Research implications of embryo cryopreservation choices made by patients undergoing in vitro fertilization

(Not) wanting to choose: outside agencies at work in assisted reproductive technology

Human choice and interventions that could seem to threaten the course of 'nature' or 'chance' are at the heart of controversies over assisted reproductive technology across Western countries. These debates focus predominately on so-called 'selective reproductive technology'. While today, the technique of in-vitro fertilization (IVF) raises few political and bioethical debates in France and other Western countries, concerns remain that human intervention might replace 'natural' processes, threatening human procreation. These polemics focus on situations that require a decision, notably embryo selection and the fate of spare frozen embryos. The choices involved are induced by the technology and organized by the law. In the French legal system, IVF patients and professionals have the opportunity and, to a certain extent, the responsibility to decide on the status of in-vitro embryos. This article shows that, in these situations, both IVF patients and professionals invoke outside agencies ('instances tierces'), both to avoid making decisions and to recover a world order in which procreation is not entirely subject to human decision. In short, there is a need to feel that procreation is not entirely dependent on human intervention; that individuals do not decide everything. It appears that the choices that are made, their nature and the type of outside agency that is invoked are highly situated.

[Between "pragmatic" interpretation and "disturbing" understanding: Embryonic cryopreservation for IVF patients]

OBJECTIVES

The aim of this article is to question the feeling of IVF patients towards embryonic cryopreservation, in order to understand their potential reluctance to freeze embryos and their difficulties to consider the fate of their frozen embryos once their parental project completed.

METHODS

Twenty-seven semi-directive interviews with homologous IVF patients were conducted. These persons were followed in two fertility centres in Marseille.

RESULTS

If all the patients interviewed have accepted embryonic cryopreservation or have accepted on principle, a majority have an ambivalent attitude towards this technique. If some share the "pragmatic" vision of professionals (embryologists, technicians and gynaecologists), they are numerous to worry about a possible deterioration of embryonic quality, or again about a disrupted order of generation. Finally, it appears that patients do not anticipate the possible fate of their frozen embryos if they are uninscribed from their parental project.

CONCLUSIONS

Patients are mainly ambivalent towards embryonic cryopreservation. They prioritize different rationality depending on the situations and issues they are dealing with.

The Fate of Unused Embryos: Discourses, Action Possibilities, and Subject Positions

Although in vitro fertilization (IVF) has offered hope to those struggling with infertility, it has also had some unintended consequences, including the fate of embryos that may be "surplus" to requirement following IVF treatment. The number of embryos in storage across the world is high, creating a dilemma for patients who need to make disposal decisions, as well as presenting an administrative and practical dilemma for clinics. Research has suggested that patients' views of the status of their embryo/s may affect their disposal decisions, and yet the nature of the links between views of the embryo and decisions to either donate or discard remain unclear. In this article, we engage in a discursive analysis of literature on disposal decisions. We discuss the range of ways in which embryos may be constructed, and demonstrate how these discourses make available or constrain particular action possibilities, and offer particular subject positions for patients. The analysis highlights the complexity of the relationship between embryo status and decision making, and may assist clinicians in supporting and guiding patients' decisions.

Frozen in perpetuity: 'abandoned embryos' in Canada

The matter of 'abandoned embryos' arises when surplus IVF embryos are frozen and stored for later use. If the fertility clinic or storage facility in question does not have clear direction about what to do with these embryos, and/or payment for storage ceases, and/or the embryo providers cannot be reached, the embryos raise an ethical and practical challenge. On the one hand, there is a commitment to respect the autonomy of embryo providers to determine what should happen to their frozen embryos. On the other hand, there are weighty reasons why fertility clinics and storage facilities do not want responsibility, potentially in perpetuity, for other people's frozen embryos. This article examines the matter of 'abandoned embryos' - the emergence of the term, its use in policy and law, and its implications in the Canadian case. We demonstrate that despite an intricate legislative framework, there are important gaps that leave fertility clinics and storage facilities in the tenuous position of discarding 'abandoned embryos' without clear authorization, or storing them indefinitely. We argue that clarity in consent procedures coupled with flexible time limits on embryo storage provide an approach that can best serve the interests of all involved.

Pre-birth characteristics and 5-year follow-up of women with cryopreserved embryos after successful in vitro fertilisation treatment

Many patients do not make a decision about the disposition of their surplus embryos until they are compelled to do so by statutory limits. In the current study, the characteristics of women who had conceived through in vitro fertilisation (IVF) and who still had embryos stored (E-S; n = 26) 5 years after IVF were compared to a cohort comparison group (C-C; n = 40). At time 1 (T1, 28 weeks pregnant) women completed questionnaires on personality traits (anxiety, locus of control and dependency) and participated in an interview on socio-demographic characteristics, family composition and stored embryos. At T2 (5 years later) women were re-interviewed and asked about beliefs about the embryos. Women in the E-S group were significantly younger, had been married or living with their partner for fewer years and had had more children than the C-C group. Further, women in the E-S group were more likely to have an external locus of control and a dependent personality than women in the C-C group. Almost all women in the E-S group (88.5%) thought of their embryos as siblings to existing children, and reported thinking about the embryos occasionally (61.5%) or frequently (34.6%). The personality differences identified may suggest that women who still have embryos after the end of fertility treatment may be in need of decision support.

