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

Parents facing polygenic embryo scores: the 'best choice of a best life' and psychological counselling

Advances in reproductive medicine and genetic technologies now offer prospective parents the option to test IVF embryos for genetic predispositions to complex diseases, such as coronary heart disease and psychiatric disorders, through polygenic embryo screening (PES). However, limited clinical data on its real-world use leaves parents facing complex decisions based on probabilistic risk scores, requiring them to weigh uncertain benefits against potential harms. While clinical, ethical, and societal concerns regarding PES have been extensively discussed, the psychological considerations have received less attention. This paper highlights the importance of decision aids as part of psychological interventions, which are crucial for helping parents navigate these choices and make informed decisions based on individual perceptions and experiences. Additionally, determining how and when to disclose genetic risk information to children presents significant challenges for families. Early disclosure may lead to anxiety, while withholding information could undermine trust later in life. Psychological counseling is therefore an essential component in supporting families through these sensitive decisions. While PES offers opportunities to reduce genetic risks, it also introduces significant challenges that require thoughtful consideration and comprehensive support for both parents and children.

Too many embryos: a critical perspective on a global challenge

Over the past decade, significant endeavors have been directed toward establishing an optimal oocyte number to maximize the chances for successful in vitro fertilization outcomes. The effectiveness of assisted reproductive technologies has greatly improved, and more good-quality embryos are being created in each cycle. However, many of these embryos remain unused. Notably, in Europe, approximately one-third of couples did not use their surplus cryopreserved embryos. Surplus embryos pose a challenge for patients and clinics. Embryo disposal practices are not the same all over the continent, with embryo donation and embryo discharge not allowed in several countries. In this scenario, limiting the number of surplus embryos by reducing the number of inseminated oocytes, according to couple clinical history, could be a strategy.

Psychosocial outcomes of children born via embryo donation

STUDY QUESTION

What are parents' perceptions of their relationships with and the psychosocial adjustments of their children who are born via embryo donation?

SUMMARY ANSWER

Families created through embryo donation have well-adjusted parent-child relationships and reassuring child psychosocial outcomes.

WHAT IS KNOWN ALREADY

Embryo donation is an effective and growing form of third-party reproduction, but there is limited research in this field. Prior studies suggest that families created through gamete donation function well regarding parent-child relationship quality and child behavioral and socioemotional adjustment.

STUDY DESIGN, SIZE, DURATION

This is a cross-sectional survey study with 187 total participants.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Parents of children born via embryo donation were recruited nationally by contacting all embryo donation programs registered with the Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) as well as medically directed embryo donation or 'embryo adoption' centers. Participants completed three online Qualtrics questionnaires. The first was a survey including 33 questions on demographics, the procurement process, and self-reported obstetric outcomes. Participants also completed two standardized measures assessing children's behavior and parents' adjustment to parenthood: the Strengths and Difficulties Questionnaire (SDQ) and the Parental Acceptance-Rejection Questionnaire (PARQ). Scoring of the SDQ and PARQ was totaled and compared to standardized values (SDQ) or previously published results on other forms of gamete donation (PARQ), such as oocyte donation and sperm donation.

MAIN RESULTS AND THE ROLE OF CHANCE

On the SDQ (n = 46), the average total difficulties scores by age were: 8.2 ± 0.98 for ages 2-4, 7.6 ± 0.93 for ages 5-10, and 3.5 ± 0.77 for ages 11-17; this is compared to the normal reported range of 0-13, which indicates that clinically significant psychosocial problems are unlikely. Across all ages and individual categories (emotional symptoms, conduct problem, hyperactivity, peer problem, prosocial), scores on the SDQ were within the normal ranges. The average PARQ score (n = 70) for all respondents was 27.5 ± 1.18 (range: 24-96), suggesting perceived parental acceptance.

LIMITATIONS, REASONS FOR CAUTION

Because this study was cross-sectional, it could not capture familial relationships over time. This survey-based study design allows for potential selection bias (parents of well-adjusted children may be more likely to participate). Additionally, the overall sample size is relatively small; however, it remains one of the largest published to date. Another significant limitation to this study is the lack of generalizability: most participants were recruited from private, faith-based, embryo donation programs who are demographically similar.

WIDER IMPLICATIONS OF THE FINDINGS

Though embryo donation is an established form of third-party reproduction, it is significantly less robustly studied compared to other forms of gamete donation (oocyte or sperm donation). This study provides a larger data set with a more expanded age range of children compared to the limited number of previously published studies. Furthermore, these findings indicate a high parental disclosure rate with respect to the use of embryo donation which contrasts previous findings.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding source was utilized for the completion of this study. No conflicts are disclosed.

TRIAL REGISTRATION NUMBER

N/A.

Non-identified and directed embryo donation: a questionnaire study on donor and recipient perspectives

With the growing challenge of abandoned surplus embryos in the ART arena, and the limited traction of embryo donation as a viable embryo disposition choice, it is important to better understand barriers to wider adoption of this opportunity. We aim to learn about perspectives and experience of participants in directed and non-identified embryo donation programmes. This was a longitudinal cohort survey study, of all participants in an embryo donation programme in a single university affiliated clinic between 2016 and 2020. Clinical data were extracted from counselling reports. Based on these data, non-identified online questionnaires were constructed and refined via Delphi procedure for face and content validity. Sixty-five online questionnaires were emailed between March-April 2021. Descriptive statistics, cross-tabulation, Fisher's exact test and t-test were used for analyses. Source of patient awareness, factors influencing the decision-making process, patient perspective and satisfaction were explored. The response rate was 67.2%. Most participants in the non-identified programme learned of it through their treating physicians, whereas most participants in the directed programme learned of it online. The main driver to donate across both cohorts was wanting to give others the opportunity to experience the joy of parenthood. Overall, 45% described moderate to marked difficulty in decision making related to donating their embryos, and this did not differ between cohorts. Non-identified donors reported feeling highly attached to the donated embryos more often than directed donors. Level of satisfaction was higher in the directed donation programme. Participants were more satisfied following directed than non-identified donation, and some even consider their counterparts as extended family. Our findings should be validated in various settings, and on larger samples.

Elective egg freezers' disposition decisions: a qualitative study

OBJECTIVE

To explore the factors that influence elective egg freezers' disposition decisions toward their surplus-frozen oocytes.

DESIGN

Qualitative.

SETTING

Not applicable.

PATIENT(S)

Thirty-one participants: 7 past; 6 current; and 18 future oocyte disposition decision-makers.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Qualitative thematic analysis of interview transcripts.

