old things that you see in the u.s. In a common medical practice So thanks for being with us in we're gonna have another question right now. Cappy Kevin would like to know what would you tell med students finishing school who are unsure about choosing family medicine as a specialty? So what would I tell medical students that are finishing school about choosing family medicine as a specialty? Well, I'm a big family medicine fan Obviously, I'm a family medicine resident and I didn't always used to be that way I actually came out of medical school and I wanted to be a surgeon I did my internship in general surgery at the Naval Hospital in San Diego and then it was really my operational experience after that internship that opened my eyes to the the true benefits of being a family physician all the humanitarian assistance missions that I did the The breadth of care that you can provide as a primary care provider and how much I loved the continuity of care seeing my patients Come back and get better and how gratifying that was that's why I chose family medicine and as a family medicine doctor in the in the Navy The things that you can do are wide-reaching you can be a physician that helps people Serve underwater on ships on the water up in the air you can be on a battlefield with the Marines You can be in hospital settings You can be very intensive in maternal and child care and you also do can do a lot of global health work From a public health standpoint. So if you're looking for a lot of different options You're someone that may get bored easily doing just one thing family medicines for you And the best family medicine training programs around are in the Navy. Trust me X summers Would is asking how do you prepare emotionally to deal with such an intense experience as yours? In Kenya recently. I'm traveling with a team to Ethiopia in a few months. What should we prepare ourselves for? So how am I doing emotionally right now, I'll be honest with you I coming from living in a mud hut for a month in rural Kenya and seeing the type of things that I did every day and then going and running back-to-back marathons and jetting down here today and back to the United States where there is definitely a Some culture shock Hey, I wanted to give a plug out To the wounded warrior hiring conference, which is going to be live streaming tomorrow Excuse me Wednesday, Wednesday morning at 8 a.m. So the wounded warrior hiring conference check that out The question before we went down was about how someone should prepare emotionally for a trip to the third world country developing nation where you're really going to see It's a pretty emotionally challenging thing and I Definitely am readjusting getting back to the United States You know what however you can deal with it by By writing it out by talking to people, but there's definitely a lot of what we call compassion fatigue that can occur when you see some of the Unfortunate things in impoverished areas and I think the thing that you Can best do to prepare yourself to go over is Go over with an open mind and try to Not go over with such an American mindset that your definitive medical care will be provided These are different countries your your largely visitors in in these areas and you need to Realize that they don't have the same type of healthcare systems that we do and Really it's that perspective that you gain You know, which you come back with a completely different Almost paradigm shift on the way that you view Our lives here in the United States and having that experience as a Navy Physician and Navy healthcare provider is I think crucial to be able to operate in times of need when we are on humanitarian assistance missions or on disaster relief missions and I Definitely even just talking about it right now helps me to to process a lot of what I saw and did over there Hey, you know, I gotta give a shout out to the Navy corpsman I just took the taxi over here from the train station in DC and You never know where you're gonna find someone that's been a Navy veteran. This guy was a Navy corpsman I was telling him I was coming over to do this and he's sporting a Navy captain on the side It does global force for good you know Navy is everywhere and it's Something that you can immediately connect to and have a dialogue with that's what it means to be part of the Navy and Marine Corps team and So I just gotta give a shout out you go Navy global force for good. All right, we'll go to the next question now Okay, Jonathan asks could you discuss the dual mission of Navy healthcare? And the warfighter role as well as the humanitarian role and how the Navy uses healthcare to spread the message of peace and hope Great question from Jonathan about there's a dual role that we have as a Navy in war fighting and and then also the humanitarian element from Going over and making friends and providing peace and it's the Navy medicine standpoint we take care of The sailors and Marines that are out there on the battlefield that are in submarines that are on ships that are in the air protecting them taking care of them if they get injured and then the medical diplomacy side is where we go out and we help to instill a sense of security by Providing health care to those in need and by so doing you gain trust and there's more order and there's less propensity for terrorism and by creating a stronger secure World and by making friends. That's what I love. It's a what we call a soft power and it's what we're doing more and more of In Navy medicine great question Jonathan. I take it that you probably have some Navy medicine experience and good on you Courtney wants to know who What personalities who your who is your favorite person to run with at the marathon New York yesterday? It was my favorite person to run with in New York yesterday You know actually it you know between Mario Lopez and Apollo ono I mean Apollo is a great friend of mine and you know he came out there and he rang it ran a heck of a race But the Jenny Finch who's the Olympic softball player actually started dead last and and then every person that she passed she Gave some money to charity for and so I think she passed upward of Like 25,000 people so I didn't actually run with her But I thought that that concept of starting last and doing it for charity was a was really cool. So 50 close to 50,000 people ran in New York yesterday. So it was a it was an honor to be out there and I Was running for charity and thanks for that question And Mike It was also as a triathlete says his Achilles left foot is crackly and wants to know what the causes may be Mike you're a triathlete and you have a left crackly ankle or Achilles Amen, you need to join Navy medicine or join the Navy So that I can see you as my patient and then I'll take care of you. All right sound like a plan Lucy would like to know how you were able to culturally connect with the Kenyans during your recent trip So a big part of Kenya is Obviously their culture and their beliefs and they a Lot of it was just being open-minded Again, I lived in a mud hut for a month. I ate ugali pretty much every meal, which is there From their corn flour mixed with mixed with water and I also sang a lot of songs with them. I tried to Show the utmost respect. They're very ceremonial and everything that they do and I also love to run with them Believe it or not every everybody runs there as much as we try to promote health and exercise here in this country You don't need to do that over there because every kid as soon as they can walk is running And so every morning I would get up and go running and even the cows over there run so those are some of the cultural things I was able to embrace over in Kenya and I Also tried to teach them some of our American culture Most importantly How we as health care providers in the United States truly Take the Hippocratic oath and we'll provide medical care No matter whether they you can pay for it or not as one of the things that I got pretty upset about over there was There You can't pay for medical care It's tough and you won't get it and a lot of you see a lot of people die So that's probably the hardest thing I dealt with when I was over there Susie would says asked about Healthy lifestyles you do a lot of work with children in the US regarding healthy healthy lifestyles How much of that was translatable to the Kenyan children you work with? great question from Susie about the healthy lifestyles and here in the United States versus overseas and It's it's that's an interesting question because Here I've done a lot You know childhood obesity is an epidemic here in the United States and the amount of chronic disease We're seeing it and our children at an early age heart disease diabetes It's just disastrous and so I speak a lot on the importance of physical activity a healthy diet and That's something that's very important for our sailors marines and their families as well It's what I talked to all my patients about each and every day. I see clinic now going over there to the to Kenya I was in a very rural area and a place where as I mentioned kids are running everywhere they go and Where everything that they eat is not processed. It's grown very fresh and so here I was in front of a group of hundreds of students and what I usually would talk about About hey, you need to be active. Hey, you need to eat healthier I couldn't really say that and It put me in an interesting position one of how to describe the kids in the United States What I could talk to them about is the importance of believing in themselves like just a little thing like a pair of shoes or Talking to somebody having someone talk to them that you can believe in yourself Here's the way you need to be healthy to wear shoes to Practice good hygiene to drink clean water providing those things and getting an education. Those are the things that are going to lead to their ability just to to realize their dreams to succeed and So it was definitely a different dichotomy in an impoverished area You see a much different Approach to talking to these children. So thanks for that question Susie and If you're interested in Navy medicine, please pursue that Susan would be very interested to know what other areas of the world can Navy medical professionals Expect to have the opportunity to work as well So Susan anywhere there's water even places where there isn't water. Navy medicine is there Now whether it's below the sea on ships up in the air or with our Marine Corps team out on the battlefield We have naval hospitals worldwide I've been stationed in Hawaii. I've been over to Bahrain in the Middle East, Kuwait Italy Japan All throughout Southeast Asia and we also have a Very the majority of our forces of our Navy medicine team is here stateside The big three hospitals that we have are in San Diego Horsemouth, Virginia, and here in Bethesda, Maryland near Washington, DC They also have regional hospitals one of which I practice out in Camp Pendleton, California So that's one thing about Navy medicine if you're up for it if you want to travel the world There's there's a place for you in Navy medicine Varun would be interested to hear if there's any one aspect of Navy