[KAMPALA] Poor regulation and lack of transparency in Africa’s fertility industry leave sperm donors and recipients vulnerable to exploitation and unethical practices, including relatives unwittingly having children together, fertility experts warn.

Consanguinity, referring to where biological relatives conceive children together, increases the likelihood of genetic disorders and other health complications in offspring.

This risk is increased in Africa by the absence of clear regulations to guide the fertility industry or systems to track and limit sperm donations.

Infertility is a growing concern in Africa, with the region having the highest global prevalence at 16 per cent, followed by the Western Pacific at 13 per cent, and European regions at 12 per cent, according to a 2019 study in the Journal of Global Health Reports.

While primary infertility – the inability to conceive a first pregnancy – is relatively uncommon in Sub-Saharan Africa, secondary infertility, where individuals struggle to conceive again after a successful pregnancy, poses a significant challenge.

To address these issues, many couples turn to assisted reproductive technology (ART), including in vitro fertilisation (IVF).

However, ART operates in a largely unregulated environment in Africa, exposing donors and recipients to risks and ethical dilemmas, including the possibility of consanguinity, according to medical experts.

Anthony Kayiira, chief reproductive embryologist at Mulago National Referral Hospital in Kampala, Uganda, tells SciDev.Net that the unregulated sale of sperm to numerous families can lead to situations where offspring unknowingly form consanguineous relationships, leading to higher risk of genetic disorders down the family line.

“Without proper oversight, we create an environment where the risk of genetic disorders rises because donors’ sperm is used too widely without accountability,” says Kayiira.

“We need stricter regulations to protect donors and recipients.”

For instance, in Nigeria, Abraham Fasasi, director of embryology services at the Omega Golden Fertility Clinic in Lagos, says men can donate sperm up to 30 times a year.

By contrast, in more regulated, wealthier countries, the limit on donations is often significantly lower than 30, to avoid the risk of consanguinity.

In the UK, for example, the Human Fertilisation and Embryology Authority stipulates that one sperm donor cannot be used to create more than ten families.

“We use one donor ejaculation per couple,” Fasasi explains. “If one donates five times a week, and the sperm quality is good, those are likely to be five couples saved,”

He adds: “I had a medical student who donated to us throughout his [time at] university and when he finished, he was willing to donate three times free of charge as a ‘thank you’ – the reason being this compensation covered his bills throughout.”

However, Fasasi agrees that sperm donation in Nigeria needs stricter regulation.

“We cannot trace how many times one has donated. As long as his sperm is of good quality and passes our tests, there’s no limit and regulations against that,” he says.

According to Fasasi, there are more than 100 fertility centres in Lagos and one donor can be a donor in as many clinics as he chooses.

When asked how many recipients can benefit from a single ejaculation, Fasasi explained that it depends on the quality of the sperm and the donor’s profile.

“If he is special donor and his sperm is of good quality, we can use it on multiple women but this is disclosed to the donor,” he said.

Guidelines by the American Society for Reproductive Medicine state that sperm banks and clinics should maintain records that restrict the number of pregnancies for which a given donor is responsible, to avoid inadvertent consanguineous conception.

However, Lisa Stark Hughes, a two-time surrogate mother from California, USA and founder of Host Mums in Uganda and Kenya as well as Gestational Surrogate Moms (GSMoms), believes sperm from donors is being sold to multiple families without the consent of donors.

“This not only exploits the donors but also raises serious ethical and genetic concerns,” she says.

Legislative changes

Unlike in countries where strict laws limit the number of offspring per donor to reduce the risks of consanguinity, many African nations lack such safeguards.

In Uganda, the industry operates with minimal regulation, despite having 14 sperm banks in operation, two of which are government-owned, according to Herbert Luswata, president of the Uganda Medical Association.

This led Ugandan legislator Sarah Opendi to table the Human Assisted Reproductive Technology Bill 2023, aiming to create a framework for donors and recipients.

“My bill is to regulate the fertility clinics [and] hospitals and those that use their services,” Opendi said.