RESULTS

Six inter-related themes were identified related to the decision-making process which are as follows: decisions are dynamic; triggers for the final decision; achieving motherhood; conceptualization of oocytes; the impacts of egg donation on others; and external factors affecting the final disposition outcome. All women reported a type of trigger event for making a final decision (e.g., completing their family). Women who achieved motherhood were more open to donating their oocytes to others but were concerned about the implications for their child and felt responsibility for potential donor children. Women who did not achieve motherhood were unlikely to donate to others due to the grief of not becoming a mother, often feeling alone, misunderstood, and unsupported. Reclaiming oocytes (e.g., taking them home) and closure ceremonies helped some women process their grief. Donating to research was viewed as an altruistic option as oocytes would not be wasted and did not have the "complication" of a genetically-linked child. There was a general lack of knowledge around disposition options at all stages of the process.

CONCLUSION(S)

Oocyte disposition decisions are dynamic and complex for women, exacerbated by a general lack of understanding of these options. The final decision is framed by: whether women achieved motherhood, dealing with grief if they did not achieve motherhood, and considering the complexities of donating to others. Additional decision support through counseling, decision aids, and early consideration of disposition when eggs are initially stored may help women make informed decisions.

Association between donor gamete use and supernumerary embryo disposition decisions

PURPOSE

The aim of this study is to determine if donor gamete use is associated with patients' decisions regarding disposition of supernumerary embryos.

METHODS

Patients who intended to undergo an IVF cycle at a single academic center signed an embryo disposition consent form to indicate their disposition preferences for any supernumerary embryos. A retrospective chart review was performed to obtain the embryo disposition declarations and demographic information. The primary outcome was the distribution of embryo disposition choices between patients who used donor gametes compared to patients who did not use donor gametes. Fisher's exact test was used to compare groups. Logistic regression models were created to determine the association between donor gamete use and disposition decision after adjusting for patient age, body mass index, and nulliparity.

RESULTS

Five hundred six patients were included. Ninety-one (18.0%) patients used donor gametes [46 (9.0%) donor oocytes, 52 (10.3%) donor sperm]. Patients using donor gametes differed from those not using donor gametes when making decisions concerning death of the patient (P < 0.01), simultaneous death (P = 0.04), separation (P < 0.01), discontinuation of ART (P = 0.01), and time-limited storage (P < 0.01). Most patients, regardless of donor or autologous gamete use, awarded embryos to themselves or their partner if given the option. For patients who did not choose this option, excess embryos were generally awarded to research or discarded rather than donating to another couple. Patients using donor gametes were more likely to award embryos to research over discarding.

CONCLUSION

Patients using donor gametes made different choices regarding supernumerary embryo disposition compared to patients not using donor gametes.

Kin or Research Material? Exploring IVF Couples' Perceptions about the Human Embryo and Implications for Disposition Decisions in Norway

In vitro fertilization (IVF) involves making embryos outside of the human body, which has spurred debate about the status of the embryo, embryo research and donation. We explore couples' perceptions about embryos and their thoughts and acceptability about various disposition decisions in Norway. Based on an ethnographic study including interviews and observations in an IVF clinic, we show that couples do not perceive their pre-implantation IVF embryos to be human lives; rather, they consider successful implantation the start of life. We suggest that this response indicates a change in the perception of the human embryo or the fertilised egg from incipient life-a viewpoint that was dominant in the discussions of embryo research in the 1980s and 1990s. We also show how this view of the pre-implantation embryo elucidates why donating embryos to research appears acceptable but donating to other infertile couples seems rather difficult. Before transfer to a woman's uterus, the embryo exists in a liminality; it is not yet human life but a living cell with potential for both research and pregnancy. When an embryo is implanted and pregnancy is confirmed, human life activates; the embryo becomes potential kin, influencing couples' struggles with donating embryos to other couples.

Patients' views on using human embryonic stem cells to treat Parkinson's disease: an interview study

BACKGROUND

Human embryonic stem cells (hESC) as a source for the development of advanced therapy medicinal products are considered for treatment of Parkinson's disease (PD). Research has shown promising results and opened an avenue of great importance for patients who currently lack a disease modifying therapy. The use of hESC has given rise to moral concerns and been the focus of often heated debates on the moral status of human embryos. Approval for marketing is still pending.

OBJECTIVE

To Investigate the perspectives and concerns of patients with PD, patients being the directly concerned stakeholders in the ethical discussion.

METHODS

Qualitative semi-structured interviews related to this new therapy in seventeen patients from two Swedish cities.

RESULTS

The participants expressed various interests related to the use of human embryos for development of medicinal therapies; however, overall, they were positive towards the use of hESC for treatment of PD. It was deemed important that the donating woman or couple made the choice to donate embryos voluntarily. Furthermore, there were concerns that the industry does not always prioritise the patient over profit; thus, transparency was seen as important.

Disposition preferences in oocyte preservation patients

PURPOSE

To characterize the frozen oocyte disposition preferences of patients undergoing medical and planned fertility preservation.

METHODS

All oocyte cryopreservation (OC) patients were identified between 2015 and 2018. Demographic information and fertility preservation (FP) indication (medical or planned) were identified for each patient. Oocyte disposition options included disposal, donation to research, or donation to a specified third party, which was decided at the time of initial consent and made available in the electronic medical record. The primary outcome was the disposition selection. Secondary outcomes included differences in demographic variables and disposition selections between medical and planned FP patients using chi-squared analysis.

RESULTS

A total of 336 OC patients with a documented oocyte disposition preference were identified in the study timeframe. Patients were on average 34.5 years old (SD = 5.1) and were predominantly White (70.2%), nulliparous (83.0%), with a BMI of 24.7 (SD = 5.4). A total of 101 patients underwent OC for medical FP and 235 for planned FP. In both groups, the most commonly selected disposition option was donation to research (50% planned, 52% medical), followed by donation to a specified third party (30% planned, 30% medical), and finally disposal of oocytes (20% planned, 18% medical). There were no significant differences in disposition selection between each group. When comparing patient variables between groups, medical FP patients were more likely to be under the age of 35 and were less likely to be nulliparous (p < .001).

CONCLUSION

This study shows that oocyte disposition choices are similar in patients undergoing OC for medical and planned indications. As donation to research was the most commonly selected option in both groups, it is time to start thinking of streamlining ways to utilize this potential research material in the future.

Disposition intentions of elective egg freezers toward their surplus frozen oocytes: a systematic review and meta-analysis

OBJECTIVE

To examine the disposition outcomes and disposition intentions of elective egg freezers (EEFs) toward their surplus frozen oocytes and the psychosocial determinants underlying these.