medicine you could change if you could There's one aspect of Navy medicine if I could change I would Well, that's a tough one. I always say that the greatest decision I ever made in my life was joining the Navy and I was a farm boy from Pennsylvania and hadn't traveled outside of the United States until I was 20 years old and that's when I was with the Navy and Since then I've been to 40 countries. I've worked with the Best team I've ever been a part of the people that you meet in the Navy well, you'll be friends with for life and Just the fact that I have been fortunate enough to be able to get an education have it paid for by the Navy and then To serve my country doing what I love truly what I love is part of a global force for good in these humanitarian assistance missions that I've been on If the Navy if Navy medicine will continue to send me and the other healthcare providers out there Practicing medical diplomacy humanitarian assistance The more I can do that the better Brenda would be interested in hearing about what you're doing in the Navy today So in the Navy today, I am a third-year resident in our family medicine program It's one of our academic training programs that is offered at the Naval Hospital Camp Pendleton out in Southern, California I have approximately 10 months to go in that training program and then after that I will go on and Serve in a capacity. They're on board ship with the Marine Corps team. I Could be with a dive unit again that I really don't know but I'm gonna be talking with my detailer about that and As long as it involves the capacity to practice global health care on there Mike has a question about your thoughts on how can you combat athletic injuries and Produce so many great runners Yeah, you know that the two top runners yesterday at New York City Marathon were both named mutai Jeffrey And then he got first smashed the course record and then a manual mutai got second And you know the when I ran Nairobi Marathon last weekend. There were about 300 elite Kenyans in the in the front pack and The the thing that produces a my opinion these great Kenyan runners is that they're doing they've run You know thousands of miles by the time they're Ten years old they run everywhere they go. It's their mode of transportation. They don't have cars they They don't have motorcycles. They they walk for hours. They walk and run for hours on end as it means to survive and It's been known in their country and at altitude where they train that this is a way to provide for your family to Succeed and become a great runner and so that pride they have in running Is something it's almost instinctual there as part of their culture and I Love training with them. They're the most gracious and and giving people and before I left I I brought over four bags full of sneakers and soccer balls and Even my my watch I gave to the nice boy Isaac who ran with me every morning. That's what humanitarian assistance is all about is You know, they're gonna remember Somebody part of the US Navy team. Yeah, that's been helping them to live their best life Oh Donna asks what what have you learned from your time on TV? And would you would you go on TV again if you had the opportunity? What have I learned from being on TV? That's what Donna asks. Well, I Went in as I said a TV virgin I didn't really didn't know what reality TV was all about then I went on the the bachelor four years ago and From that you you learn a lot one about yourself about how much editing they do after the fact and How important it is to always project your your your true self and your true values and if you live by your values and You continue on that path. There might be a lot of things that happen in life, but if you're able to project your thoughts and And help others going on TV and the public platform that it gave me has allowed me to do A lot of good will I go on TV again? Not in a reality TV Show type of way if it's a documentary that highlights what we do is part of Navy medicine as part of the team Global force for good. Absolutely. I will and if it's a documentary that helps with the public health issue global health issue absolutely, I will and I'm very I I'm gracious and thankful for the time that I had on television no regrets But I wouldn't do that type of show again There's a question from Twitter about sailors deployed around the world, especially ships and subs in Small environments any recommendations to remain fit at sea? It's tough The question is about remaining fit at sea and when you're on a Los Angeles class submarine which I've been in the past Any space is it is it is very crucial? And so we actually will jam these air climbers or treadmills into the engine room and you get the nuclear reactor right there And you're wearing your dosimeter or making sure that you're not getting too much radiation And the sub is going this way and that and you're trying to stay on the treadmill and avoid that water pipe above your head Hey, if you're determined to do it you can do it use a lot of stretch bands a lot of plyometric exercises even running in place and It's tough, you know, you don't have a Vast field or track where you can work out obviously on board a ship or a sub But if you're determined to do it, which you should be you can make it happen Simone and Simone and asks about volunteering in Kenya The main hurdle that she dealt with was feeling like she couldn't help She asked I wonder if you ever feel like that and how'd you handle that situation? That's a great question Simone about feeling of being helpless in certain situations in Kenya and I Definitely felt that way. I can recall it one day, especially where I had two patients that were gravely ill and needed health care attention at a hospital and the hospital there Doctors were on strike for a variety of reasons and these patients didn't end up making it and We didn't have the resources. We didn't have the antibiotics at hand. We didn't have the What these patients needed to get to get care and as a medical provider As a Navy doctor, I knew what we needed but Just did not have those resources and this the structure that was there wasn't supporting us and That's a time where again, you need to take yourself out of your mindset here in the developed first world and realize that This is the way things are here and sometimes you can't do everything You can just do to the greatest of your ability with what you have at that present time Got a question from Navy intern His question is as a Navy intern about to be assigned as an undersea medical officer Are there opportunities to participate in humanitarian assistance and disaster response mission? Well, hey Who ya I'll tell you that right now. You're Going the right route as a undersea medical officer. That's what I did and who ya deep sea and there are always opportunities in the Navy to do humanitarian assistance mission and You'll get there and no matter where you choose to go. I encourage you to Talk to everybody around you and tell them that if a mission comes available that you're the man to do the job, you know, so seek it out and make it be known and The opportunities will find you I guarantee you there's a lot more opportunities to do humanitarian assistance missions within Navy medicine than there are in the civilian world. Okay on Twitter Exercise works has asked any chance you clever medics could design an easier way of giving adrenaline to arrests than IV Interesting question that I'm not sure exactly what we're doing in terms of giving adrenaline IV. I know there's other routes that are being looked at subcutaneously Intramuscular endotracheal tubes But what I can tell you is that we have a very robust Navy Medical Research Center and So much of what comes out of what we see and treat on the battlefield or Underwater or on ships or in the air is Translated back in helping our medical care here in the United States And for instance the the combat trauma care that the research that's come out of that is being used each and every day Now in trauma centers around the United States the malaria research That we do through the Navy Medical Research Center is cutting edge and is helping to provide Malaria cures throughout the world So if you're interested in research, you don't just need to be a physician in Navy medicine, but our research teams are constantly innovating and traveling around the world to do so thanks for your question Andy is asking via Twitter. What surprised you most about your recent trip to Kenya? Sandy my recent trip to Kenya what surprised me most about it. Oh wow I was very surprised one by the level of respect and Dignity that these people maintain it in such an impoverished area it would not be uncommon to see a Someone walking or running in a full suit and tie surrounded by muddy areas and cows and also I mentioned earlier, but the The formalities in which they greet everyone who passes by them and How much that sense of community plays into their their culture was really eye-opening and many times I Said wow, you know the American mentality of you know get it done very individualized is Much different over there where we have this great sense of community in many ways it reminded me of Navy community Navy medicine structure in which we are so intricately connected and it's definitely a team mindset versus that of a individual Thanks for that question Melinda is asking continuing the discussion of Kenya. She's asking what efforts do you see? Being done locally to prevent the spread of HIV AIDS while you were there Melinda great question about HIV AIDS and the progress that's been made over the past decade in HIV screening the education on what HIV AIDS is and how it's transmitted family planning and the help that's been given from Pharmaceutical companies and from numerous governments around the world to provide To provide the medicines. It's it's outstanding and USA ID and concert with many others around the world these organizations including The US Navy have done a lot Towards educating people on this their rates have gone from upwards of 40 percent down to less than 5 percent. It's really a remarkable story on how How key education and provision of resources can help and really save lives if the trouble is now You have a lot of orphans and taking care of them Is what I saw there's numerous homes there Taking care of these kids that don't have parents and you see a lot of grandparents and aunts and uncles taking care of a large group of kids and That's so so important Michelle has a question about the Military and the Navy's detailing system She wants to know how you became a resident of camp panel and was this something you applied for or were you given orders to go there? So the whole detailing system in the Navy is is something where you try to Get the best fit for for both parties involved. Obviously there are needs of the Navy where Where there is water where there are Marines where there are sailors You're gonna have a need to treat so I'm not gonna be able to go to the middle of the country Maybe another branch of the service might be better for that my ability to Be part of the family medicine program at Camp Pendleton was due to