'Good Quality' by Professor Ayo Wahlberg is a fascinating description of sperm donation in China, based on his fieldwork conducted between 2007-14. Anyone familiar with donor programmes will recognise the challenges of sperm donor recruitment, retention and quality assurance described, although Professor Wahlberg argues that this, set within China's cultural, juridical, economic and social landscape, has resulted in a unique style of sperm banking.
Professor Wahlberg, an anthropologist at the University of Copenhagen in Denmark, may well be correct. Appreciating the complexities of China's recent political past, the decimation of science and research during the Cultural Revolution and the impact of the 'one child' policy are all important to understanding the incredible challenges that assisted reproduction technology has faced in China.
Indeed, while fertility treatment would generally be considered a treatment for those experiencing subfertility, support for its development and legalisation in China appears to be primarily based on the concept of fertility treatment as a means to improve population quality, including avoiding transmission of genetic diseases.
China is now the second largest economy on the planet. However, its economic reform appears to be in stark contradiction to restrictions in democracy and freedom within the current Communist political system, just as sperm banking and fertility treatment in China apparently defies the country's traditions of patrilineal culture and dynastic succession.
Societal influences heighten the stigma of infertility. Secrecy and anonymity are the norm. Until very recently, donor insemination (or IVF using donor sperm) was only available to married couples with a 'qualification of pregnancy' certificate. This document historically allowed couples to have children legally, and was used by the authorities to control the population. Even now, ID cards, a valid marriage certificate and a written commitment to China's family planning policy are still requirements for fertility treatment. As such, single women and same-sex female couples are prohibited from using sperm banks.
Despite this, the numbers are eye-watering. China's population is currently 1.4 billion. With an estimated one to two million azoospermic men (whose semen contains no sperm) and documented ongoing decline in sperm quality attributed to lifestyle choices and environmental pollution, demand for donor sperm is huge. Waiting time for treatment is defined by donor sperm availability and estimated to be at least three years.
Yet in spite of such high demand, import and export of sperm is forbidden and very limited commercialisation exists. Furthermore, fertility clinics and sperm banks are required to follow Ministry of Health regulations, to ensure ‘improvement of population quality’. Sperm donor recruitment is therefore highly selective, with donors generally targeted cyclically from top universities, who are young, intelligent and in good health.
Despite selective recruitment, only 10 to 30 percent are accepted as sperm donors. Beyond this, 40 to 60 percent of submitted samples may be rejected from qualified donors because they don't meet quality criteria, and there is a five-woman pregnancy limit. In the clinic described, over 100 samples are handled by andrology each day. The work involved in sperm banking on this scale is breathtaking. An integral part of sperm banking in China has necessarily been development of a high-throughput approach, both in the laboratory and clinic.
Finally, an intriguing part of Professor Wahlberg's commentary is the phenomenon of a generation of single children following the one-child policy. Intense competition among one-child cohorts (currently in their 20s and 30s) for university places, top jobs and even partners has not only resulted in reproductive deferral, but also family planning practices that may contribute to infertility (for example, termination of pregnancy).
And while social sperm freezing is available for both single and married men, social egg freezing is not an option for Chinese women. The exponential rise in demand for fertility treatment in China is therefore set to continue.
'Good Quality' offers candid descriptions of donor recruitment, screening and philosophy towards routinisation of sperm banking in China. It is an enlightening read, not least because it considers the background to fertility treatment in China, as well as the unique style and scaling developed in response to mass demand. The idea of 'improving population quality' is not a concept shared by donor sperm programmes in the UK, but Professor Wahlberg describes some notable similarities to UK practice.
Indeed, his book conveys many messages applicable to donor recruitment and sample quality for any clinic undertaking sperm banking: donor recruitment appears to be most effective through word-of-mouth or personal contact with those who champion the cause, embarrassment and lack of familiarity may dissuade individuals even if they are highly motivated to donate, and clinic feedback is valued by those eventually deemed unsuitable to become donors.
As such, the book unexpectedly contributes insights that may well be useful to inform clinical care. Certainly the strategy of lifestyle interventions to improve the sperm of potential donors so that they qualify to donate is worth noting. Given their apparent success, I can't help wondering whether a similar intervention strategy might be worthwhile trying with patients too.