DESIGN

A systematic review and meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Actual EEFs (women with oocytes in storage), potential EEFs (women investigating elective oocyte cryopreservation or about to freeze their oocytes), and women of reproductive age (women in the community aged ≥18 years).

INTERVENTION(S)

A systematic review was undertaken and electronically searched MEDLINE, Embase, and PsycINFO on the Ovid platform for conference abstracts and peer-reviewed articles, published in English after January 1, 2010. A search strategy combined synonyms for oocyte, cryopreservation, donation, disposition, elective, and attitude. Eligible studies assessed disposition outcomes (how an oocyte was disposed of) and disposition intentions (how women intend to dispose of an oocyte) and/or the psychosocial determinants underlying disposition outcomes and intentions. The Joanna Briggs Institute Prevalence Tool was used to assess the risk of bias. A meta-analysis using random effects was applied to pool proportions of women with similar disposition intentions toward their oocytes.

MAIN OUTCOME MEASURE(S)

Disposition outcomes and intentions toward surplus frozen oocytes: donate to research; donate to others; discard; unsure. Psychosocial determinants (beliefs, attitudes, barriers, and facilitators) of disposition outcomes and intentions.

RESULT(S)

A total of 3,560 records were identified, of which 22 (17 studies) met the inclusion criteria (8 studies from Europe, 7 from North America, and 2 from Asia). No studies reported on past oocyte disposition outcomes. Seventeen studies reported on the future disposition intentions of 5,446 women. Only 2 of the 17 studies reported on the psychosocial determinants of oocyte disposition intentions. There was substantial heterogeneity in the pooled results, which was likely a result of the significant variation in methodology. Actual EEFs were included in eight studies (n = 873), of whom 53% (95% confidence interval [CI], 44-63; I², 87%) would donate surplus oocytes to research, 31% (95% CI, 23-40; I², 72%) were unsure, 26% (95% CI, 17-38; I², 92%) would donate to others, and 12% (95% CI, 6-21; I², 88%) would discard their eggs. Psychosocial determinants: One study reported that 50% of these women were aware of friends and/or family having difficulty conceiving, which may have contributed to their willingness to donate to others. Potential EEFs were included in 4 studies (n = 645), of whom 38% (95% CI, 28-50; I², 84%) would donate to research, 32% (95% CI, 17-51; I², 91%) would donate to others, 29% (95% CI, 17-44; I², 89%) would discard, and 7% (95% CI, 1-27; I², 77%) were unsure. Psychosocial determinants: No studies. Women of reproductive age were included in 5 studies (n = 3,933), of whom 59% (95% CI, 48-70; I², 97%) would donate to research and 46% (95% CI, 35-57; I², 98%) would donate to others. "Unsure" and "discard" were not provided as response options. Psychosocial determinants: One study reported that the facilitators for donation to others included a family member or friend in need, to help others create a family, financial gain, to further science, and control or input over the selection of recipients. Barriers for donation included fear of having a biological child they do not know or who is raised by someone they know.

CONCLUSION(S)

No studies reported on the disposition outcomes of past EEFs. Disposition intentions varied across the three groups; however, "donating to research" was the most common disposition preference. Notably, the second disposition preference for one-third of actual EEFs was "unsure" and for one-third of potential EEFs was "donate to others." There were limited studies for actual and potential EEFs, and only two studies that explored the psychosocial determinants of oocyte disposition intentions. Additionally, these data suggest that disposition decisions change as women progress on their egg freezing journey, highlighting the importance of ongoing contact with the fertility team as intentions may change over time. More research is needed to understand the psychosocial determinants of oocyte disposition decisions so fertility clinics can provide EEFs with the support and information they need to make informed decisions about their stored eggs and reduce the level of uncertainty reported among EEFs and the potential risk of psychological distress and regret.

CLINICAL TRIAL REGISTRATION NUMBER

PROSPERO 2020: CRD42020202733.

Unmet communication needs and moral work in the disposition decision concerning surplus frozen embryos: The perspectives of IVF users

The disposition decision is a frequently unresolved issue for many IVF users with surplus frozen embryos (SFEs), and this study draws attention to their experiences and moral work, locating it in the Jewish-Israeli context that legally enables the donation of SFEs to research but prohibits donation to other infertile people. To explore the (mis)understandings and (mis)communication underlying IVF users' decisions concerning the fate of their SFEs, the records of 674 IVF users with SFEs stored for more than 5 years during 1996-2011 were analyzed, and 89 IVF users with different disposition decisions were recruited for semi-structured interviews. With an average of 5.1 SFEs, after an average of 8 years of storage, no response to a written request for a disposition decision came from 60% (n = 404) of IVF users with SFEs. Payment for storage and defrosting were the two most frequent choices (13%, n = 89 and 89, respectively) followed by donation to research and transfer (7%, n = 47 and 45, respectively). Three themes emerged from the interviews: misunderstanding the consequences of not returning the disposition form, communication gaps regarding donation to research, and the unmet wish to donate embryos to infertile people. We conclude by discussing the experiences and views of IVF users as reflecting the implications of the liminality and boundary-work surrounding the frozen embryo as a moral work object, and their consequences for policy recommendations.

Analysis of clinical factors and reasons that influence the disposition of cryopreserved embryos in Japanese patients with infertility treated in our clinic

AIM

To investigate the clinical factors and factors that affect the decisions regarding storage of cryopreserved embryos obtained using assisted reproductive technology.

METHODS

Clinical characteristics affecting the decisions regarding cryopreserved embryos were analyzed in 5724 Japanese couples who underwent in vitro fertilization (IVF) or intra-cytoplasmic sperm insemination (ICSI) and embryo transfer over 4 years since April 2015 at our clinic. Statistical analysis was carried out using JMP software.

RESULTS

The number of oocytes retrievals and embryos stored, outcomes and number of children, and age of the female patients and male partners were related to the decision-making regarding cryopreserved embryos. Childbearing and no wish for another child were the major reasons for discontinuing embryo storage. The number of oocytes retrievals and embryos in storage, age of the female patients, and sex of the child were independently associated with this decision-making in 2682 patients with a single child. Women with male children were more likely to choose discontinuation of embryo storage than those with female children.

CONCLUSION

Already having a child and not wishing for further treatment due to age along with the presence of a male child affect the decision to continue or discontinue embryo storage in Japanese patients with infertility.

Embryo cryopreservation and utilization in the United States from 2004-2013

Objective

To evaluate the quantity and use of embryos cryopreserved at assisted reproductive technology (ART) clinics in the United States from 2004 through 2013 and to characterize trends in ART cycles in which all embryos were cryopreserved.

Design

Retrospective analysis.