Supporting Opendi’s bill, Luswata said: “It’s time to have this bill because there are many things which can go wrong in involving science if they are not well regulated.”

Youth ‘exploited’

During a meeting with the Ugandan parliament in October last year, Ruth Sekindi, director of monitoring and inspections at the Uganda Human Rights Commission, brought up concerns about the age of sperm donors.

She suggested some clinics were taking advantage of young people who aren’t mature enough to make the best fertility decisions.

“Young people’s bodies are not to be exploited for the benefit of older, wealthier couples and individuals,” said Sekindi, adding: “Many of them do it for money.”

Sekindi wants to see age restrictions included in the Human Assisted Reproductive Technology Bill. Current regulations allow donations from men as young as 18, but she believes that this is still too young for them to understand the full implications, including the risk of consanguinity.

“Carrying a child for another person at 18 or 19 is not an appropriate option,” Sekindi said. “Obtaining gametes or sperm from minors is also prematurely burdensome.”

Surrogacy advocate Stark Hughes, who has gone through assisted reproduction herself, says she has seen how it can bring joy and hope to families struggling with infertility, and empower people to build their families in a way that is right for them.

However, she recognises the ethical complexities surrounding sperm donation in Africa.

“The most critical ethical considerations include establishing clear standards and regulations, addressing family limits, and ensuring transparency about genetic ancestry,” says Hughes, who was invited to help create ethical legislation for surrogacy in Uganda.

“In many African countries, there is a lack of clear guidelines and regulations surrounding sperm donation, which can lead to inconsistencies and exploitation,” she adds.

Clear regulations could limit the number of donations and offspring per donor to safeguard genetic diversity, prevent overreliance on a single donor, and reduce risks of accidental incest to protect the well-being of donors, offspring, and the broader gene pool.

Senior embryologist Claire Nakalema checking sperm quality using a high-resolution microscope at the Women’s hospital in Bukoto, Kampala.

To ensure ethical practices, Stark Hughes stresses the importance of education and awareness-raising in holding organisations to account and promoting best practice.

She also emphasises the need for community involvement and support in the reproductive process.

“In many African cultures, large families are celebrated and societal attitudes towards fatherhood and community support can enhance the willingness of men to donate,” she says.

“By investing in education and training, governments and regulatory bodies can cultivate a culture of integrity and respect, ensuring that third-party reproduction is guided by compassion, transparency, and accountability.”

Cultural complexities

In many African societies, infertility carries social stigma, leading couples to seek fertility treatments without fully understanding the long-term genetic and social implications.

In some communities, the concept of sperm donation itself is taboo, making it challenging to recruit diverse donors and avoid genetic overlaps.

In Nigeria, Fasasi tells SciDev.Net that finding donors from certain cultural or religious backgrounds, such as Muslim communities, can be particularly difficult.

This can narrow down the donor pool, increasing the likelihood of consanguinity.

“We need to approach this issue with sensitivity and respect for cultural beliefs while prioritising the establishment of clear regulations to safeguard genetic diversity,” Fasasi said.

Most governments adopt laws from higher-income countries, often referencing guidelines and recommendations from organisations such as the European Society of Human Reproduction and Embryology (ESHRE).

However, these imported frameworks may not address Africa’s unique social, economic, and cultural contexts, such as religious and societal taboos, according to analysts on the continent.

This lack of clear regulation and legal framework has sparked concerns around informed consent, donor exploitation, and the need for stricter oversight.

Cash incentives

Joseph, a graduate at Makerere University who did not wish to give his full name, told SciDev.Net that he and some of his friends donated sperm multiple times in 2020 for 100,000 Ugandan shillings (about US$27) per donation to a private hospital in Kampala.

The criteria for donation included studying a desirable course, such as the sciences, as recipients wanted to have intelligent children.

Joseph says if he had reflected more on his earlier decision, he may not have donated.

He says he and his friends focused on the money, even though it was a small amount, and didn’t think much of the long-term implications.

