The emotions, concerns and reactions of sperm donor candidates to their rejection by a sperm bank

Abstract

Purpose

To explore the emotions, concerns and reactions of sperm donor candidates to their rejection by the sperm bank.

Methods

An online questionnaire was administered at Cryos International in the USA and Denmark to sperm donor candidates who had received notification that they were ineligible to donate.

Results

A total of 101 rejected donor candidates completed the questionnaire. The majority were disappointed and surprised by the rejection but only a relatively small group had concerns about their health, fertility or manhood. More than half of them (54.5%) were satisfied with the way they were informed of their ineligibility while 17.8% were neutral, and 27.7% were dissatisfied. Approximately half (47.5%) thought that the information provided to them was sufficient while 24.8% were neutral and one in four (27.8%) considered it as insufficient. The most frequent suggestions for improvement were to provide an information leaflet specific to the reason of rejection, offer personal counselling and explain better what the implications are for them.

Conclusion

There is room for improvement in the information provided to donor candidates about the reason for their rejection. Although some information is already currently provided, a minority of donor candidates considered this to be insufficient. However, rejected candidates do not request more information on their own initiative. Routine provision of an information sheet specific to each reason for rejection may improve the experience of these men.

Introduction

For decades, sperm banks and fertility clinics have been recruiting men to become sperm donors [1]. It is common knowledge that only a small fraction of the candidates is ultimately retained as donors. The recent study by Pacey et al. in Cryos revealed that thousands of men either drop out or are rejected as donors during the process, resulting in an acceptance rate of 3.79% [2]. The acceptance rates in different sperm banks and clinics range from 3 to 23%. A study in a British clinic reported that out of a total of 1101 applicants, 3.63% were released as sperm donors [3]. One study in China reported that 23.38% of potential donors were accepted, and a Spanish study mentioned an acceptance rate of 20.87% (167/800) [4, 5]. Comparing these rates between countries and clinics is hampered by the fact that clinics differ in the steps they use in the calculation: the starting point (initial interview, online form, first visit), the order of the steps (sperm sample testing, medical questionnaire) and the use of different standards in sperm quality. Ping et al. [6] started counting from the moment of the first interview while Pacey et al. [2] took the online form as the starting point. Chinese banks, for instance, reported using much higher criteria for semen quality than those recommended by the WHO [4]. Moreover, there is a large variability in screening procedures employed by sperm banks [7]. Genetic screening may be performed through genetic testing for the legally required genetic conditions, expanded carrier screening with smaller or larger panels or a self-reported family history. Psychological screening may be carried out using standardised instruments such as the MMPI, a clinical interview with a mental health professional or an appointment with a doctor.

Sperm donors are mainly motivated by the wish to help other people to have a child [1, 5, 8]. Other reasons such as financial gain and the wish to procreate may also play a role [8]. However, regardless of their motivation, little is known about the impact of a rejection by the sperm banks on men applying to become donors. How does the rejection affect their lives and are there any long-term consequences? No other study on the concerns and reactions of sperm donor candidates who were rejected by a sperm bank could be found after a thorough search of the academic databases. A search was conducted in the following databases (PubMed, Embase, Web of Science, Scopus and Google Scholar) for the following search terms (‘sperm donation’ OR ‘sperm donor’ OR ‘screening’ OR ‘rejection’ OR ‘drop-out’ OR ‘deferral’ OR ‘recruitment’). This paper focuses on donor candidates (DCs) who were rejected by the sperm bank.

The procedure at Cryos sperm banks is largely similar across all locations, with some variations. In both the USA and Denmark, donor candidates begin by completing an online application form. However, the US form is more detailed, asking specific questions about the DC’s age, height, background check, sexual activity with men and family history of mental illness. It concludes with a list of seven mandatory requirements. In contrast, the Danish application is shorter and does not include such detailed criteria until later in the approval process.

Once the application is submitted, a counsellor or nurse at the sperm bank reviews it. If no disqualifying factors are found, the DC is invited to provide a sperm sample. If the sample meets the bank’s quality standards, the DC is asked to complete a medical questionnaire. If no issues are identified through this questionnaire, the candidate undergoes a medical and psychological examination.