Setting

Not applicable.

Patient(s)

Registry data from the Society for Assisted Reproductive Technology.

Intervention(s)

Historical cohort of U.S. ART cycles reported to the Society for Assisted Reproductive Technology Clinical Outcomes Reporting System between 2004 and 2013.

Main Outcome Measure(s)

Number of embryos cryopreserved and factors associated with having cryopreserved embryos.

Result(s)

The percentage of fresh cycles in which all embryos were frozen increased dramatically each year after 2010: 15.6% (2010), 19.9% (2011), 30.7% (2012), and 40.7% (2013). During 10 years, 1,954,548 embryos were cryopreserved and 717,345 embryos were transferred. In freeze-only cycles from 2004 to 2013, there was a significant increase in the percentage of women with diminished ovarian reserve (19.9% to 34.1%) and in those who used preimplantation genetic testing (3.2% to 6.9%). During the 10-year period, there were 294,575 fresh cycles with embryo transfer and at least one embryo cryopreserved. Overall, 52.5% (n = 154,543) did not undergo a subsequent frozen embryo transfer, 29.5% (n = 40,462) were left with no frozen embryos, 50.4% (n = 68,875) had one–five embryos, and 20.0% (n = 27,396) had ≥six. Factors associated with having excess embryos included donor oocyte cycles and increased antimüllerian hormone levels.

Conclusion(s)

There has been a sharp increase in U.S. ART cycles in which all embryos are frozen and this may result in more embryos in storage.

The ethics of embryo donation: what are the moral similarities and differences of surplus embryo donation and double gamete donation?

Over the years, the demand for ART with donated embryos has increased. Treatment can be performed using donated ‘surplus embryos’ from IVF treatment or with embryos intentionally created through so-called ‘double gamete donation’. Embryo donation is particularly sensitive because treatment results in the absence of a genetic link between the parent(s) and the child, creating complex family structures, including full genetic siblings living in another family in the case of surplus embryo donation. In this paper, we explore the ethical acceptability of embryo donation in light of the similarities and differences between surplus embryo donation and double gamete donation. We will argue that no overriding objections to either form of embryo donation exist. First of all, ART with donated embryos respects patients’ reproductive autonomy by allowing them to experience gestational parenthood. It also respects IVF patients’ reproductive autonomy by providing an additional option to discarding or donating surplus embryos to research. Second, an extensive body of empirical research has shown that a genetic link between parent and child is not a condition for a loving caring relationship between parent(s) and child. Third, the low moral status of a pre-implantation embryo signifies no moral duty for clinics to first use available surplus embryos or to prevent the development of (more) surplus embryos through double gamete donation. Fourth, there is no reason to assume that knowledge of having (full or half) genetically related persons living elsewhere provides an unacceptable impact on the welfare of donor-conceived offspring, existing children of the donors, and their respective families. Thus, patients and clinicians should discuss which form of ART would be suitable in their specific situation. To guarantee ethically sound ART with donated embryos certain conditions have to be met. Counselling of IVF patients should involve a discussion on the destination of potential surplus embryos. When counselling donors and recipient(s) a discussion of the significance of early disclosure of the child’s mode of conception, the implications of having children raised in families with whom they share no genetic ties, expectations around information-exchange and contact between donor and recipient families or genetically related siblings is warranted. Importantly, conclusions are mainly drawn from results of empirical studies on single gamete donation families. To evaluate the welfare of families created through surplus embryo donation or double gamete donation additional empirical research on these particular families is warranted.

Consenting and ethical considerations in embryo cryopreservation

PURPOSE OF REVIEW

An emerging body of literature has elucidated the growing burden of surplus embryos left in storage without any clear disposition. An out dated consent process is a significant but easily remedied contributor to this problem. We propose a novel approach to consenting for disposition of surplus embryos.

RECENT FINDINGS

Decisional conflicts that stem from the moral status of embryos and from evolving personal values contribute to surplus embryos being left in storage. Barriers to donation of embryos to research or to other patients also discourage embryo disposition decisions. A flawed informed consent process compromises the physician--provider relationship and complicates decision-making.

SUMMARY

Centralizing the process of donating embryos to research and to patients would lower barriers to these disposition options. The informed consent protocol must be redesigned as a longitudinal, narrative process compatible with the evolving values and fertility outcomes of patients. Counselors should be integrated into all discussions regarding embryo disposition from the onset of fertility treatment through its conclusion to facilitate the decision-making process.

Knowledge and attitudes of subfertile couples towards disposition of supernumerary cryopreserved embryos: an Indian perspective

In many cases, supernumerary embryos are cryopreserved for future use following assisted reproductive technology (ART) treatment. Once a couple has completed their family following treatment, the fate of these excess cryopreserved embryos becomes uncertain. The options available for the disposition of cryopreserved embryos are donation to other infertile couples, donation to research and discontinuation of cryostorage. In order to evaluate the knowledge and attitudes of subfertile couples from the Indian subcontinent regarding the fate of their excess cryopreserved embryos, a cross-sectional study was planned at a university-level infertility unit. A two-stage structured interview was conducted with the couples. Some questions in the interview were hypothetical in nature. In total, 87 couples were interviewed, of which 33 (37.9%) were unaware of the options for disposition of supernumerary embryos. Forty (46%) couples indicated a preference to donate their embryos to other subfertile couples, while 10 (11.5%) couples preferred donation to research. Twenty-four (27.6%) couples opted for donation to both other couples and research, while three (3.4%) couples indicated a preference to discontinue storage. Penalized bivariable logistic regression showed that none of the factors examined (i.e. age, education, income or presence of a living child) influenced the couple's decision regarding embryo donation. The majority of subfertile couples preferred to donate the embryos rather than discontinue storage. The donation of embryos to other subfertile couples was the most preferred option for disposition of embryos.

Discarding IVF embryos: reporting on global practices

PURPOSE

To provide a global scale report on a representative sample of the clinical embryology community depicting the practice of discarding supernumerary IVF embryos.

METHODS

A web-based questionnaire titled "Anonymous questionnaire on embryo disposal practices" was designed in order to ensure anonymous participation of practicing clinical embryologists around the world.

RESULTS

During a data collection period of 8 months, 703 filled-in questionnaires from 65 countries were acquired. According to the data acquired, the majority of practitioners, dispose of embryos by placing them directly in a trash can strictly dedicated for embryo disposal for both fresh and frozen cycles (39% and 36.7% respectively). Moreover, 66.4% of practitioners discard the embryos separately-case by case-at different time points during the day. Over half of embryologists (54%) wait until day 6 to discard the surplus embryos, while 65.5% do not implement a specially allocated incubator space as a designated waiting area prior to disposal. The majority of 63.1% reported that this is a witnessed procedure. The vast majority of embryologists (93%) do not employ different protocols for different groups of patients. Nonetheless, 17.8% reported the request to perform a ceremony for these embryos. Assessing the embryologists' perspective, 59.5% of participants stated that the embryology practice would benefit from a universally accepted and practiced protocol.