My applying for that position and in getting accepted into it and There are other family medicine programs that are tremendous So Jacksonville, Florida has one Pensacola, Florida Camp Lejeune, North Carolina and also up in Bremenham Washington and so Those are also optional programs that I could have done many residents will train in and outside institutions and And then come back into the Navy and serve their time as physicians Michelle question and she wants to know what the path to becoming a Navy medicine professional is So if you want to be part of the Navy medicine team if you like what you're hearing and you want to follow a Path similar to me or similar to some flight surgeons out there or orthopedic surgeons or OBGYN docs or You want to be a physician's assistant the Navy nurse Navy dentist if you want to be part of the Navy Healthcare team the best thing to do is to go on to the Facebook and Look at the Navy medicines page like it send a tweet to at Navy medicine and Really get engaged with the conversation familiarize yourself of what Navy medicine is all about and through that you can find your local recruiter to talk to and We'll set you up on the path to becoming a part of the Navy medicine team Okay, and We've got time for one last question and this one is from Eric in Los Angeles one last question from Eric in Los Angeles All right, he's very interested in Navy corpsman and how long the EMT nursing process For corpsman would be what does it take to make a Navy corpsman? so Eric to become a Navy corpsman first kudos for wanting to go that route I think Navy corpsman are the you know, they're the true heroes amongst us. They're the ones that are the most decorated People in the military and all of our history.  I'm at dr. Andy Baldwin or go to the at Navy medicine Twitter handle or go to the Navy medicine Facebook page and Ask away and we'll get you where you want to go. That's one thing. I piece of advice I have for everyone and I've sure learned it in the Navy's if you want something if you have a dream Go for it. Ask for it. Let it be known. Don't just expect that something is going to be given to you And I hope that you listening today. You've learned a bit more about the Navy medicine team I had an incredible experience over in Kenya operating in a steer environment learning Better ways and techniques to provide a humanitarian assistance care. I'm grateful to my family medicine program back there at Camp Pendleton Marine Corps base at the hospital there in Southern California. I'm grateful for the Navy for giving me this opportunity and I Want to thank captain serrat and the folks at chin foe for putting this on today We apologize the server crash. There were too many people Wanting to log on so next time we got the increase our capacity and If you got more questions we Oh, yes one last thing so coming up It is Veterans Day. It's just a number of days away and we're trying to reach 400,000 fans on our US Navy Facebook page. So do us a big favor. We're close and Go online go on Facebook and like the US Navy I'm Navy Lieutenant Commander Andy Baldwin coming to you from Washington DC and It's been a pleasure being with you this afternoon. Thank you


Good afternoon. On behalf of the McLean Center and the Department of Obstetrics and Gynecology and the Bucksbaum Institute, I welcome you to this, our 12th lecture in the 2016-17 series on reproductive ethics. As you know, this is a series that Julie Core was single-handedly responsible for. Julie, raise your hand so we can just acknowledge it. It's my pleasure now to introduce today's speaker, Susan Clark. Dr. Clark is Professor of Clinical Obstetrics and Gynecology and Psychiatry at Northwestern University's Feinberg School of Medicine. Prior to coming to Northwestern, Dr. Clark was an instructor and director of women's mental health services in the Department of Psychiatry at the Harvard Medical School. Dr. Clark has more than 20 years of experience in providing direct psychological counseling to infertile couples and in conducting research on multiple aspects of assisted reproduction, including psychological aspects of fertility preservation and gamete donation. Dr. Clark's primary research and clinical interest is on the impact of infertility on mood and functioning, as well as psychological aspects of oocyte donation. Dr. Clark has authored over 40 peer-reviewed papers and numerous monographs related to assisted reproduction and female infertility. One recent paper of Professor Clark's is entitled Perspective Study of Depression and Anxiety in Female Fertility Preservation and Infertility Patients. This paper was published in 2014 in the journal Fertility and Sterility. Dr. Clark's talk today, as you can see behind me, is entitled Ethical Issues in Gamete Donation. Please join me in giving a warm welcome to Professor Susan Clark. Well, good afternoon. Thank you, everyone, for inviting me here. It's my pleasure to be here today to talk about ethical issues in gamete donation. I am, as Dr. Stigler pointed out, a clinical psychologist in the section of reproductive endocrinology and infertility. And sometimes at the beginning of a talk like this, I like to just say, how did I get here today? And I got here on kind of a fluke. I was an intern in clinical psychology with a specialization in women's mental health. And I was working through all the different sections of the Department of OB-GYN at University of Connecticut. I did gynecologic oncology, maternal fetal medicine, general OB-GYN. And then the section chief of reproductive endocrinology called my supervisor and said, boy, we could really use a psychologist down here. Could you send her down? And so I went down there and I worked there. And I loved it. And I finished my internship. And he said, hey, do you want to stay? And I said, absolutely. And I stayed, met my husband, which was the best thing of all about being at University of Connecticut. And that's really what began my career and my interest in this field. So to begin with today, I first want to disclose I have no conflicts of interest or other disclosures to make. Today what I want to go through is talking about ethical controversies and gamete donation, particularly egg donation. But before we can do that, I want to bring you into my world of infertility and infertility treatment. So we'll have a little bit of overview of infertility, an overview of the clinical process of egg donation, which is very important to understand for our later discussions on the ethics, and then the ethical controversies that I will highlight, payment to donors, post-donation medical and psychological well-being of donors, and issues of informed consent, and last, privacy and disclosure to offspring about their gamete donation origin. 94% of Americans either have a child or want a child. We are in a very pro-baby, pro-reproduction culture, just like most other Western cultures. But unfortunately, about 12% of individuals of child-bearing years suffer from some kind of infertility. Infertility defined is 12 months of appropriately timed intercourse that does not result in a pregnancy. And you can see the causes of infertility are numerous and are really broken down as indicated on this graph. The bad news is for women, our fertility declines as we age. And this is just a graph of fertility trends over many decades. And as you can see, once we're at about 37, moving to 47, our chances of having a successful pregnancy approach zero. What this, the meaning of this in the world of egg donation is as women are delaying having children, their fertility is declining, so they need to get eggs from someone else. And so that's why this piece of information is important for the context of our discussion today. So a couple tries on their own for many, many months. They're struggling. They're very sad. They go see their doctor. The doctor says, go to a reproductive endocrinologist. They may try chlomaphine citrate in timed intercourse or interuterine insemination. They do that typically two to six months. If that doesn't work, they move on to a little bit more invasive, injectable fertility medicines and timed interuterine insemination. If that doesn't work, then they move on to in vitro fertilization, kind of the big guns of infertility treatment. If that doesn't work, then we move on to gamete donation. The reason I wanted to show you this progression is because as couples move through these treatment processes, if they don't get pregnant, their levels of depression, anxiety, and marital discord often increase, which is why I often see them somewhere along the lines in this process. In vitro fertilization was created in 1978. Actually, the first successful birth was Louise Brown in London. And this we credit to Steptoe and Edwards, who were able to take the egg from Mrs. Brown and inseminate it with the sperm of Mr. Brown in a petri dish and put it back in Mrs. Brown's uterus. People were just wild about this technology because they were very concerned about fertilization taking place outside the body. And it was really quite a big deal at the time. The reason why IVF is important is because that technology allows for egg donation to take place because an egg donor goes through these first steps of IVF and then gives her eggs to the intended mom. So the steps of in vitro fertilization are as followed. 9 to 15 days of injectable fertility medicines. These are done subcutaneously once or twice a day. While a woman is taking these medicines, she's also being seen at the clinic for ultrasounds and blood tests every two to three days to see how her body is responding to the medicine. Once it's determined that she's reached the maximum development of the follicles that contain the mature eggs, she'll undergo an egg retrieval under sedation. And anywhere from three to over 20 eggs can be retrieved. Sperm is produced by the partner or obtained from a sperm bank. The eggs are fertilized in the lab. Over the course of three to five days, the embryologists watch their development. They pick the best one to transfer back into the uterus of the intended mom. She goes on injectable progesterone for 11 days, then comes in for a blood test to see if she's pregnant. All of this is about 30-plus days and $15,000 to $20,000. So let's just take a deep breath and understand another reason why couples who are going through this can be very stressed. Illinois is one of 13 states in the United States that provides some form of infertility coverage for most large insured groups. That can mean anything from a $10,000 lifetime limit up to kind of the Cadillac or the Rolls Royce of infertility coverage, which is four full cycles of IVF. The egg retrieval, and again, we want to consider this when we're thinking about an egg donor, the egg retrieval is done under sedation with ultrasound guidance with needle aspiration of the follicular fluid and the egg. And then that's sent to the embryology lab for the fertilization. In 1992, Congress passed the law, the Fertility Success Rate Act. That mandates that IVF practices report their success rates to the Society of Assisted Reproductive Technology, who then, in turn, gives it to the CDC. They compile