Methods

Design

The study design was a questionnaire-based survey of men aspiring to become sperm donors at the sperm and egg bank Cryos International. An online questionnaire was developed specifically for rejected donors. The questionnaire was deliberately kept short as it was expected that the respondents would be difficult to convince to participate. The questions were selected based on the reasons for donor candidate rejection found in the literature and used in the sperm bank [2]. The questionnaire first asked for the reasons for their rejection and then presented statements on how they felt about being rejected, their concerns and plans for the future (13 statements). The next section asked about how they were informed and how they thought the process could be improved. The last part of the questionnaire asked some biographical data (age, educational level, partner, children and identity-release/non-identity-release position). The answers were analysed anonymously.

Ethics approval was obtained from the Ethics Committee of the Faculty of Philosophy and Art of Ghent University (approval 2022-30 of 06/10/2022).

Study population

The study population consisted of all DCs who were rejected for failing to meet the inclusion criteria (e.g., application declined, poor sperm quality, medical questionnaire or genetic testing) and who consented to be recontacted. The DCs were contacted by email and invited to participate in the study. Emails were sent to 1472 donor candidates starting in December 2022 till January 2024 with intervals of 2 months. The questionnaire was accessed online by a link to the MS Dynamics 365 Customer Voice platform. When using the ‘single response’ feature in Customer Voice, each participant receives a unique invitation. This invitation ID is stored in Customer Voice, ensuring that the questionnaire can only be completed once per invitation. This setup helps prevent multiple responses from the same participant, even if they attempt to use different devices or browser settings. All data were retrieved from Customer Voice and converted to MS Excel for storage.

A digital reward was provided to encourage DCs to respond. The reward of $20/150DKK could be converted to a gift card in selected online stores. The reward was given to all DCs who completed the questionnaire, using the tremendous online platform and thereby guaranteeing anonymity of the respondents for the sperm bank. The settings of the questionnaire ensured that participants could only answer the questionnaire one time.

Statistical analysis

The statistical analysis was performed online at Quick Statistics Calculators (socscistatistics.com) using 2-sided Fisher’s exact and t tests as indicated in the tables. p values <0.05 were considered statistically significant. In order to get a better view of which factors influence the perception and experience of the donor candidates, we dichotomized the answers on the item ‘I am satisfied with the way I was informed about not being eligible’ into those who answered ‘fully agree’ and ‘rather agree’ (satisfied) on the one hand and those who answered ‘neither agree nor disagree’ (neutral) and ‘rather disagree’ and ‘fully disagree’ (dissatisfied) on the other hand. Then the statements were dichotomized in the same way, and comparisons between the two groups were performed to identify statistically significant differences.

Results

Demographic characteristics

Out of the 1472 emails that were sent, 891 (60.5%) were opened. Data collection was stopped after 14 months with 101 rejected donor candidates answering the questionnaire, resulting in a response rate of 11.3% of those who opened the email. About one in five (18.8%) DCs applied in the USA, the others (81.2%) in Denmark. Their mean age was 28.5 years (range 18–57; SD 8.12). The mean age of those who were satisfied with the information was significantly lower than that of those who were neutral or dissatisfied (26.0 v. 30.4, p=0.0364). DCs had a bachelor degree or equivalent (41.6%) or a master degree or higher (17.8%). About half had a partner (46.5%), and one in five (19.8%) had children of their own. Approximately, half of those who had made a decision intended to become an identity-release donor (29.7%); 25.7% intended to become a non-identity-release donor while the remainder had not yet decided (44.6%). An overview of the demographic characteristics can be found in Table 1.

Table 1.