CONCLUSION(S)

This study uniquely provides insight into global embryo disposal practices and trends. Results highlight the divergence between reported practices, while indicating the significance on standardization of practice, with embryologists acknowledging the need for a universally accepted protocol implementation.

[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.

Percepciones y creencias sobre criopreservación embrionaria en mujeres y hombres que se realizan técnicas de reproducción asistida en Santiago, Chile

Background and objetive

Although embryo cryopreservation is frequently used as part of assisted reproductive technology, quantitave information addressing how infertile couples live the experience of having cryopreserved embryos is lacking in Chile. The aim of this study is to examine men and women's perception and beliefs regarding their cryopreserved embryos, as well as their perspective on embryo donation and disposition. Methods: 153 women and men with frozen embryos from a public hospital, Instituto de Investigactiones Materno Infantil, and a private clinic, Clínica Las Condes, in Santiago, Chile, responded between May 2015 and May 2016 to an anonymous online survey addressing their perceptions and beliefs concerning their cryopreserved embryos.

Results

Respondents considered their frozen embryos to be equivalent to a child (53.2%) or a potential child (40.7%). Only 8% regard them as an organized group of cells. Over 60% of respondents disagree with destroying surplus embryos or using them for research. Participants from the public hospital are more willing to donate their embryos to another couple than those from the private center (61% vs 40%; P=0.016); 34% of respondents agreed to donate surplus embryos to same sex couples.

Conclusion

This study reveals that Chilean couples are emotionally bound to their frozen embryos, and that discarding them is not an option. The results from this survey will help strengthen counseling for couples to enable them to make informed decisions regarding their surplus embryos.

Using Surplus Embryos and Research Embryos in Stem Cell Research: Ethical Viewpoints of Buddhist, Hindu and Catholic Leaders in Malaysia on the Permissibility of Research

The sources of embryos for Embryonic Stem Cell Research (ESCR) include surplus embryos from infertility treatments, and research embryos which are created solely for an ESCR purpose. The latter raises more ethical concerns. In a multi-religious country like Malaysia, ethical discussions on the permissibility of ESCR with regard to the use surplus and research embryos are diversified. Malaysia has formulated guidelines influenced by the national fatwa ruling which allows the use of surplus embryos in ESCR. Input from other main religions is yet to be documented. In light of this, this study addresses (i) the ethical viewpoints of Buddhist, Hindu and Catholic leaders on the permissibility of using surplus and research embryos; and (ii) the moral standpoints of religious leaders towards attaining a consensus on the practice of ESCR in Malaysia. Responses from the religious leaders were obtained via semi-structured, face-to-face interviews. The findings show that generally the Buddhist and Hindu leaders approve the use of surplus embryos. Their responses on the creation of research embryos for ESCR are varied. Meanwhile, the Catholic leaders distinctively objected to ESCR regardless of the embryo sources, referring to it as the destruction of life. Taking into account the diverse views, this study explores the response of the religious leaders for a general consensus wherever possible. The ethical discourse surrounding ESCR in a multi-religious setting offers new perspective, which needs to be explored in a broader global community.

Factors associated with the disposition of frozen embryos after a live birth through IVF treatment in China

OBJECTIVE

To investigate infertility patients' attitudes towards frozen embryos and the factors that influence patients' decisions.

STUDY DESIGN

This is a cross-sectional quantitative observational study conducted between 1 April 2010 and 1 April 2015. Patients underwent IVF with embryo cryopreservation and successfully delivered at least one baby were called to complete a questionnaire regarding decisions about embryo disposition and reasons for their preferred option. The chi-square test was used to compare the attitudes about embryo disposition between subgroups. A multinomial logistic regression was performed to examine the effects of various individual characteristics on the decision. The effects were presented by adjusted odds ratios (OR) and their 95% confidence interval (95% CI).

SETTING

Guangzhou Women and Children's Hospital.

RESULTS

Among 769 interviewed couples, 718 couples (93.4%) completed the questionnaire. A total of 462 couples (64.3%) continued to store embryos. Among the participants who discontinued storage, 214 couples (83.6%) chose to discard embryos, and 42 couples (16.4%) agreed to donate embryos for research. Having no college education and longer storage duration were associated with an increase in the likelihood of discontinuing storage. The couples having twins from IVF were more likely to discontinue storage (OR=6.33, 95%CI: 4.37-9.39) compared to those having only one child. Regarding the choice of discarding or donation for research among those who decided to discontinue frozen embryos, females aged 30 or above were more willing to donate their embryos for research (OR=2.85, 95%CI:1.12-7.23).

CONCLUSION

The preference for embryo disposition was associated with the number of children, storage duration, and the couple's education. Chinese patients generally chose to store cryopreserved embryos and were less receptive to the concept of embryo research compared with patients in other developed countries.

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.

Embryo donation and understanding of kinship: the impact of law and policy

STUDY QUESTION

What is the impact of law and policy upon the experience of embryo donation for reproductive use?

SUMMARY ANSWER

Access to, and experience of, embryo donation are influenced by a number of external factors including laws that impose embryo storage limits, those that frame counselling and approval requirements and allow for, or mandate, donor identity disclosure.

WHAT IS KNOWN ALREADY

To date only three qualitative studies in Australia and New Zealand have been completed on the experience of embryo donation for reproductive purposes, each with a small cohort of interviewees and divergent findings.

STUDY DESIGN, SIZE, DURATION

Embryo donors, recipients, and would-be donors were interviewed between July 2010 and July 2012, with three additional interviews between September 2015 and September 2016, on their experiences of embryo donation. The sampling protocol had the advantage of addressing donation practices across multiple clinical sites under distinct legal frameworks.

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

Participants were recruited from five Australian jurisdictions and across 11 clinical sites. Twenty-six participants were interviewed, comprising: 11 people who had donated embryos for the reproductive use of others (nine individuals and one couple), six recipients of donated embryos (four individuals and one couple) and nine individuals who had attempted to donate, or had a strong desire to donate, but had been prevented from doing so. In total, participants reported on 15 completed donation experiences; of which nine had resulted in offspring to the knowledge of the donor.