Deciding the fate of supernumerary frozen embryos: parents' choices

Embryo cryopreservation is a routine procedure in assisted reproductive technologies. Although couples have been informed about all potential procedures, some of them face the dilemma of what to do with surplus frozen embryos. The purpose of this qualitative study was to evaluate the attitude of patients toward their surplus cryopreserved embryos. Fifty patients who had undergone successful IVF cycles, and had surplus embryos cryopreserved were selected from a clinical database. We could contact twenty two patients agreed to participate in the study and responded the interview. Seventeen participants (77.3%) believed that cryostoraged embryos were 'life'. Patients who would discard embryos rather than donate to research expressed their concern about the misuse of embryos. Those who would discard rather than donate to other couples considered that donating an embryo would be like giving away a child. Seven patients were unsure whether life had begun at this stage of development. Although some couples thought of their embryos as little more than biological material, others envisioned them as living entities or 'virtual' children. The decisions on whether to donate embryos to another couple, or discard them were coloured by strong values about human life and equated with child abandonment.

Fertility patients' views about frozen embryo disposition: results of a multi-institutional U.S. survey

OBJECTIVE

To describe fertility patients' preferences for disposition of cryopreserved embryos and determine factors important to these preferences.

DESIGN

Cross-sectional survey conducted between June 2006 and July 2007.

SETTING

Nine geographically diverse U.S. fertility clinics.

PATIENT(S)

1020 fertility patients with cryopreserved embryos.

INTERVENTION(S)

Self-administered questionnaire.

MAIN OUTCOME MEASURE(S)

Likelihood of selecting each of five conventional embryo disposition options: store for reproduction, thaw and discard, donate to another couple, freeze indefinitely, and donate for research; likelihood of selecting each of two alternative options identified in previous research: placement of embryos in the woman's body at an infertile time, or a disposal ceremony; importance of each of 26 considerations to disposition decisions; and views on the embryo's moral status.

RESULT(S)

We found that 54% of respondents with cryopreserved embryos were very likely to use them for reproduction, 21% were very likely to donate for research, 7% or fewer were very likely to choose any other option. Respondents who ascribed high importance to concerns about the health or well-being of the embryo, fetus, or future child were more likely to thaw and discard embryos or freeze them indefinitely.

CONCLUSION(S)

Fertility patients frequently prefer disposition options that are not available to them or find the available options unacceptable. Restructuring and standardizing the informed consent process and ensuring availability of all disposition options may benefit patients, facilitate disposition decisions, and address problems of long-term storage.

Report on the donation of supernumerary embryos from fresh IVF and ICSI treatment cycles for human stem cell research

BACKGROUND

Research involving human embryos promises exciting therapeutic advances but raises ethical and moral dilemmas for scientists and potential donors. The aim of this study is to report the proportion of couples donating supernumerary fresh embryos for development of stem cell lines from a single centre and the characteristics of those who donate.

METHODS

Couples undergoing assisted conception treatment in a teaching hospital received research information between January 2005 and July 2006. Counselling and consenting was performed by a dedicated research nurse. Demographic data was collected for couples who enrolled in the study.

MAIN OUTCOME MEASURES

To determine the proportion of couples willing to donate surplus embryos for stem cell derivation and to examine the characteristics of those who consent to donate.

RESULTS

Of 508 couples, 353 (69%) expressed an interest in research on their treatment consent forms. Sixty-six percent of those interested in research and 87% of counselled couples consented to donation. The demographic characteristics of those who agreed to donate were similar to those of all couples attending the unit.

CONCLUSIONS

Approximately half of couples consented to donate under the described system in our centre. Detailed information provision helps the majority of those counselled to proceed to donation.

Disposition of cryopreserved embryos by infertility patients desiring to discontinue storage

OBJECTIVE

To review our patients' decisions for disposition of their cryopreserved embryos and compare the findings with those reported in the scientific literature. Patients who no longer wish to store their cryopreserved embryos have three choices: discarding, donation to research, or donation to someone else for initiation of a pregnancy.

DESIGN

Retrospective review of patient records from January 2002 to July 2007 to determine preferences for embryo disposition.

SETTING

University hospital.