Demographic characteristics

Characteristic	%	Satisfied (n=55) %	Neutral or dissatisfied (n=46) %	p value*
Mean agea	28.5	26.0	30.4	0.0364
Partner = ‘yes’	46.5	45.5	47.8	0.8434
Children of their own= ‘yes’	19.8	16.4	23.9	0.4531
Country of application is DK = ‘yes’	81.2	85.5	76.1	0.3077
Highest educational level
Secondary school	34.7	34.5	34.8	1
Bachelor degree or equivalent	41.6	38.2	45.7	0.5439
Master degree or higher	17.8	21.8	13.0	0.3031
None of the above	5.9	5.5	6.5	1
Initially chose to become
ID-release donor	29.7	21.8	39.1	0.0801
Non-ID-release donor	25.7	30.9	19.6	0.2545
I did not make the decision	44.6	47.3	41.3	0.6879

^aAge is in years, not %; significance level tested by two-tailed t test

^*2-sided Fisher exact, satisfied group vs. neutral or dissatisfied group.

Reasons for rejection and information process

The main reasons for rejection of DCs were family medical history (25.7%), medical risk identified in the questionnaire (18.8%) and failure to meet the eligibility criteria (17.8%). However, 15.8% reported that they were not given a specific reason, and 11.9% could not remember why they were rejected. The reasons for rejection and the information process are presented in Table 2.

Table 2.

Reasons for rejection and information process

	All (n=101) %	Satisfied (n=55) %	Neutral or dissatisfied (n=46) %	p value*
Reason for rejection (more than one reason possible)
Did not meet eligibility criteria (e.g., age)	17.8	18.2	17.4	1
Family history	25.7	27.3	23.9	0.802
Genetic risk after genetic testing	5.0	5.5	4.3	1
I cannot remember	11.9	9.1	15.2	0.372
I did not receive a specific reason	15.8	12.7	21.7	0.288
Poor sperm quality	8.9	5.5	13.0	0.293
Medical risk identified from questionnaire	18.8	23.6	13.0	0.208
Medical risk identified after consultation	4.0	1.8	6.5	0.328
How were you informed about the result?
Email	22.6	18.2	28.3	0.244
Telephone	68.3	78.2	56.5	0.031
During an appointment	5.9	0	13	0.007
By telephone and email	3.0	3.6	2.2	1
Do you think the provision of this information could be improved? =yes	36.6	18.2	58.7	<0.001
If yes how? (more than 1 possibility)	n=37	n=10	n=27
By advising people to see a medical professional	18.9	20.0	18.5	1
By explaining better what the implications are for me	27.0	40.0	29.6	0.462
By offering an information leaflet specific for the reasons of rejection	35.1	40.0	37.0	1
By offering personal counselling	32.4	10.0	44.4	0.065
Other (free text)	18.9	0	25.9	0.155

^*2-sided Fisher exact, satisfied group vs. neutral or dissatisfied group.

A total of 101 rejected donor candidates completed the questionnaire. More than half of them (54.5%) were satisfied with the way they were informed of their ineligibility while 17.8% were neutral and 27.7% were dissatisfied (see Table 3). The majority were informed about the rejection by telephone (68.3%) or email (22.8%). Those DCs who were informed by telephone (78.2% vs. 56.5%, p=0.031) were significantly more satisfied while those who were informed during an appointment (0% vs. 13%, p= 0.007) were significantly less satisfied. DCs who were satisfied were significantly less likely to believe that the provision of the information could be improved (18.2% vs. 58.7%, p<0.001). About one in three (36.6%) thought that the provision of information could be improved. The suggestions made by the DCs who believed that the provision could be improved (n=37) were, in descending order of importance, ‘provide an information leaflet specific to the reason of rejection’, ‘offer personal counselling’, ‘explain better what the implications are for me’, ‘advise people to see a medical professional’ and ‘other’. Approximately, one in four (27.7%) of all respondents thought that counselling should be available when the refusal message is delivered. The level of satisfaction was not related to the reason for which they were rejected.

Table 3.