MAIN RESULTS AND THE ROLE OF CHANCE

Donors positively desired donation and did not find the decision difficult. Neither donors nor recipients saw the donation process as akin to adoption . The process and practice of donation varied considerably across different jurisdictions and clinical sites.

LIMITATIONS, REASONS FOR CAUTION

Because the pool of donors and recipients is small, caution must be exercised over drawing general conclusions. Saturation was not reached on themes of counselling models and future contact.

WIDER IMPLICATIONS OF THE FINDINGS

The differences between our findings and those of a previous study are attributable to varied legal and counselling regimes. Therefore, law and policy governing embryo storage limits, counselling protocols and identity disclosure shape the donation experience and how it is described.

STUDY FUNDING/COMPETING INTEREST(S)

This research was supported by Discovery Project Grants DP 0986213 and 15010157 from the Australian Research Council and additional funding from UTS: Law. There are no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

Donation of surplus frozen pre-embryos to research in Israel: underlying motivations

Background

The high number of IVF procedures performed in Israel has had an unforeseen consequence: accumulation of large amounts of surplus frozen embryos. After five years that the frozen embryos are kept for free, patients need to make an embryo disposition decision. One option is donation for research. The donation rate in Israel is very low. Our aim was to understand the attitudes, values and perceptions of female IVF patients that decided to donate their surplus frozen embryos to research.

Methods

The study setting was a tertiary IVF unit which during the 2000–2009 period treated 241 patients who had their frozen pre-embryos stored for more than five years. The study population consists of the 12 patients (from among the 241) who had decided to donate their excess frozen pre-embryos to research. In-depth interviews were carried out with 8 of those 12 patients.

Results

IVF patients who donated their surplus frozen pre-embryos to research viewed the frozen embryo as a valuable resource that does not have human identity yet. The majority expressed a gradualist approach to the human status of the embryo as requiring successful implantation and development in the uterus. All the respondents chose donation to research not because it was their first choice but because they did not want or were unable to use the pre-embryos in the future, in addition to not willing to thaw them. For many of the respondents, donation to research was accompanied by a sense of uncertainty. All would have preferred to donate their pre-embryos to infertile women or couples, an option which is currently prohibited in Israel.

Conclusions

The moral reasoning behind decisions that patients make regarding excess pre-embryos is important for health care practitioners to consider when offering decision-making alternatives and counseling. For our respondents, the scarcity of donating excess frozen pre-embryos to research may reflect patients' preference for embryo donation to infertile couples. Recommended ways to increase donation to research may include public education and awareness, as well as targeted communication with IVF patients by multi-professional IVF unit teams comprised of a medical doctor and a professional trained in bioethics.

Couples' willingness to donate embryos for research: a longitudinal study

INTRODUCTION

Decision-making on embryo disposition is a source of distress and is subject to change over time. This paper analyzes the willingness of couples undergoing in vitro fertilization to donate cryopreserved embryos for research from 15 days after embryo transfer to 12 months later, taking into account the influence of psychosocial, demographic, and reproductive factors.

MATERIAL AND METHODS

Prospective longitudinal study, with 74 heterosexual couples undergoing in vitro fertilization in a public fertility centre in Portugal, recruited between 2011 and 2012. Participants were evaluated twice: 15 days after embryo transfer and 12 months later.

RESULTS

A significant decrease in patients' willingness to donate embryos for research over time was observed [86.5% to 73.6%; relative risk (RR) = 0.85; 95% CI 0.76-0.95]. A higher education level (>12 years) [adjusted RR (RRadj ) = 0.79; 95% CI 0.64-0.96], considering research on human embryos to be important (vs. very important) (RRadj = 0.59; 95% CI 0.39-0.85) and practicing a religion less than once a month (vs. at least once a month) (RRadj = 0.73; 95% CI 0.53-1.00) seemed associated with unwillingness to donate embryos for research over time. Change towards non-donation happened mainly among couples who first considered that it was better to donate than wasting the embryos. Change towards donation occurred mostly among those stating that their priority at time 1 was to have a baby and who became pregnant in the meantime.

CONCLUSIONS

Quality of care guided by patients' characteristics, values, preferences, and needs calls for considering the factors and reasons underlying couples' willingness to donate embryos for research over time as a topic in psychosocial guidelines for infertility and medically assisted reproductive care.

Patient Decision-Making About the Disposition of Surplus Cryopreserved Embryos in Canada

OBJECTIVE

The objective of this study was to identify factors that contribute to patient decision-making for disposition of surplus cryopreserved embryos in Canada.

METHODS

In 2013, interviews were conducted with 45 IVF patients from three clinic sites, representing a total of 33 households. Patients interviewed all had unused cryopreserved embryos in storage in 2010. Initial demographic data collection was followed by one in-depth semi-structured interview conducted in 2013. Data were managed and coded thematically.

RESULTS

Most patients (21 patients, representing 16 households) renewed storage agreements to keep embryos in storage at the time of the interview. Among patients who did not renew their storage agreements at some point between 2010 and 2013, six patients (representing 5 households) had since used all their embryos, two patients (representing one household) had decided to keep their embryos in storage in perpetuity, three patients (representing 3 households) discarded their embryos outright, and 13 patients (representing 9 households) donated their embryos to research or clinical training. Among patients who donated to research or clinical training, three key themes emerged: a desire to "give back," to contribute to scientific progress, and to avoid "wasting" embryos. These patients were not always certain about whether they had chosen research or clinical training.

CONCLUSION

This study demonstrates the applicability of international findings about embryo disposition decision-making to the Canadian setting. Moreover, it identifies that while patients making disposition decisions often choose to donate embryos to research and/or clinical training, they are not always certain about what these options entail. Clinicians, counsellors, and others must ensure that patients are not only aware of their embryo disposition options, but that they understand the nature of these options as well.

Psychological Counseling of Female Fertility Preservation Patients

Young cancer patients are increasingly interested in preserving their fertility prior to undergoing gonadotoxic therapies. Although the medical safety and treatment protocols for fertility preservation have been well documented, limited research has addressed the emotional issues that arise in fertility preservation patients. We briefly review the literature on the psychosocial issues in adult female fertility preservation treatment and describe our experiences within this patient population. Our findings suggest that several important issues to be addressed during the psychological counseling of adult female fertility preservation patients include: (1) preexisting psychological distress in patients undergoing treatment, (2) choice of fertility preservation strategy in the face of an uncertain relationship future, (3) decision making regarding use of third-party reproduction (e.g., sperm/egg donation, gestational surrogacy), (4) treatment expectations regarding pregnancy and miscarriage, (5) ethical issues related to treatment including the creation, cryopreservation, and disposition of embryos/oocytes, and (6) decision regret from patients who declined fertility preservation.