it so consumers can look at each clinic across the country and see what their pregnancy rates are. There is usually a two-year lag, so the data that I'm showing here from the CDC that was published in 2016 is actually from 2014. Now, as you can see, the pregnancy rates are really good if you're under 35. And we'll remember that graph and we'll say, oh, yeah, that, of course, makes sense because you haven't had that drop in fertility yet. As we approach 40 and get past 40, the pregnancy rates are around 8% for a 43- or 44-year-old woman using her own eggs. In comparison for a donor egg cycle, the success rate is 67%. So when women are looking at these data and they see those numbers, after they've been through a couple of cycles of IVF and it doesn't work, you can see why they might think, oh, OK, I'm going to think about using a donor egg at this point. And again, the donor egg data is for all ages because the age of the recipient at this point doesn't matter because the success rate is tied to the age of the eggs. Most egg donors are between the ages of 21 and 28. And that's why we see those rates. So now that we know a little bit about infertility and its treatment, let's think about egg donation in terms of the actual clinical process. We can dig a little bit deeper. The practice guidelines are provided by the American Society of Reproductive Medicine, which is our professional society that guides how we practice. So every few years, they come up with their updated guidelines, the most recent of which is 2013. To become an egg donor, you need to find women who want to donate. This is an ad from an Ivy League university in America whose number I blocked out.  There's also a lot of word of mouth amongst donors about being donors. And they definitely showed the bright, shiny picture of a lovely young woman appealing to her altruism to help another woman have a baby. So what's going to happen next? Well, we only will take a woman between the ages of 21 and 30. Proven fertility is desired but not required because obviously, many women in that age range have not had a pregnancy yet. No owner, operator, lab director, or employee of a practice can serve as a donor. For this, we can thank Dr. Cecil Jacobson, who you will remember in 1993, was charged with 52 counts of felony and fraud for using his own sperm to inseminate dozens of his patients. Yes, I see a person, I see you not even in the audience. You remember that case. He lost his medical license. He served five years in prison and now runs a farm in Utah, in case anybody's wondering what happened to him. So what's going to happen if a woman wants to be a donor? She's going to call the agency and she's going to go through a very brief phone screening. How old are you? Are you healthy? Do you take any medicines on a routine basis? Do you smoke? If you smoke, you cannot be a donor. And it's just one of our hard and fast rules. Unfortunately, it's one of the things that women are not always candid about, and so they can get all the way through the screening. And when we do the toxicology screen and we find nicotine, they're out. So we have to be very cautious about that. If the phone screening goes well, the agency will send them a personal health history form, which is about 25 pages long.  Then it asks for any of your medical history.  And then all of that information that you might know about as many first degree relatives as you can. That information gets sent back to the agency. The agency staff looks it over. And if it looks good, they call the young woman in and say, well, let's sit down and meet and talk about what it's like to be a donor. They then take her through the steps of taking the injectable fertility medicines, doing the monitoring, and then undergoing the egg retrieval. And oftentimes, women leave that office and they never come back. And so we see some attrition there. If that all goes OK, they send them on for the psychological screening. The psychological consultation, and this one of the things I've done, so many of these, they start to have a certain pattern to them.  We just talk about how they learned about being a donor. Do they know anybody who's had infertility? It's very interesting to me that many women who are donors often have had a pregnancy termination.  And if I can do this for someone else, it will somehow help me in the previous pregnancy that I ended. So that always is a very interesting motivation, I think. After they do the psychological consultation, we then have them do psychological testing. We use the MMPI-2, which is the Minnesota Multiphazic Personality Inventory. It is the most widely used psychological test in the world. And it's used particularly in employment screening settings, firefighters, police officers, airline pilots, and then we added ag donors. And so one of the programs of my research was my colleague Sharon Covington was to collect normative data on donors so we could get a sense of the MMPI profile for a successful donor and the MMPI profile of a donor that is not successful or is not someone that we would want to donate. Other programs use personality assessment inventory and the others use the Milan. I'm very comfortable with the MMPI because I know if there's ever any kind of controversy, I have all kinds of empiric data to back me up. And I know that I could defend that decision if I ever needed to. Donor exclusion criteria are all very clear. And these are, again, in the ASRM guidelines. Significant psychopathology on interview is an immediate rule out. Family history of a heritable psychiatric disorder also a rule out. And it's interesting with this because if you have that information, for example, that maybe the donor's mom had manic depressive illness, that has to be disclosed to the recipient couple. And that donor will never be chosen. And so we just kind of rule it out at the beginning. Substance abuse or dependence, current use of a psychoactive medication, including any of the SSRIs or any of the medicines that are pretty highly prescribed in this population. A history of sexual or physical abuse without treatment. And this you have to be very careful with. You don't want to re-traumatize a person who has been a victim of a sexual or physical assault, impaired cognitive functioning, or inability to give informed consent. And you may say, what do you mean impaired cognitive functioning? Sometimes people come to these consultations under the influence of a substance. And it's very obvious. It makes the decision very easy, because obviously, if they are coming to a medical appointment under the influence of a substance, they're not going to be an appropriate donor. It's difficult to recruit donors. And so this is a study that German and her colleagues did a long time ago. But I'm pretty sure the numbers are true even now. If you get over 1,100 phone calls from women who say they want to be a donor, from those, they'll send out about 364 questionnaires, those personal and health history questionnaires I talked about. Of those that they receive back, they will only interview 89 women. So either they didn't get the questionnaire back, or there was something on the questionnaire that ruled that woman out. Of those 89, 53 dropped out, 36 remained, and 14 completed a donation. So that's the level of attrition that we get as you go through the donor screening process. This will be important when we start thinking about supply and demand and payment. ASRM has said that donors can only donate six times. We have studied donors across the country and have found that most donors donate once or twice. Agencies are very interested in figuring out what are the predictors of women who will donate more than once, because recruiting donors is such a resource-intensive process, they would love to have a way to figure out who could stick in with it for a few more cycles. To my knowledge, no one has ever been able to discern what those predictors would be. So most, I'm sorry? Did somebody have a question? Oh, I'm sorry. So most donors donate once or twice. So here's Sally and Bob. Now we're turning to the recipient or intended parent's side of the equation. And in real life, Sally and Bob don't look nearly this happy or nearly this rested. They are typically pretty sad and pretty tired and very anxious to begin their treatment process. So on the intended parent's side, when the physician makes the recommendation for egg donation, what happens on their side of things? Well, the first thing, again, is the psychological consult. We do a psychosocial history, again, talking to them about their history as a couple, their plans that they had for having children, how their infertility treatment had gone. Then we talk to the woman about how far she is in the grieving process of grieving the loss of a genetic connection to her potential child. Most women, this takes a good three to six months. It's a very active grieving process because she has in her mind the idea of the child that she's going to have. And now we're changing that plan a bit. And so it takes a little time for her to really adjust to that idea. We review the egg donation treatment process just in terms of mapping out the cycle, having the donor get stimulated and doing the actual transfer. I assess for depression. We discuss privacy and disclosure. And we discuss donor selection. And donor selection is probably the thing we spend the most time on. And I've heard it from all kinds of different perspectives. We have some couples who say, just want a healthy donor. And that's literally all they say. It doesn't matter, ethnicity doesn't matter, height, weight, hair color, eye color, none of that matters. Then we have couples who will come in and say, well, she needs to be five eight and Danish, very musical and should have been a high school athlete. If you have her SAT scores, that would be ideal, but like a grade report would be fine too. And so I stop and I say, okay, tell me why you want that information. What is it that you're imagining? And again, you get into the idea of the woman grieving the loss of the genetic connection and wanting to feel some kind of kinship with the donor who she perceives to be similar to her. We then talk about it's very difficult to be so precise in what you're looking for in a donor. It's usually a trade off of the more characteristics you're looking for the longer it's going to take. And so we have that discussion as well in terms of what their plan is for when they want the treatment to commence and when they want the match to take place. We do also talk about privacy disclosure at that very early stage because one of the predictors of telling the child is how many other people you've told during the course of your treatment process. And so if a couple at this stage when they're meeting with me before anything has happened, if they've already told both sets of parents, all their siblings, three best friends and the milkman, they will have no ability to not tell that child and they need to be aware of that. So we need to plan that disclosure even at that very early stage. So the intended parents are finished with me, they go and try to get a donor. There are many donor