Emotional reactions and information management

	Total (n=101)			Satisfied (n=55)	Neutral or dissatisfied (n=46)
	Agreed (fully + rather) %	Neutral %	Disagreed (fully + rather) %	Agreed %	Agreed %	p value Satisfied vs. neutral or dissatisfied*
Emotional reactions**
I was disappointed when I was told I was not eligible	64.4	15.8	19.8	78.2	47.8	0.0019
I was surprised when I was told that I was not eligible	58.4	18.8	22.8	67.3	47.8	0.0679
I regret to have started the plan to donate	13.9	16.8	69.3	12.7	15.2	0.7777
The information made me worry about my health	12.9	15.8	71.3	16.4	8.7	0.3724
I am concerned about my fertility	11.9	13.9	74.3	12.7	10.9	1
I started doubting my manhood	7.9	11.9	80.2	9.1	6.5	0.7246
Managing the information
I am satisfied with the way I was informed about not being eligible	54.5	17.8	27.7
The information provided to me about the result was sufficient	47.5	24.8	27.7	65.5	26.1	0.0001
I think I need to have more testing	23.8	20.8	55.4	18.2	30.4	0.1664
Counselling should be available when the refusal message is delivered	27.7	41.6	30.7	29.1	26.1	0.8249
I am glad that I have learned about the problem now	32.7	42.6	24.8	36.4	28.3	0.4043
The information will allow me to take action in the future	37.6	26.7	35.6	41.8	32.6	0.4112
Social management
I wonder whether I should inform my (future) partner about the result	13.9	13.9	72.3	18.2	8.7	0.2486
Did you contact or do you plan to contact a professional (doctor, fertility specialist) about the result? (yes)#	9.9	13.9	76.2	12.7	6.5	0.3993
Did you talk to others (partner, friends, family) about the result? (yes)#	58.4	3.0	38.6	61.8	54.3	0.5439

^*2-sided Fisher exact, satisfied group vs. neutral or dissatisfied group.

^**The items were dichotomised between those who (fully and rather) agreed vs. neutral or (fully and rather) disagreed.

^#The answering options were yes, no, don’t know. ‘Yes’ is mentioned under ‘agreed’, ‘don’t know’ under ‘neutral’, and ‘No’ under ‘disagreed’.

Emotional reactions and information management

In terms of emotional reactions, 64.4% were disappointed and 58.5% were surprised by the rejection. A small percentage (13.9%) also regretted having started the plan to donate. A small group were worried about their health (12.9%), concerned about their fertility (11.8%) or doubted their manhood (8%) after receiving the information. The emotional reactions and ways of managing the information are presented in Table 3.

The group who were satisfied with the information was significantly more disappointed about not being eligible (78.2% v. 47.8%, p=0.0019). They were also more surprised than the other group but this was not statistically significant (67.3% vs. 47.8%; p=0.0679). About half (47.5%) thought that the information provided to them was sufficient while 24.8% were neutral, and one in four (27.7%) considered it as insufficient. The satisfied group was also more likely to believe that the information provided about the results was sufficient compared to the dissatisfied group (65.5% vs. 26.1%, p=0.0001). About one in four (23.8%) thought that they needed to have more testing. A larger group saw positive aspects of the information: 32.7% were glad to have learned about the problem now, and 37.7% thought that the information would enable them to take action in the future.

Regarding the communication with others after the rejection, 9.9% planned to contact a professional (doctor, fertility specialist) about the result, and 13.9% wondered whether they should inform their (future) partner. Most of the respondents (58.4%) talked about the results with others (family, friends, partner).