PATIENT(S)

Patients who elected to discontinue embryo cryostorage.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Patients' decisions regarding embryo disposition, length of storage, treatment outcome, age at oocyte retrieval, and age at time of disposition.

RESULT(S)

A total of 149 disposition requests were reviewed, with 59% donating to scientific research, 38% discarding, and 3% donating to a known or anonymous person/couple for attempted pregnancy. There was no significant difference in the choice selected between patients who achieved a pregnancy with delivery compared with those who did not. Patient age at retrieval and at the time of disposition as well as the total time in storage was not significantly different between patients electing to discard and those donating to research.

CONCLUSION(S)

Patients in our program wanting to discontinue cryostorage were more likely to request that their surplus embryos be used for scientific research.

Patients' attitudes to their embryos and their destiny: social conditioning?

The clinical management of embryo storage and disposal is dynamic and subject to changes in the cultural context such as public debate and the implementation of public policy. Studies of the decisions made by patient couples for their embryos, and trends in decision-making over time and in relation to issues arising in the cultural context are rare. Studies of the attitudes that patient couples have towards their frozen embryos have largely focused on measuring patients' intentions in relation to publicly contentious outcomes. A small but expanding number of interview studies are illuminating the meaning that couples attribute to frozen embryos and how this influences decisions for their destiny. This chapter maps both quantitative and qualitative studies of patients' attitudes and decisions illuminating similarities and contradictions in study findings, and ultimately highlights the range of attitudes in patients, clinics and the community towards what is evidently a difficult and morally challenging decision to end the storage of frozen embryos.

Deciding the fate of supernumerary frozen embryos: a survey of couples’ decisions and the factors influencing their choice

OBJECTIVE

To investigate the decisions that couples make regarding supernumerary frozen embryos, the factors influencing these decisions, and the degree of difficulty involved in reaching a decision; and to canvass attitudes toward donating embryos to stem-cell research.

DESIGN

Anonymous postal survey.

SETTING

A large, private IVF clinic in a major city in Victoria, Australia.

PATIENT(S)

A consecutive cohort of couples who contacted the Monash IVF clinic in relation to embryos in long-term storage.

INTERVENTION(S)

Subjects completed a survey regarding decisions about surplus frozen embryos.

MAIN OUTCOME MEASURE(S)

Couples' decision regarding supernumerary embryos and reasons for the decision, experience of deciding, and attitudes about embryo donation for stem-cell research.

RESULT(S)

Forty percent (123/311) returned completed questionnaires. The most common decision was donation to research (42%). Altruistic motives and desire not to waste embryos were determinants of embryo donation. Determinants of disposal were not wanting a full sibling to existing children and opposition of embryo research. Forty-five percent found deciding distressing. The majority (69%) approved of embryo donation to stem-cell research.

CONCLUSION(S)

Most couples preferred embryos to come to some use rather than being disposed of. Almost half the sample reported finding the decision making distressing. A majority approved of embryo donation for stem-cell research.

Human embryonic stem cell derivation: from the IVF perspective to therapeutic applications

Human embryonic stem cells (hESC) are capable of proliferating indefinitely in an undifferentiated state and are pluripotent, being able to differentiate into most cell types under the correct conditions. Since the establishment of the first hESC line in 1998, the hope has existed that these cells could constitute an unlimited cell source for replacement therapy in the treatment of various diseases and disabilities. However, there is opposition and concern within society towards hESC derivation. The purpose of this article is to introduce the medical and scientific issues surrounding hESC derivation for clinical use concerning the source for this research (human embryos donated from in vitro fertilization procedures), and the methodologies implicated in feeder-free, xeno-free derivation that will allow potential clinical applications.

Parent identity and 'virtual' children: why patients discard rather than donate unused embryos

BACKGROUND

Many patients prefer to donate unused embryos when surveyed. However, it is a source of frustration and curiosity that clinical audits of embryo outcomes show the majority changed their minds. In many clinics, the number of recipients continues to outweigh the number of donors. To plan effective counselling practices, it is important to understand the dynamics of decision-making for patients when determining outcomes for unused embryos.

METHODS

Twelve couples and nine women (n = 33) who had discarded unused embryos were interviewed using a narrative structure and various interview techniques. Interview transcripts underwent qualitative analysis through which data were grouped thematically according to similarities. Differences were also examined.

RESULTS

Participants described their initial choice to donate embryos as an idealistic plan rather than a purposeful decision. Their change of mind was due to two factors: (i) a change in their standpoint from a childless couple to parents; and (ii) a change in the symbolism of the embryo from representing a chance to become pregnant to representing a 'virtual' child in cryo-storage. The meaning of embryo donation was likened to child relinquishment.

CONCLUSION

Counselling and social policy need to take account of the symbolism of the embryo and reform current practices.