Embryo donation programs and policies in North America: survey results and implications for health and mental health professionals

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.

[Some present and future ethical dilemmas surrounding advancements in in vitro fertilization.]

The growing field of assisted human reproduction has achieved unimaginable milestones. Its continuous development and the innovations it generates at times pose both ethical and legal dilemmas. This essay aims to elucidate the progressive changes occurring in the realm of the origin of life due to the development of new options and strategies in assisted human reproduction. First, it constructs an interdisciplinary reflection on human nature and the changes society faces from the perspectives of science, ethics, and law, particularly from the perspective of Spain. Second, it provides a brief overview of current or future biomedical techniques in the field of human reproduction. It concludes with a discussion of the need to reflect on the rapid advancement of science in assisted human reproduction.

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.

Embryo donation: national trends and outcomes, 2000 through 2013

BACKGROUND

Limited published data exist detailing outcomes of donor embryo cycles. Patients and clinicians would benefit from information specific to donor embryo cycles to inform fertility treatment options, counselling, and clinical decision-making.

OBJECTIVE

We sought to quantify trends in donor embryo cycles in the United States, to characterize donor embryo recipients, and to report transfer, pregnancy, and birth outcomes of donor embryo transfers.

STUDY DESIGN

This retrospective cohort study of frozen donor embryo transfers uses data from Centers for Disease Control and Prevention National ART Surveillance System to quantify trends in the use of donor embryos and corresponding rates of pregnancy and live birth from 2000 through 2013. For 2007 through 2013, years reflective of current practice, rates of cancellation, pregnancy, miscarriage, live birth, singleton and twin live birth, and delivery of a full-term singleton infant of normal birthweight (≥37 weeks, ≥2500 g) are reported.

RESULTS

Among all frozen transfers from 2000 through 2013 (n = 391,662), the annual number of donor embryo transfers increased significantly from 332-1374, however the proportion of donor embryo transfers among all frozen transfers did not change significantly (2.3-2.6%). Both overall pregnancy and live birth rates per frozen donor embryo transfer increased significantly (33.3-49.1% and 26.5-40.8%, respectively) (P < .01). Among all initiated donor embryo cycles from 2007 through 2013 (n = 7289), the overall cancellation rate prior to transfer was 7.1%. Among all transfers from 2007 through 2013 (n = 6773), 3193 (47.2%) resulted in pregnancy and 2589 (38.2%) resulted in a live birth. Among all pregnancies, 535 (16.9%) resulted in a miscarriage. Among all live births, 1929 (74.5%) delivered a singleton of which 1482 (76.8%) were full term and normal birthweight.

CONCLUSION

The increasing availability of donor embryos, low chance of cancellation, and increasing likelihood of achieving live birth can inform consumers and providers who are considering assisted reproductive technology options. Collection of data surrounding donated embryo formation would allow for additional studies that can elucidate predictors of success among donor embryo transfers.

A hierarchy of needs? Embryo donation, in vitro fertilisation and the provision of infertility counselling

OBJECTIVE

The aim of the paper is to examine how those working in, using and regulating assisted conception clinics discussed infertility counselling and its provision within the context of embryo donation and in vitro fertilisation.

METHOD

35 participants were recruited for semi-structured, face-to-face interviews. All data were analysed using thematic analysis.

RESULTS

The thematic analysis revealed recurring themes based upon the portrayals of infertility counselling, embryo donation and in vitro fertilisation.

CONCLUSIONS

This paper suggests that an implicit hierarchy exists around those using assisted conception techniques and their infertility counselling requirements, which was dependent upon the assisted conception technique used. As a result, some people using assisted conception techniques felt that their needs had been overlooked due to this covert hierarchy.

PRACTICE IMPLICATIONS

Those working in, using or regulating assisted conception clinics should not view infertility counselling as restricted to treatments involving donation, or solely for people within the clinical system.

What do patients want? Expectations and perceptions of IVF clinic information and support regarding frozen embryo disposition

OBJECTIVE

To describe frozen embryo holders' expectations and perceptions of IVF clinic information, support, and storage fees and their relevance to embryo disposition decision making.

DESIGN

Qualitative interview study.

SETTING

Three northern California IVF practices.

PATIENT(S)

One hundred six families (110 women and 74 men) with an average of six frozen embryos in storage for 5 years.

INTERVENTION(S)

Three in-depth interviews over 1 year.

MAIN OUTCOME MEASURE(S)

Thematic analysis of interview transcripts.

RESULT(S)

Although embryo holders expected that IVF clinics were under obligation to assist in the disposition decision and would be their main source of information, these expectations did not become manifest until years after embryo cryopreservation. Patients expressed a variety of preferences for the timing, format, and content of information and support, ranging from detailed written information to counselor/advocates that could provide logistical guidance and/or psychologic support. Embryo holders perceived an insufficiently defined infrastructure to facilitate donation to other couples, whereas donating to medical research was seen as less complicated and more likely to be encouraged and supported by physicians and clinics. Although increasing storage fees motivated disposition decision making, they could be interpreted as coercive and/or not reflective of actual clinic costs.