agencies in Chicago and in any of the big cities in the United States. Most couples meet with more than one agency because agencies differ in terms of their style and kind of how they do things. They then make a down payment which is held in escrow and then they start reviewing the donors that are available to them from the agency and then make the final selection. This is another $15,000 to $16,000 on top of the price of the IVF. About half of that goes to the donor, half of that goes to the agency and all the screening, the legal and all of the work that the agency is doing. The match is made when the agency faxes our nurse, the matching documents, the nurse sends them on for their legal consultation and then the nurse begins to map out what the cycle timing is going to be. Much to the dismay of many intended parents, that cycle is determined by the donor, not them. So it's when the donor is ready to do this, the treatment begins and the mom is matched to the donor's cycle. The legal consultation takes place with I believe you had Nanette Elster speaking to you last week. Nanette is one of the people we refer to for these contracts to talk with people about their roles as a donor or as an intended parent. The two parties have separate but coordinated legal representation to develop the contracts that clarify the rights and the roles and responsibilities of each party. Intended parents receive the right to have the eggs, the embryos and any resulting children and get to decide what to do with any unused embryos that they don't use. Only if the donor agrees to that. The donor may say after you're done, Mr. and Mrs. Smith, I get to decide what happens with those embryos. I may decide to throw them away but the Smiths may want to donate them on to another couple so the lawyers help them clarify that. They also may say, they are very clear that the children born of the donated eggs are not the legal heirs of the donor. This is one of the areas that's very complex if you're doing known donors and it's often why we frown on using known egg or sperm donors because of the inheritance and the legal complications of that. So as I said, egg donation takes six to nine months for the screening and the matching. Treatment takes place on the donor's availability so we're real busy at winter break and summer break and unused frozen embryos stay frozen and are typically used to create full genetic siblings for the egg donor child. And so around the country, I think one of my colleagues, David Hoffman, years ago did a survey. There are over a million frozen embryos in the freezers of IVF practices around the country. And so it's just one of these things as a practice we always are keeping track of and always trying to talk to couples about what do you want to do with these embryos and when are you going to make a disposition decision. So now you know what I do at work all day and now you have an idea of what we do with egg donation. I want to move now to some of the issues that I find kind of troubling and I think in the field we can agree are somewhat controversial. I am not an ethicist, I am just a person who can kind of highlight maybe some of the concerns that we have with the way egg donation is currently done in the United States. In the early days of egg donation, it was all done on a known donation basis. That first case in Australia in 1983 was a sister to sister donation. As and also women going through tubal ligation would also go through an egg harvest and then those eggs could be used for donation. But very quickly demand outstripped supply and agencies began recruiting and compensating donors. The first agency in Chicago opened in 1996 and many others have followed after that. What we get concerned about are the donors are young and most recipients are older, upper income and there's a big disparity between the need for money on the side of the donors and the supply of money from the intended parents. And so always asking that question is when is payment coercive versus an appropriate compensation for the donor's time and effort? This all happens and the backdrop of the National Organ Transplant Act that actually bans payment for human organs and tissue but allows and you can see the quote, reasonable payment for the removal, transport, implantation and processing of that tissue. Reasonable payment has never been defined and to my knowledge there's never been a case saying you can't do this because you're paying donors. Germany, Norway, Sweden and Japan have completely banned egg donation. Canada, the UK, France and some states in Australia allow egg donation but with no compensation. They'll like pay for your parking, maybe they'll buy you lunch but no compensation as we think about it here in the United States. The United States, Turkey, the Czech Republic and South Africa allow payments to donors. The Ethics Committee of the American Society of Reproductive Medicine had a position statement in 2007 saying that financial compensation of donors is justified but the compensation should be structured to reflect the time, effort and discomfort of the donor. So when you have a donor cycle, the money is put in escrow. So for example now a donor makes $7,500 to $8,000 in Chicago for one donation cycle. That money is put in an escrow account. She gets a portion of it when she's completed her medical screening. She gets another portion of it when she begins her medication. She gets another portion of it when she finishes her medication and she gets the last bit when she's done with the egg retrieval. And so that's in keeping with the spirit of the ASRM guidelines. In 2007 they said payments over $5,000 need justification and over $10,000 is not appropriate. In 2007 the national average was $4,200. 85% of programs paid donors the same meaning they didn't pay a premium for donors with proven fertility, certain physical attributes or certain ethnicities. There are certain ethnicities that are very difficult to get for recipient couples. To get a Jewish donor, we send most of our couples to New York. Very, well the agencies in New York have a lot more. It is very difficult to get Japanese donors. It's very difficult to get South Asian donors. And so there's certain groups that are just very difficult to recruit or are not interested in being donors. Higher compensation, not surprisingly, on the coasts, lower in the Midwest and in the South. Everything changed a couple years ago. A very concerted effort by a donor, she organized a group of donors and brought a class action suit against ASRM for price fixing and unfair competitive practices. She felt that donors should have the right to get the amount of compensation that they felt they were worth. And if they had those desired characteristics shouldn't they have the opportunity to get more money for them? According to the Wall Street Journal on February 3rd of last year, ASRM settled. So they've removed language about specific dollar amounts in the compensation. The new Ethics Committee document came out last month and so we all read it hot off the presses. They still said financial compensation to donors is justified because it advances the ethical goal of fairness to donors. Failure to provide compensation would demean their contribution but they took out any specific language about dollar amounts. So they really want us to provide accurate information but not to have undue influence financially for donors. So we should talk to them about the potential risks both medical and psychological and legal. We should always make compensation based on time and burden. Importantly, we should not link it to the number of eggs or the outcome of the cycle. Some practices had talked about splitting batches of donors so that you could have donor A give eggs to couple one and couple two. That really fell out of favor because in the lab eggs are like any other tissue in the human body. Some are really good, some are kind of medium and some are not good at all. And so who's gonna be the one wanting to split that batch of eggs in the lab? I know it wouldn't wanna be me and I don't think it's any of the embryologists I know. So now they're back to one donor, one couple. Egg donors can have up to 40 eggs retrieved at any one given time. But they don't want those donors, those super donors to be compensated more highly than other donors. So here's what I found lately. You can go on any website and Google we need an egg donor and you will find these ads. Genius Asian egg donor needed $35,000. We're looking for an attractive and intelligent egg donor. Compensation is $75,000. So you get the picture of how things are going to go. This concerns me very deeply, but I don't know what the answer is in terms of how you manage this, in terms of managing the donor's needs and the intended parents' needs to engage in this collaborative reproduction. The forces that are pushing compensation higher obviously is the removal of the monetary guidelines. Also, agencies will tell you we need to pay them more because we need to get more donors because we have more intended couples who need eggs. So we have to keep everything going. Also, agencies talk about wanting to retain donors. And so again, they talk about adding a premium to donors who will donate more than once. And all of this is due to the increase in number of recipients who are desirous of this treatment. Some countries ban payments to donors. Donors that do not offer compensation have long wait times and a very short availability of donors. This has really led to the develop of a phenomenon called reproductive tourism. We get couples from all over the world who come to the United States, not just our clinic, but all IVF clinics, come to the United States, do a cycle of egg donation or sperm donation that they can't do in their home country, get pregnant and fly home. The other issue that I should just note for you is if you look at the National Health Service in the United Kingdom, they now have nine donors on their pool of donors. And so people come to the United States to get donors. Just a little summary, the pros and cons. People who are pro payment for donors say it's fair to donors. It maintains a high number of donors and creates more children in our very pro child society. People who argue against donations say it's a commodification of life. It undermines the altruism of a donor. Children are seen then as products. And this is the one of all these that stick with me that also is concerning to me that this is only available to really wealthy people. We have to acknowledge this. This is not something that's available to people across the board and particularly in this day and age of concerns about healthcare spending. It's a real concern. There's a very unequal distribution. So now we're gonna turn to something a little bit less contentious but equally important in my view. Second issue I wanna talk about is post donation wellbeing of egg donors. So you have this lovely young woman come to be a donor. She undergoes a medical procedure for which she will obtain no health benefit. Other examples of individuals like this are kidney donors or research subjects that are exposed to medical procedures. A