Discussion

From our search of the literature, we believe that this is the first study worldwide that scrutinises the emotions, concerns and reactions of sperm donor candidates to their rejection by the sperm bank. The surprise and disappointment reported by around 60% of the respondents could be explained by the fact that they, like most men, take their fertility for granted [9].One reason why men donate is the desire to test the quality of their sperm [10]. Previous studies have shown that sperm quality has a psychological impact on men. Men with low sperm counts have reported feelings of humiliation, despair and depression [11]. Low sperm quality can result in a threatened sense of masculinity [12]. Men with higher motile sperm counts were more likely to report feeling ‘at ease’ or ‘excited’, while men with low motile sperm count were more likely to report feeling ‘concerned’ or ‘frustrated’ [13]. Although these findings were mostly from studies on non-donors, there is no reason to believe that such reactions would not occur in DCs. In the present study, only 8.9% of the respondents reported that poor sperm quality was the reason for their rejection but in Pacey et al. [2], 22% of the men who provided a sperm sample at the same sperm bank were rejected because of poor sperm quality. This suggests that there may be a bias in our sample, indicating that men rejected for poor sperm quality were less likely to participate in the study. However, it is also possible that they were more likely not to remember or not to have been given a specific reason. They may also be confused. For instance, they may have been given information about sperm count but in the end they may not know how to interpret this information: is it normal or is it just not good enough to be a donor? [14]. A possible solution for most groups, but especially for those who could not remember, would be to provide all rejected DCs with a written explanation of the reason for their rejection. Nevertheless, different supportive measures may be needed for DCs disqualified for different reasons. DCs rejected for psychological reasons may, for instance, need referral to a mental health professional.

A considerable proportion of the respondents was rejected for genetic reasons, either after genetic testing (5%) or after taking their family history (25.7%). Candidates who tested positive after genetic testing received a message by email in which they were offered the opportunity to call or write if they had any questions or wanted more information. Our study was not designed to find out how they coped and interpreted the genetic information. The findings of a qualitative study of oocyte donors showed that donors with a positive genetic test result did not always understand what this meant and what the implications were for their own future reproductive plans [15]. The same may also be true for our respondents.

Most DCs were informed by telephone or email. It is very difficult to suggest possible explanations for why DCs who were informed during an appointment were less satisfied. Candidates who were rejected because of low sperm quality received an email containing some basic information about the effects of freezing and variations in sperm quality. The message also offered them the opportunity to call or write if they had any questions or wanted more information. It has been suggested that patients with male factor infertility should be given the opportunity to verbalise their concerns and questions about their own reproduction [16]. However, sperm bank staff responsible for these donor candidates confirmed that requests for more information from unsuccessful candidates were very rare. One solution may be to provide more information as part of the standard procedure, rather than expecting them to ask for more information.

A few DCs regretted that they were rejected for reasons that could have been listed on the website. Two donors were refused because of their high BMI, another for having had sex with another man, and still another for not being a resident in Denmark. Under current Danish tissue legislation, men who have sex with men are not eligible to donate sperm. Such negative experiences can be avoided by mentioning the exclusion criteria on the website and/or in the initial application form.

Limitations

Our results cannot be compared with other studies since no other studies on the views and experiences of excluded sperm donor candidates were found. Moreover, general recommendations about measures to be taken by the sperm banks may be challenging given the large variation in screening procedures and screening criteria. In addition, the response rate of 11.3% of those who opened the email was relatively low. However, given the fact that these men had ended their relationship with the sperm bank by being rejected, their reluctance to participate was expected. It is also possible that dissatisfied DCs were more likely to respond than the others. A further limitation is that the DCs were required to select the reason(s) for their rejection from a closed list of options that did not allow further specification. The option ‘did not meet eligibility criteria’ mentioned age as an example but may have served for very diverse criteria. A more detailed list (including, for instance, psychological health) would have provided more information. Moreover, donors are disqualified when they meet the first point of disqualification. This does not preclude there being more than one issue that would make them unsuitable to serve as donors. A different order of the screening steps would result in a different distribution of exclusion criteria.

Conclusion

The experience of the rejected sperm donor candidates was generally positive. Only about one in four thought that the information provided was insufficient, and about the same percentage were dissatisfied with the way in which they were informed of their ineligibility. Nevertheless, these men had come forward to help others, and it could be argued that sperm banks and fertility clinics have a moral obligation to strive to minimise negative effects. More targeted information about the reasons for rejection and a better accompaniment of rejected candidates may contribute to improve the level of satisfaction of this group.

Data Availability

The data are available upon reasonable request.

Declarations

Competing interests

EL, JGL, LT and ABS are employed by Cryos International. GP and AP are members of the External Scientific Advisory Committee (ESAC) of Cryos.