CONCLUSION(S)

Frozen embryo-holding patients' expectations of information and support to assist them with disposition decision making and embryo donation suggests that IVF clinics may benefit from a review of their frozen embryo counseling, storage, and disposition policies and procedures.

How couples who have undergone in vitro fertilization decide what to do with surplus frozen embryos

In a qualitative interview study of 77 families with stored frozen embryos, we found that while embryo disposition decision making was influenced by individual life circumstances, embryo quantity/quality, personal values, embryo conceptualization, and clinic information, it was a stepwise process that could be represented as three sequential questions: (1) Will the embryos be used for additional attempts at conception? If not, (2) Will the embryos remain in storage? And if not, (3) Will the embryos be donated to other people or to science, or will they be destroyed? While almost two-thirds (63%) of participants kept their embryos in storage after 5 years, either passively through disagreement or indecision or actively to maintain embryo potential, avert feelings of loss, or as psychological or genetic "insurance," IVF clinic support and detailed information about options motivated families to make disposition decisions.

Gamete donors' and recipients' evaluation of donor counselling: a prospective longitudinal cohort study

BACKGROUND

Those considering donating or receiving gametes are required to undergo counselling to ensure that they are aware of and consider the psychosocial, emotional and ethical complexities of donor conception before proceeding.

AIMS

The aim of this study was to evaluate gamete donors' and recipients' views about donor counselling and beliefs about disclosure of the use of donor gametes to conceive, before and after attending counselling.

METHOD

All donors and recipients and their partners who attended donor counselling at Monash IVF, Melbourne, Australia, for the first time between February 2003 and March 2004 were asked to complete self-report questionnaires. Using seven-point Likert scales where higher scores indicated more positive views, participants rated the importance of discussing a range of topics before, and the usefulness of discussing these after attending counselling.

RESULTS

Pre-counselling questionnaires were completed by 152 of 184 (83%) individuals and 72 (47%) of those also completed the post-counselling questionnaire. Donors' post-counselling ratings were significantly higher than their pre-counselling ratings. For recipients the pre- to post-counselling changes were less pronounced. Both donors and recipients rated matters relating to disclosure and the possible future interaction between donor and child the most useful to discuss. More participants favoured disclosure after than before counselling (84% vs 66%, P = 0.01).

CONCLUSIONS

This study suggests that counselling is beneficial for those contemplating donor procedures, particularly donors, and that most have a positive attitude towards disclosure after counselling.

Health policy considerations for our sexual minority patients

Homosexuality and transsexuality are still widely viewed by lay individuals as morally negative and deserving of legal proscription. Peer-reviewed data confirm that experiences of legal discrimination are associated with stress-related health problems, reduced utilization of health care, and financial and legal challenges for individuals and families, especially those with children. In the last 3 years, the American Psychiatric Association, American Psychological Association, and American Psychoanalytic Association have each reviewed the research on sexual orientation and identity, and each has confirmed that sexual orientation and gender identity do not correlate with mental illness or immorality. They have each endorsed laws that confer equality to sexual minorities, including nondiscrimination in employment, medical insurance coverage, adoption, and access to civil marriage. The American College of Obstetricians and Gynecologists (ACOG), by virtue of its history of advocacy for women's health, is in a position to promote policy and make similar recommendations, recognizing that sexual minority women's health and their family issues are an integral component of taking care of all women. The College should review the policies of America's premier mental health associations and consider including sexual orientation and gender identity in its own nondiscrimination policy, and ACOG should issue a policy statement in support of laws to provide safety from violence and discrimination, equal employment opportunities, equal health insurance coverage, and equal access to civil marriage.

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.

[Embryo donation in France: practice and difficulties. Strasbourg's experience]

OBJECTIVE

The aim of this study was to present the situation of embryo donation in France and around the world, to expound the difficulties of its practice and the results obtained in our centre 3 years after the introduction of this procedure.

PATIENTS AND METHODS

Embryo donation in France is controlled by implemented decrees published between 1999 and 2004. The couples, who have stored frozen embryos since at least two years, were contacted for a pluridisciplinary medical consultation. The indication of embryo donation was evaluated for the recipients through a pluridisciplinary approach.

RESULTS

Among the interviewed couples, 16.7% have chosen embryo donation but only half of them have completed the procedure (6% of the couples with frozen embryos). The main indications for embryo donation were a double sterility, unexplained genetic disease, ART failures (poor fertilization or bad embryo quality) and oocyte donation when the delay was too long for the couples. The pregnancy rate was 28.6% after the 21 first embryo transfers.

DISCUSSION AND CONCLUSION

The results of embryo donation confirm the international experience both considering the poor number of donated embryos, medical indications and results. Embryo donation has its place among ART techniques, but one should not ignore the general debate on ethical questions raised by this procedure.

The social implications of embryo cryopreservation

OBJECTIVE

To summarize the existing literature regarding the social implications of embryo cryopreservation and outline areas in need of further study.