thorough discussion of the procedures and its risks are necessary for the process of informed consent. And in the world of egg donation we get concerned about this because in the need to get more donors oftentimes the discussion of the risks and benefits can be short changed or not even covered at all. But then we have to ask ourself the question what are the risks? What is it that we need to inform these young women about in terms of what the consequences might be for their decision to become a donor? In 2006 the Institute of Medicine convened a panel looking at the risks of oversight donation for stem cell research because they were interested in beginning stem cell research at an institute in California. So they gathered a group of us together and stuck us in a room for a couple of days to review all the literature on the medical risks and the psychosocial risks of egg donation and it resulted in this report. All of the data that we had to review was obviously from egg donors who donated for clinical purposes because at the time they were not donating for stem cell research purposes. The IOM report just to summarize it identified three short term medical risks to donors. Ovarian hyperstimulation syndrome or OHSS. This is when the ovaries respond really robustly to the medicine and a woman gets very bloated, she gains weight, she can have nausea, she can have shortness of breath and in very serious cases she can have ovarian torsion where the ovaries twist inside the pelvis and that is a very serious problem. It's estimated that one to 11% of donors experience some level of OHSS. The next risk is the surgical risk of bleeding or infection related to the retrieval process. That risk is estimated to be at about 1%. The next risk is the risk of anesthesia, of the sedation that the donor goes through during the time of the egg retrieval. That risk is also estimated to be about 1% or less but there was one study that actually followed up with donors and about 4% of them said they had nausea or vomiting after the anesthetic. Psychological risks include mood swings from the medication, about half the women report transient depression, anxiety and irritability while on these medications. Regret is a more difficult risk to define but you find about 15% of donors who will say, I really regret having been a donor and it's not the week or two after they donate, it's a few years after they donate and they say, you know, I'm not sure I really wanted to do this. The other thing they are very concerned about is future contact with the child. Very much concerned that someday they will receive a knock on the door to say, hey mom, here I am. And so these are the kinds of things that stick with them psychologically and can cause them some distress in years to come. The long term medical risks, not surprisingly is impaired fertility for our population of donors. About 12% of donors who subsequently tried to get pregnant had infertility. 5% of them actually had to go get infertility treatments themselves. The last risk that we get concerned about is the risk of cancer. We have, I wanna be very clear, we have no data but the IOM concluded that it's a plausible concern that there would be an increase in breast, ovarian and or endometrial cancers in women exposed to these medications over several cycles. It is unknown though whether a healthy young woman would experience this because they're not, they don't have any underlying infertility causes that might make infertile women more susceptible to those types of cancers. So it is unknown whether there is a cancer risk for donors. There are two papers though that I think really opened up the conversation about this. And I will draw your attention to the one by Schneider in 2008 and Schneider is a physician and she was the mom of the donor who died. And she wrote very poignantly and very meaningfully about watching her donor go through the donation process three times, four years later she developed colon cancer and she died at the age of 31. Now we all know that a couple of cases does not causality make and I'm not implying that. Why Schneider's paper was important though is it was very much a call to we've got to do a better job and inform consent process with donors. It's not just a question of here girls, we want your eggs, sign this form. We really need to talk to them about the risks and benefits for themselves. It may seem like an obvious point to many of you. It is not in the day-to-day practice maybe as thorough as we might want. Certainly maybe not as thorough as research subjects undergoing the informed consent process for a medical study. Post donation well-being and informed consent are important because we really want to make sure we know what the risks and benefits are from what the donor has experienced. The few studies that are there do recommend detailed counseling for donors including numerical estimates of risks included in the consent forms. The long-term follow-up of donors, physical and psychological health I believe is an imperative and I'm not aware of any initiative to do that. And certainly with the number of donors increasing this can be a concern in the decades going forward. And specifically we also want to think about saying something to a donor like there are no significant long-term risks is very different than saying we don't know of any significant risks and we have to say we don't know because we haven't looked. I think people are hesitant to look at this because what if there are risks? What is this going to do to this whole model of how all of this is happening? That doesn't mean it's not a good idea and it doesn't mean it's not necessary in my view. Last, let's talk about privacy and disclosure and this is the topic that is very near and dear to me because it takes up a lot of my time in my counseling with my couples. Because I've been at Northwestern for 22 years I've had the privilege of couples coming back to me. They may have an eight-year-old child and the father is dying of cancer and the child was born of sperm, donor sperm and now the mom is saying what do I do? Do I tell, do I not tell? He's on his deathbed, he's not gonna be here. Do I add that into the mix? Or a lesbian couple who has a five-year-old daughter and kind of goes to school one day and says oh, I have two moms. Other people have moms and dads and some people have one mom, I have two moms. How did I get in the family? And then we talk about the narrative for how you tell the child about their donor origin. Kurt Vonnegut has a very good quote that I like to think about when I think about privacy and disclosure. Keeping big secrets is difficult even for really smart people. It is the most controversial aspect of gamut donation. Then there are numerous medical personality and cultural factors that affect disclosure. You'll remember that the first case of donor sperm use was in 1906 at Jefferson Medical Hospital in Pennsylvania and that was a live donation. The husband didn't know, the woman didn't know and only was it known after the fact that a donor had been used. Sperm donation has had a very long history of privacy because people were concerned about disclosing male infertility and the effect that that might have on the man and his sense of self-esteem and his sense of virility. That has carried over into the practice of egg donation even in current times. In the past 25 years though, there's several factors that have been pushing us to more disclosure and more openness. The first is the open adoption model where we know that adoptees are getting more and more access to information about their biological parents.  Ethics statements from ASRM and the Human Fertilization and Embryo Authority also have come down to say disclosure is the way to go. You need to tell your child, the child has a right to know. And in both Denmark and the United Kingdom, there is legislation to that effect. When you're a donor in those countries, you're registered and you agree to become known to the offspring when the offspring is 18 years old. The last thing that's changing the landscape here in the United States is the donor sibling registry. The donor sibling registry was started by Wendy Kramer who is a single mom by choice who had a child with banked donor sperm. Her son was really interested in knowing do I have any siblings? So she started this website where women who've had kids with donor sperm can register. They say what year their child was born, what bank they used and what their donor number was and then you can search the data set and see if there's any other offspring from that donor. One of my former patients has twin 18 year olds. Her daughter spent a week in Cape Cod with her 18 half siblings. And that was a really, really interesting thing to hear about. What do patients actually do?  But what do couples actually do? Tallendini did a summary of the world's literature, which is 16 studies, to find out what couples do in terms of disclosure. And I'll draw your attention to the top line for sperm donor families, about 21% of them have told their child, 36% plan to tell, 30% are not gonna tell and 13% don't know. The numbers are a little bit different with egg donor families in that most, about half, plan to tell and only 16% plan not to tell. Many donor moms will say to you, yeah, I'm gonna for sure tell. I'm the mom because I carried the baby. I've got that gestational connection to the baby and that gives me that feeling of security and attachment with the child. So I'm not really threatened by the notion of informing my child that we used a donor egg. Most parents tell others during the fertility treatment about using donor gametes to conceive. We first documented this in 2004 in a study of five different clinics where couples were using donor gametes to conceive. Most people regret telling others. If you ask them after the fact, if there was one thing that they would do differently in the treatment process, that's what they say. They would say if we had it to do over again, we would maintain privacy. It was interesting when we were doing long-term follow-up studies. This is years ago when I was at University of Connecticut, we were studying families of donor sperm and we always had a plan to call around the time of the child's birthday just to check in with the families and see how they were doing and seeing how the child was and what their disclosure plan was.  