Posthumous reproduction with surplus in vitro fertilization embryos: a study exploring users' choices

OBJECTIVE

To report results of analysis of in vitro fertilization (IVF) users' choices regarding the potential use of their surplus cryopreserved embryos for posthumous assisted reproduction (PAR).

DESIGN

Examination of signed consent forms.

SETTING

Public IVF clinic.

PATIENT(S)

A total of 498 individuals who had signed consent forms for cryopreservation of surplus embryos.

INTERVENTION(S)

Content analysis of consent form.

MAIN OUTCOME MEASURE(S)

Agreement to PAR; importance of appropriate counseling within the consent process.

RESULT(S)

Approximately 68% of individuals consented to the use of surplus embryos for embryologist training and improvement of assisted reproductive techniques, and 56% consented to the use of surplus embryos in a research project; 73.5% of men and 61.8% of women agreed to leave their cryopreserved embryos to their partners for reproductive use in the event of their death.

CONCLUSION(S)

Our results demonstrate that a majority of both men and women agree to leave their frozen embryos to their partners for PAR in a "real life" context, i.e., in which they were required to provide consent for this prospective option. PAR involves complex issues, including the psychologic aspects of initiating a pregnancy while mourning the loss of a loved one or the effect on the prospective child. We argue that in light of the acceptability of PAR-as demonstrated by our results-further research is required regarding how to best counsel and inform IVF users about the choices they are making in this context, to ensure that their consent for PAR is in fact well informed.

Low participation rates amongst Asian women: implications for research in reproductive medicine

The last two decades have witnessed tremendous advances in the field of reproductive medicine, especially assisted reproductive technology and stem cell research. As research continues in future, it is vital to ensure that individuals from all ethnic backgrounds are represented in the study populations so that the findings of the research can be generalised for the benefit of all. Many studies, however, have noted a trend of low participation rates amongst Asian women in reproductive research. Inequalities in the ethnicity of research participants can be a source of substantial bias, and have major ethical and scientific ramifications. Several factors such as educational status, fear of wrong-doing, communication barriers, and socio-cultural beliefs have been suggested to play a role. There is a need for further exploration of the factors influencing Asian women's decision to accept or decline participation in reproductive research and for development of effective targeted strategies for research recruitment with the aim of encouraging research participation as well as donation of cryopreserved embryos or other reproductive tissues.

Attitudes towards embryo donation in Swedish women and men of reproductive age

BACKGROUND

When performing in-vitro fertilization (IVF), more embryos than needed are often derived. These embryos are usually frozen and stored, but as ruled by Swedish law they have to be discarded after 5 years. In other countries it is legal to donate the excess embryos to other infertile couples who for different reasons cannot undergo the procedure of IVF. The aim of the present study was to investigate public opinion in Sweden regarding different aspects of embryo donation.

METHODS

A questionnaire regarding attitudes towards aspects of embryo donation was sent to a randomized sample of 1,000 Swedish women and men of reproductive age.

RESULTS

A total of 34% responded to the questionnaires. A majority of the respondents (73%) were positive towards embryo donation. Seventy-five per cent agreed that it should be possible to donate embryos to infertile couples. Approximately half of the participants (49%) supported embryo donation to single women. A majority of the participants emphasized that demands should be imposed on the recipient's age (63%), alcohol addiction (79%), drug addiction (85%), and criminal record (67%). Forty-seven per cent of the respondents agreed that the recipient should be anonymous to the donor, and 38% thought that the donor should remain anonymous to the child.

CONCLUSIONS

The results of the present study indicate support for embryo donation among a subset of the Swedish population of reproductive age. If embryo donation were to be allowed in Sweden, strategies for treatment and counselling need to be developed.

Patients' attitudes towards the surplus frozen embryos in China

Background. Assisted reproductive techniques have been used in China for more than 20 years. This study investigates the attitudes of surplus embryo holders towards embryos storage and donation for medical research. Methods. A total of 363 couples who had completed in vitro fertilization (IVF) treatment and had already had biological children but who still had frozen embryos in storage were invited to participate. Interviews were conducted by clinics in a narrative style. Results. Family size was the major reason for participants' (dis)continuation of embryo storage; moreover, the moral status of embryos was an important factor for couples choosing embryo storage, while the storage fee was an important factor for couples choosing embryo disposal. Most couples discontinued the storage of their embryos once their children were older than 3 years. In our study, 58.8% of the couples preferred to dispose of surplus embryos rather than donate them to research, citing a lack of information and distrust in science as significant reasons for their decision. Conclusions. Interviews regarding frozen embryos, including patients' expectations for embryo storage and information to assist them with decisions regarding embryo disposal, are beneficial for policies addressing embryo disposition and embryo donation in China.

Review: Public perspectives on the utilization of human placentas in scientific research and medicine

Placental tissues are frequently utilized by scientists studying pregnancy and reproduction and in diverse fields including immunology, stem cell research, genetics, cancer research, and tissue engineering, as well as by clinicians in many therapies. Though the utilization of the human placenta in science and medicine has benefitted many people, little is known about public perspectives of this phenomenon. This review addresses placental donation, collection, and utilization in science and medicine, focusing on public perspectives. Cultural values and traditions, ethical paradigms and concerns, public understandings of science and medicine, and political considerations may impact perceptions of the utilization of the placenta in science and medicine, but systematic study is lacking. It is argued that knowledge of public views gained from empirical investigation may underpin the development of collection protocols and research projects that are more responsive to public will, spur more extensive utilization in science and medicine of this unique organ, and/or aid in the realization of the mobilization of knowledge about the placenta for clinical and educational ends. New avenues for research on public perspectives of the placenta are proposed.

Impedance of novel therapeutic technologies: the case of stem cells

Embryonic stem cell (ES) technology has advanced considerably within the past three decades and has gained prominent distinction within the emerging field of regenerative medicine. As it now enters the nascent stages of clinical application, many hopes and expectations arise along with questions as to where the technology will go. This paper evaluates the technical and practical obstacles that must be overcome before it can fully translate into the clinical context, the existence of strong opposition to the technology, political and legal barriers that have impeded its progression, and the role of healthcare reform in creating new social and economic priorities. In contrast to the technological imperative, a driving force seeking to implement the most recent scientific advances into medical practice, we refer to such translational obstacles as "technological impedance." Rather than expending inordinate effort to preserve existing systems that continue to possess major hurdles, we advocate fostering interdisciplinary approaches in the development of new generation platforms and embracing disruptive innovations that create solutions to technological impedance and move us forward in healthcare delivery. Clin Trans Sci 2012; Volume 5: 422-427.