RESULT(S)

The potential social impact of oocyte cryopreservation has not been investigated. Embryo cryopreservation has been increasingly used to improve the cost-effectiveness of in vitro fertilization (IVF) and expand the options available to infertile couples, yet its widespread adoption has occurred more rapidly than our ability to study the social consequences for the couples and health professionals involved. For maintaining cryopreserved embryos, the existing literature is fragmented and incompletely explores the effects on an infertile couple's psychosocial health and personal relationships, their family planning strategies, or their preferences for the disposition of the embryos. Managing unclaimed embryos continues to create challenges for assisted reproduction professionals.

CONCLUSION(S)

We currently lack a thorough understanding of the numerous social implications of cryopreservation. Major areas for future research include the impact of stored embryos on couples' fertility intentions and psychosocial health, factors that affect couples' decisions about embryo disposition, strategies to minimize unclaimed embryos, and the consequences of oocyte/ovarian cryopreservation.

[Genetic risks in embryo donation]

Embryo donation is now an acceptable practice which offers new therapeutic possibilities to many infertile couples. It can be proposed for genetic reasons like the existence of hereditary diseases in the families of both members of a couple, leading to a high risk of transmission to a child, or when a male or female sterility is associated with a transmissible genetic abnormality from the other partner. Embryos eligible for donation may have been conceived by in vitro fertilization performed because of a male or female infertility of genetic origin. As a consequence, they are considered at increased risk of carrying a known or unknown genetic abnormality related to parental infertility. A consultation should be provided before donation acceptation for defining exactly the causes of the initial in vitro fertilization and checking the genetic screening in the couple. According to recent guidelines established by the Genetics Commission of the French Federation of CECOS, some embryos could be excluded from donation process.

[Embryo donation in France, in Europe and in the United States]

Embryo donation, although proposed in a number of ART centres in the world is more often contemplated than performed, and very few publications report results on this subject. There is a great variability in program procedures and policies according to centres in the same country and between countries. In France, this activity is developing slowly. This is due to both the absence of information on the way to organise this activity at the medical level, and to legal constraints imposed by law.

Embryo donation: a review

BACKGROUND

Embryo donation is currently an uncommon procedure associated with many ethical, legal and psychosocial implications. It is, however, the only answer to infertility in some patients. This article summarizes the indications for embryo donation as well as the procedure and considerations in the preparation of both the donors and the recipients.

METHODS

A MEDLINE search was conducted for all English articles using the keywords embryo donation, in vitro fertilization and gamete donation.

CONCLUSION

Embryo donation might indeed be the answer to many infertile couples who would otherwise have to resort to childlessness or adoption. The advent of in vitro fertilization and cryopreservation of the spare embryos make these embryos a ready source for potential donors. The success rates of both fresh and freeze-thawed embryo transfers have been encouraging and there do not seem to be any long-term clinical implications for the offspring. However, there remain many legal and psychosocial issues associated with embryo donation.

Egg and Embryo Donation and the Meaning of Motherhood

As part of a larger study on donor-assisted conception, this paper reports research which explored the ways in which women who have donated or received eggs or embryos interpret such donations in the context of motherhood. Narrative analysis of women's accounts revealed that egg and embryo donations are not interpreted as incompatible with motherhood; that they may be explained as contributing to the significance of motherhood through the desire to assist some women to whom motherhood has been denied; and that the welfare of offspring of donated eggs and embryos is considered by donors. Differences were found between the meanings of egg donation and embryo donation, including likening eggs to cells and embryos to children, and in donors the expression of stronger maternal connection to the offspring of donated embryos. These accounts reveal individual variation, complexity, and change, reflecting (among other things) the dynamic process of narrative revision.

Changing attitudes towards third-party reproductive techniques

A growing number of children around the world are conceived through third-party reproductive techniques. The increased demand for these programs has resulted in an ongoing trend towards greater openness and less anonymity in gamete donation. This has led to changes in public policy regarding the identity of donors, to a greater concern for the well-being of donors, and to calls for disclosure to offspring about their donor gamete conception.

Access to services at assisted reproductive technology clinics: a survey of policies and practices

OBJECTIVE

Our goal was to investigate policy on patient access to services at assisted reproductive technology clinics in the United States.

STUDY DESIGN

Surveys asked about a variety of ethically and socially challenging cases and were mailed to directors of all Society for Assisted Reproductive Technology-associated assisted reproductive technology clinics.

RESULTS

Written policies on access to services are present at 40% of assisted reproductive technology clinics. Universal agreement was not found on any issue; 79% of clinics treat single women, 27% treat patients with a history of schizophrenia, 10% treat patients who use alcohol excessively, 7% treat human immunodeficiency virus-positive women, and 2% would treat patients previously convicted of child abuse. A breakdown of the responses indicated that some clinics are more permissive in terms of access to services than others, whereas some are more restrictive.

CONCLUSIONS

The data demonstrate considerable variability in policy among clinics on most access-to-services questions. The results highlight the importance of ongoing discussion of the ethical and legal issues related to access and the need to develop consistent methods to deal with complex cases.