He's like, hi, how are you? It's Susan, yeah, how are you? Fine, fine. How are you doing? How often do you think about using donor to conceive? I'm going through the questions in the study. And he goes, Susan, I only think about it when you call. I said, oh, really? Okay. So I go back to the group and I said, you know, we really need to rethink this methodology because we are now influencing the process and that is not okay. So we stopped. But it really, it taught me something very important in the process of doing clinical research in something like this, which is, in many respects, a very large social experiment in human reproduction. You don't know where you're influencing the process. Why do parents tell their children? First and foremost, parents will tell you the child has a right to know and that their kind of central belief about parenting is honesty is the best policy and that then informs their decision. The other reason they say is that we've told so many other people now we have to tell the child. We have no degrees of freedom around this. And the other is that the child should have access to their genetic information. Reasons why parents don't tell, they'll say to you, oh, there's no reason to tell. It's nothing important about this. They will also say the rearing parent is the real parent. They also talk about their community or their culture would be very negative about the use of donor gametes. And then the last is they think that their child would be somehow harmed or stigmatized in school, with friends, if it became known publicly that they were a child of a donated sperm or egg. Arguments to tell are often based on the belief that children who are told will have better psychological and social adjustment than children who are not told. Interestingly, there is no support from this position and this is work done by Susan Golembach and her colleagues at Cambridge. They're really the only people in the world who are doing these wonderful longitudinal studies of certain samples of donor gamete children. But they don't find any differences in psychological and social adjustment between children who are told and children who are not told. What do donor conceived individuals want? Nobody knows because you can't study them because half of them don't know who they are. So it becomes a very tricky thing to think about. When you set out internet ads, doing subject recruitment for people who are born via donor sperm or donor egg, by definition, those are children who've already been told. So you've got a systematic bias already in your sample. When we think about counseling couples in this treatment process, we always talk about the respect for an individual to know genetic information about themselves. In my role as a mental health professional, I have to stay neutral. I know what I would do, but I know that being dogmatic is rarely helpful. And so instead what I wanna do is help them consider what are the pros and cons of disclosure? What are the pros and cons of privacy? Specific to their family, specific to their beliefs, specific to their community. We also want to explore what are the basic values in parenting? What are we trying to do when we've raised our child? What kind of values are we trying to instill in them? The other thing we talk about, and this is the simplest thing in the world, but it sometimes feels like a great hurdle, is what is the narrative for how the child came into the family? And the couple be like, I don't know how to tell them they were born of donor sperm. Well, okay, mom and dad wanted you very much. You need an egg, you need a seed. We didn't have a seed for daddy, so a very nice man gave us a seed. We put them together and that made you. Oh, and they're like, oh, well, the child's gonna have so many questions. They're gonna get so worked up about it. I said, maybe, but more times than not, they'll just say, oh, what's for dinner tonight? And they're gonna move on. Because the easier you are with that information, the easier it's going to be for the child to assimilate that information. They'll come back and ask questions. They'll find out what they need to find out, but they will take their lead from you in terms of how you're talking to them as the parent. The other thing that's really changing the landscape in this line of work is the huge amount of genetic information that we have access to. People may have genetic tests in a medical setting that gives them information that they previously didn't know. And also over-the-counter gene testing with 23andMe and other things, you can start to see who you're related to and who you're not. And that will change this field very dramatically. In conclusion, gamete donation has led to the creation of tens of thousands of children. Genetically unrelated to one or both parents. The ethical concerns persist about payment to donors, informed consent and the well-being of donors, and information sharing to offspring and others. Large long-term studies are needed to understand this complex form of family building to better guide parents and to better guide children. Fundamentally, we're always asking, what is it that makes us a parent? This is the thing that always keeps me coming back to this line of research. Is it nature or is it nurture? And as this t-shirt says, either way, it's your parent's fault. I thank you very much. I'll be happy to answer any questions. Thank you so much. That was a great talk. Thanks, William. What responsibility is there, if any, to those women who are being screened to be donors, especially those who have a positive finding on the MMPI or other psychological screening? Is there some kind of track for future care? What is the responsibility to those? What we do is we bring them back in and we have another separate appointment with them. You typically don't show people the actual profile of the MMPI, but you absolutely interpret the results back to them and say, the tests indicated you might be having difficulty with depression or it looks like there's a problem, maybe with some rapid thoughts and maybe some hypomania. Have you thought about talking to someone? We can get you connected to where you need to get connected to take care of this. You wanna be very, very diligent with that, both on the psychological side and on the medical side. Many donors do not have access to regular medical care and very commonly if we see it like a positive pap screen, the intended parent's like, oh, well wait, when is she gonna be back?  She's gotta go get her own health needs taken care of. So yeah, there's definitely follow-up steps when we find something on the screening. And that was gonna be my kind of follow-up question. So I presume that some, if not a good number of these women are uninsured, underinsured in terms of complications from the procedure, et cetera. Whose responsibility is it? Should there be such an issue? So what happens is there's an insurance company that provides specific insurance for egg donors and the agencies purchase that for the donors at the expense of the intended parents. So the intended parents pay for that. So if there's any hospitalization, anything at all, they have that policy covering the donors. So comparable to what we heard last week in terms of surrogacy. Yes. You got me thinking about the parallels between egg donation and organ donation. And it strikes me that two differences are that organ donors, I don't think, get paid. And the second is that organ recipients, but not egg recipients, get ranked and there's a list. I'm sorry, I missed that last part. People waiting for an organ go into a list and get ranked, whereas it doesn't sound like egg recipients do. No, it's really just a matter of when the timing is right for them to find the donor that they're gonna get matched to. There's definitely a supply and demand component to it, but I think it's not like the list with recipients. Could you just to follow up on this? I was quite surprised to see how quickly the American Society of Reproductive Medicine settled that lawsuit. The matter of a year or two, conceding that free market system had, they must have sensed that they were not gonna prevail in court, and two years is a very quick decision. You wonder if something like that might not apply going forward to solid organs also. I mean, claims like that. But the two year, when the AMA was fighting questions about advertising, they fought it for 12 years before they lost. But this was a two year fight. This was quick. They gave it up. Oh yeah, Matt, yeah, we'll get up there. Matt. Yeah. It's called in terms of the social test experience, and now with our new president, we're gonna be done to stay with it. So, how do they call the inequality directly? I don't think, I don't know is the answer to that. I think it is really plausible that insurance coverage for this is gonna go away if I had to guess, and that is gonna change the market really dramatically, particularly in the states like Illinois where they do mandate at least some form of coverage, but I don't know. The inequality is very unsettling. It has that very coercive feeling to it of donors doing this for the money. Most of them will tell you though they do have an altruistic motivation as well, but they wouldn't do it if they weren't getting compensated. So it happens all the time that women who are, who might smoke and might drink and might be depressed and might have some other imperfection of that sort, get pregnant deliberately or otherwise and have babies. Yep. Given that, how do you justify these severe restrictions and goals of perfection essentially that apparently are used in the agencies to screen out anybody who isn't perfect from being an egg donor? It is a very good question, absolutely. I think the agencies are responding to the intended parents. They will accept more donors. Like the criteria we had listed there, when you get to that point, you're not excluding that many because there's not that many you're gonna have a substance abuse issue or a mental health issue. Many intended parents are not gonna select those donors and that's why they make the justification for it, that they're gonna have a donor there that doesn't get selected. It's really interesting when you talk to those women who want to donate and don't get picked, talk about a long-term psychological consequence. And I've talked with some of them and it's very sad because they really want to be helpful and they really want to participate in this process and then they end up going, you know, what is it about me that nobody wants to take my genes? So yeah, it's a concern. Please. I was a little late so we'd be able to cover this but I'm wondering now that they're frozen egg banks. Yes. They do this process because it's a different relationship like just buying eggs from a bank versus like choosing a donor who's going through this process just for you. People do worry about that. I think the thing that is going to keep this process, the live match donors around for a little while longer is the frozen egg technology just became non-experimental in 2013 and you need 10 eggs to create one potential viable pregnancy. So you have a six to 10% chance per egg. So you could have all those banked eggs that you want but you're never gonna have as many as you're gonna need to meet the market demand if that makes sense to you. Once the technology for freezing eggs becomes more robust and more mature, I think it will actually change and it'll be much more like the model of frozen sperm. I was fascinated if I heard you correctly when you said that donors might negotiate with the agencies or with the potential recipients that they had control over the additional eggs that were not used. The disposition, yes. And now in a free market system can they sell those eggs to the highest bidder? Well, what's interesting is usually embryo donation doesn't get compensated. And I don't know why that is but typically embryo donation is not compensated and because the embryos exist in banks and they get matched to recipient couples, there's not that money that is changing hands. Darren. Yeah, just a mundane question. Did the recipients get to see pictures of the potential donors? 