Acceptability of stem cell therapy by pregnant women

BACKGROUND

Cell-based therapies may soon be used to treat disorders in the perinatal period. Our aim was to assess pregnant women's knowledge, attitudes, and acceptance of different types of stem cell therapies.

METHODS

Pregnant women attending an Australian tertiary center were asked to complete a questionnaire to seek their views on the potential therapeutic use of stem cells in the future. Outcome measures were women's acceptability of different types of stem cell therapies for themselves and their baby, ethical concerns, knowledge, and willingness to use stem cells for different indications.

RESULTS

A total of 150 women completed the questionnaire. More women were happy to use any stem cell type (82%) than placental stem cells only (12.5%), adult stem cells only (2%), embryonic stem cells only (0), and 3.5 percent would not use. With respect to use for their baby, more women were happy to use any stem cell type (83%) than placental stem cells only (13%), embryonic stem cells only (2%), adult stem cells only (0), and 2 percent would not use. Ethical concerns were highest with embryonic stem cells (25%), than adult stem cells (11%), and placental stem cells (10%). Twelve percent of women were very confident and 66 percent reasonably confident with their knowledge, whereas 17 percent understood little and 5 percent reported no understanding. Acceptance of using any stem cell therapy was 75 percent for severe medical disorders, 57 percent for moderate disorders, and 25 percent for mild medical disorders.

CONCLUSIONS

Pregnant women are confident with their knowledge of stem cells and overwhelmingly support their use to treat both themselves and their baby. The level of this support, however, is proportionate to the severity of the medical disorder. (BIRTH 39:2 June 2012).

"Something of the two of us". The emotionally loaded embryo disposition decision making of patients who view their embryo as a symbol of their relationship

OBJECTIVES

This paper describes a recently identified conception of the cryopreserved embryo as a symbol of one's relationship (SOR).

METHODS

A questionnaire was sent together with the embryo disposition decision (EDD) form to patients for whom embryos were cryopreserved at the department in Ghent, Belgium. We collected data on patient characteristics, their EDD attitudes and the reasons for their willingness or unwillingness to consider each of the disposition options (donation to others for reproduction, donation for science and discarding).

RESULTS

The SOR view was found more often in patients who were less educated and whose last treatment was less than 3 years ago. Viewing the embryo as a SOR was not linked to more difficult decision making, but to more emotionally loaded decision making. In particular, patients with this view more often reported feelings of grief. This view was also linked to the outcome of the decision making process.

CONCLUSION

The conception of the embryo as a SOR is part of an affective attitude towards embryos that has an impact on patients' disposition decisions. Alongside patients' values and principles, it is important that counselors acknowledge and clarify patients' affective conceptualizations.

The decision-making process for the fate of frozen embryos by Japanese infertile women: a qualitative study

Background

Previous studies have found that the decision-making process for stored unused frozen embryos involves much emotional burden influenced by socio-cultural factors. This study aims to ascertain how Japanese patients make a decision on the fate of their frozen embryos: whether to continue storage discard or donate to research.

Methods

Ten Japanese women who continued storage, 5 who discarded and 16 who donated to research were recruited from our infertility clinic. Tape-recorded interviews were transcribed and analyzed for emergent themes.

Results

A model of patients’ decision-making processes for the fate of frozen embryos was developed, with a common emergent theme, “coming to terms with infertility” resulting in either acceptance or postponing acceptance of their infertility. The model consisted of 5 steps: 1) the embryo-transfer moratorium was sustained, 2) the “Mottainai”- embryo and having another child were considered; 3) cost reasonability was taken into account; 4) partner’s opinion was confirmed to finally decide whether to continue or discontinue storage. Those discontinuing, then contemplated 5): the effect of donation. Great emotional conflict was expressed in the theme, steps 2, 4, and 5.

Conclusions

Patients’ 5 step decision-making process for the fate of frozen embryos was profoundly affected by various Japanese cultural values and moral standards. At the end of their decision, patients used culturally inherent values and standards to come to terms with their infertility. While there is much philosophical discussion on the moral status of the embryo worldwide, this study, with actual views of patients who own them, will make a significant contribution to empirical ethics from the practical viewpoint.

Trends in embryo disposition decisions: patients' responses to a 15-year mailing program

BACKGROUND

This study examined the responses of patients of a Belgian fertility center to mailed requests to make or renew an embryo disposition decision (EDD), over a period of 15 years, to investigate trends in the decisions.

METHODS

A retrospective analysis was performed on a mailing program from 1992 to 2006, for patients, of the Department of Reproductive Medicine, Ghent University Hospital (Belgium), from whom embryos had been cryopreserved at least 2 years.

RESULTS

In 15 years, 3840 EDD forms were prepared for 2334 couples or female patients. The number of forms increased from 21 in 1992 to 558 in 2006. Each year, around a third of the forms were not returned. In general, a quarter of patients who received more than one form never answered. Donation to others for reproduction was overall the least popular option and decreased over the years. The rising trend in decisions to discard reversed into a negative trend from the introduction of donation for science (1997). Since then, donation for science has been the most popular option and its popularity increased with time. In 15 years, 2504 embryos were donated for science. More than a quarter of the patients who chose more than one final EDD in different years did not select the same EDD the second time.

CONCLUSIONS

This study showed a positive trend in donation for science and a negative trend in donation to others and discarding. A substantial number of individual patients chose different types of EDDs in consecutive mailings, which shows that advance EDD directives should be used with caution.

Physical symptoms throughout IVF cycles

The physical impact of in vitro fertilisation (IVF) is not well explored. The aim of this prospective controlled longitudinal study was to examine the impact of 11 symptoms during an entire long down regulation (LDR) cycle and to determine the effect of the mean recombinant follicle stimulating hormone (RecFSH) dose and ovarian responsiveness of patients and outcome had on reported symptoms. The severity of symptoms was measured using a daily questionnaire to determine a total summary score (TSS) for each symptom, a summary symptom score (SSS) based on all TSS and a mean daily severity for each symptom. Outcome was determined by beta human chorionic gonadotrophin (β-hCG) test result. 79.1% of women undertaking LDR IVF cycles had significant physical symptoms. Treatment symptom severity peaked at oocyte retrieval, with prominent symptoms including bloating, abdominal pain/cramps and fatigue. No relationship was found between outcome, RecFSH dose and ovarian responsiveness with reported symptoms. In conclusion, IVF places a real physical burden on women should be encouraged to reduce undertaking LDR cycles. The impact of the symptoms, particularly the increase in severity leading up to day of oocyte retrieval suggests that women may be warned to reduce stress and activities during this time.