“I now feel I was treated like a commodity,” says Joseph. “The clinic’s interest was my sperm, not my well-being. I was exploited for my biology.”

Kayiira says an increasing number of young men are eager to donate sperm due to the perceived monetary incentives.

He believes that many donors are not fully aware that the pay is little and that donating too many times can lead to genetic complications resulting from consanguineous relationships.

“We need stricter regulations to protect both donors and recipients,” says Kayiira.

“We also need to create more awareness because many think they are providing a service for a big paycheck.”

The lack of regulation means that each fertility centre in Uganda can have its own compensation policy, Kayiira explained.

In more affluent countries such as the UK, it is illegal for sperm donors to be paid, other than for reasonable expenses such as travel. US guidelines also state that payment should not be such that money becomes the primary motivation for donating.

But in Uganda, a fertility clinic can pay to secure a sperm donor who has certain characteristics desired by a potential recipient, according to Kayiira.

In the UK, donors are also informed that children conceived from donations made after 1 April, 2005 will be able to find out their donor’s name, date of birth, and last known address once they turn 18.

Social division

As in Uganda, a lack of comprehensive legislation governing sperm donation in Kenya leaves room for varying practices and potential exploitation, say experts in the sector.

They stress the urgent need for clear legal frameworks to protect both donors and recipients, ensuring ethical practices, transparency, and affordability.

In addition to this, the costs for recipients of sperm donations can be huge, while donors are barely compensated.

Meanwhile, sperm recipients pay between US$2,000 and US$4,000 for insemination, a price that excludes additional fertility clinic expenses.

Nakalema says most clients come from South Sudan, Ethiopia, and Eritrea.

Fertility Point Clinic in Nairobi charges Ksh 55,000 (about US$400) for a sperm donor, in addition to US$3,900 for the IVF procedure itself, an inquiry by SciDev.Net found.

These exorbitant costs place such fertility treatments out of reach for many Kenyans, raising concerns about equity of access to reproductive healthcare.

The clinic says it uses an agency to source sperm donors, but patients are also allowed to provide their own.

Others say the disparity between what donors are paid and what patients are charged is exploitative and socially divisive, with only wealthy people able to access treatment.

Nigeria has made some progress in regulating sperm donation under the 2014 National Health Act.

In Nigeria, sperm donors typically receive compensation ranging from ₦50,000 to ₦100, 000 per donation (US$30–US$60), depending on the fertility centre.

Fasasi says that while donors remain anonymous and do not receive information about the recipients, recipients are provided with the donor’s profile.

Call for transparency

In South Africa, fertility centres have specific guidelines for sperm donors.

For instance, one centre’s website states that donors can contribute up to ten times, with a mandatory one-week gap between donations, and they are advised to abstain from ejaculation for at least three days before each donation.

However, Letlhokwa George Mpedi, vice-chancellor and principal at the the University of Johannesburg, South Africa, says there is a need for clearer regulations.

“Current legislation is often unclear and can be confusing,” he said.

“While the law addresses some ethical considerations, significant gaps remain, and there is a strong argument for increased oversight of assisted reproductive technology,” he added.

In South Africa, the National Health Act sets out the regulatory framework, but inadequate donor screening, insufficient regulation of sperm banks, and unclear legislation create ethical violations and exploitation risks, experts say.

Mpedi says the legislation that exists is not comprehensive enough to address the concerns raised adequately, or to deal with newer developments in this field.

For Kayiira, of Mulago National Referral Hospital, Kampala, the lack of regulation creates an environment in which unscrupulous individuals can take advantage of vulnerable people.

He says there needs to be a concerted effort to strengthen regulations, improve informed consent, and ensure fair compensation.

“We need to work together to create a more ethical and transparent industry,” Kayiira urges.

He believes that prioritising the welfare of donors and recipients will ensure that sperm donation remains a safe and ethical option for those experiencing infertility.

This piece was produced by SciDev.Net’s Sub-Saharan Africa English desk.