37% of recipients want to or have seen a photograph of their donor. And I know that because it was one of the things we studied in a paper that we did. Some of them want to, some of them don't. The ones who do very much have this feeling of I wanna make sure she looks nice. The ones who don't say, I don't wanna be feeding my baby at two in the morning when I'm really, really tired and have this image of this other person in my head or I don't wanna be walking down Michigan Avenue and say, oh my gosh, are you my donor? So it's about 37% to see a photograph. Can they see one if they want to? It depends, it depends. Some agencies will have photographs of the donors as children. Some of them have photographs in current time. It really just depends on what the parties want and what the agency typically will do. Yeah, I'm wondering about cases where you have an egg donor and a surrogate carrier. Does that come up often and create a lot of complications? Comes up all the time and it does. It's very complex to organize because you're screening the donor, you're screening the surrogate and then you're coordinating all those legal contracts. Some of the biggest issues that come up there are prenatal testing and termination of pregnancy if any medical, health issues are found in the fetus. And so you have to make sure you've counseled all parties ahead of time about what's going to happen because ultimately the surrogate's gonna be the one who's gonna get to decide. But you have to make sure the egg donor knows that and you have to make sure the intended father knows that or the partner of the intended mother if it's a same-sex couple. Did you follow that? I hope I didn't confuse you.  They have a surrogate, they have their egg donor and then the partners typically will alternate in terms of whose sperm is used to create the embryos. What is the position of the religious hospital regarding the procedure? I'm sorry. What is the position of the religious hospital? Religious hospitals. Oh, yeah. What is the position of religious hospitals? Religious hospitals don't do this. Yeah. Is the position. Many religious traditions are not enthusiastic about what we do. And I think that's putting it diplomatically. So interesting story. I actually started the process of applying to donate an egg in the past because I thought it was so fascinating. And you keep saying you screen the candidates and eventually I didn't get selected because I had far too much family history issues. But I thought it was interesting. I could have easily lied with any of the questions. Like, do you have depression? Do you have family history of depression? Do you have history of substance abuse? I mean, on the application, I could have said no, no, no, no, right? And like, how would you have actually screened me officially to find out if. All of this is based on self-report. And so it would start with the questionnaire and then it would be follow-up questions on the questionnaire. And during the psychological consultation, but it's a very, very good point.  Recipients do ask when they're gonna start doing genetic testing of donors. And that's coming down the pike. Some practices in New York will routinely screen donors just to look at their karyotypes, I believe is the correct term. And people ask us all the time, well, are you backing up this information?  Are you doing all the medical tests that need to be done? And that's not the current state of the practice at this point. It's not like you could go find my mother or my father and you don't know what I mean. Exactly. Okay, exactly. Thank you. Well, I want to thank you for the group that Dr. Clark, that was a fabulous talk. Well, thank you very much. Thanks so much. Thank you so much for having me.


Let's be honest, a lot of us think that kind of hating your partner has to sound like this. But more often, it sounds like this.  If you don't put that water bottle down. Truth is, along the way, most of us at least somewhat learned how to love, but few of us ever learned how to effectively cope with not loving everything about our romantic partners. And that's what this episode is largely about. And also, I have got to tell you why this topic is really, really right on time for me. So let's get into it. All of it. All right, let's talk about hating your partner sometimes, which is fine. Hating your partner sometime, which is fine. I feel like it would be weird if you didn't feel a sense of hate in a relationship. And that can be on many different levels of like, I lay in bed and I listen to my partner drink out of their water bottle. And I swear I can hear every molecule down their throat.  I'm like, if you don't put that water bottle down, you know, it's, I'll end you with it. It's some like simple stuff like that where I'm just like, and then there's some big stuff that you can be like, okay, we actually need to talk about this. At the beginning of the pandemic, my partner and I decided to move in with each other. What was the inspiration for the move in? Was it we're scared? Let's come together. Was it let's save money? Was it I love you so much. I want to spend more time with you. We were more afraid to be apart than we were to be together because at that time we didn't know really how the pandemic or COVID worked. If you are around someone, are we allowed to see each other? Are we just asking all these questions? So when we moved in, it was good. And the place that we found, honestly, I wish I could love it. It was so cute, but I can't.  And it was like us only being in the house with each other, you know, and someone so easy to bounce anchor and frustration out and the fights that we would get into the struggles that we had. And it came to a point after March that we were going to move out from one another. And so 10 months, right? Yeah. Yeah.  Oh, and honestly praise anything that I said that because it's the best thing we've ever done. But that also immediately put us into a uncomfortable place of like, so if we move out, do we break up? No, we're going to stay together. This is going to work. I was not as confident as I sounded. I was more in a place where I'm not in control of this, you know, I'm going to do my part. I'm going to show up for me. I'm going to show up for you. And if that ends in us being together, beautiful. Are we supposed to always like our partners in order for it to be the right person? And are we giving a message to people who are in toxic relationships that if they don't like their person that that's okay.   I always felt like I was the therapist. I was the one pumping you up doing this, doing that. And what was I getting in return? Absolutely nothing. Just to even have a partner willing to understand my OCD willing to really be there, even after those terrible fights. I think when I look back at those, the things that made stuff toxic, I was in support.  So for you, I'm hearing it was the circumstances that were the issue, not the connection. When you change the circumstances, the two of you moved out. What happened next? It was great. Honestly, after that weird part, after we kind of got established, it like I was the fact that I was driving to their house and like packing a bag and you know, making sure I had breakfast and going to their place. It felt like a spark all over again from like the first times that we started dating each other. Did you move out with a what if like let's see if this is better? I will say there was definitely the notion in my mind of like, is this really going to work out though? And we did let me also say this before we moved out, we had a very serious talk with each other of like, okay, we're not going to move out and just expect things are going to be different. Like yes, there was a lot of outside circumstances, but also we need to change some things within ourselves. Is there one aha that you can share? If Kate was feeling a certain way like hurt, it would be hard for Kate to tell me that because they were afraid of my reaction. So then that had to be spoken about in many different conversations of like, okay, one, it's really hard to put me in that corner of like, okay, now I have to react in a certain way knowing that you're afraid of that to also being a black woman and Kate is a white person, like you monitoring how I'm reacting to things isn't is a feeling the best I know that is not where they were coming from. I know this has to do with stuff before me. We don't really get taught conflict resolution ever, right? Anger management is for the person who hit a kid with their car. It's not for everybody else, but all of us have issues with anger to manage. And I remember being certain relationships where with those places of hurt, especially if you have pent up hurt. It's like a person who has their arm blown off and a person who has a missing leg coming together and being like my legs blown off.  And then it now becomes an argument of like, who gets fixed first? And then meanwhile, both people just bleed out. We have to prioritize somebody. And I think in our relationship with Jared, I don't know if he subscribes this rule, but I often try to push it is like the person who comes with the problem gets prioritized. You can afterwards, we've solved my problem. Then you come and say, here's what you did that caused me or that could help me in the future. But the first thing is first, like if I'm the one who brought it up, then let's please work on my broken leg first. Someone's listening to this right now and they're in a place where they're in love with their partner, but out of like with their partner. What reflection points would you offer them? Take moments away. Whatever you can do, I would go on drives. I would listen to podcasts. I would go sit in my car in the parking garage, you know, to going and staying a weekend somewhere else. I went home for four months and stayed with my parents. Those moments alone to be like, okay, back to the drawing board. What are these things that I am benefiting from in the relationship? How am I being seen? What am I giving? Do those look somewhat equal? Do I think I could do more? Do I think I could be treated better? If I take out every external situation, am I still happy?  Like it can take several and that's okay. I don't want any more dry time together. It's not because just excuse yourself.  It's okay. We'll be fine without you. So I think that we like, but it's something special to be able to exist with somebody where you don't have to be alone during those times. Like I don't want to have to like pretend upbeat if I'm like tired. How do you bring the vibe down though? So do you sometimes. I know. And I'm admitting that. But it's nice to like, I'm like, yo, I get it right now. You're pregnant right now. You've been dealing with a lot. I get it. You know what I mean? It's nice to be got. It's nice to be understood. Are you open to therapy at this time? Yeah. Oh, I wrote not at this time. Oh, okay.