ESHRE Task Force on Ethics and Law 11: Posthumous assisted reproduction

Single men's attitudes towards posthumous use of their sperm cryopreserved due to illness in Israel

BACKGROUND

Banking of frozen spermatozoa by single men opens the possibility of procreation long after their death. Requests for posthumous reproduction by the families of the deceased are growing, raising an ethical debate, especially when written instructions were not left by the patients and in cases of unplanned perimortem collection. The issue of the progenitors' intention to procreate after death is the key to ethically based decision-making in these cases.

OBJECTIVES

To evaluate the attitude of single men cryopreserving spermatozoa before life-threatening medical situations towards post-mortem usage of their cryopreserved spermatozoa.

MATERIALS & METHODS

Adult single men prior to sperm cryopreservation before cytotoxic therapy were asked to sign a structured form declaring their will and instructions for the usage of their cryopreserved spermatozoa in case of their demise.

RESULTS

Four hundred fifty-two men of diverse ethnicity, religious and cultural backgrounds signed the form providing instructions for the use of their cryopreserved spermatozoa in case of mortality. Their age was 27.4 ± 8.06 years. Seven (1.5%) patients willed their spermatozoa for posthumous reproduction to a sibling, 22 (4.9%) to parents, and 26 (5.7%) to their informal female partners. The significant majority (n = 397; 87.8 %) of the single men were ordered to destroy their cryopreserved spermatozoa in case of their expiry. Note that, 26-39 years old men were less likely (81.8% vs. >90% in other ages) to order sperm destruction, as well as men with a poorer prognosis (83% vs. 90%).

DISCUSSION

In this study group, most single men cryopreserving spermatozoa in the face of future life-threatening morbidity do so for their own future live parenthood, and are not interested in posthumous reproduction.

CONCLUSION

Our results doubt the claim that single men who had an unplanned perimortem sperm collection can be universally presumed to have wished to father a child posthumously. Any claimed assumed consent in these cases should be considered for each case individually based on its specific circumstances.

Ethical and Practical Considerations of Perimortem Gamete Procurement for Palliative Care Providers

Requests for perimortem gamete procurement (PGP) typically arise by a surrogate decision maker after the unexpected death or incapacitation of a reproductive-aged individual. Palliative care clinicians should have a working knowledge of the medical, ethical, and practical considerations pertaining to such requests. In this paper, we describe a case in which the PGP request originated from an incapacitated patient's parents. We review the technologies associated with PGP and posthumous assisted reproduction (PAR) and discuss the ethical and legal issues involved in such cases, including recent position statements from national and international reproductive health groups. Finally, we provider readers with a stepwise approach for considering requests for PGP.

Assisted human reproduction legislation: Acknowledging the voice of health care professionals

OBJECTIVE

Ireland is one of 5 European countries which currently lacks specific legislation on Assisted Human Reproduction (AHR). Draft legislation was introduced in 2017 and revised in 2022 with a view to enacting legislation this year (2022). This study sought to ascertain the views of healthcare professionals to proposed AHR legislation, prior to the implementation of that legislation.

STUDY DESIGN

A survey questionnaire based on all clinically relevant aspects of the Irish draft AHR Bill 2017 was distributed to relevant healthcare professionals using an online platform.

RESULTS

Over 200 healthcare personnel indicated strong support for the availability of AHR techniques, access to treatment for all patient populations regardless of relationship or gender status, and appropriate legislation and regulation in the field. Views of respondents are at variance with several proposals surrounding surrogacy, with 84 % favouring a pre-birth order to assign parentage from birth, rather than the proposed birth order 6 weeks after birth. The majority also support legislation around international surrogacy. Contrary to the draft Bill, respondents believe that men, as well as women, should be able to use posthumously any stored gametes or embryos belonging to the deceased partner or the couple. While the majority favour altruistic gamete donation, respondents support more generous compensation for donors, such as compensation for time lost at work.

CONCLUSION

This study has uniquely ascertained the views of healthcare professionals to imminent AHR legislation. It is hoped that the results will help inform the national legislation as it nears completion. Similar studies could help other countries, and policy bodies such as ESHRE to frame good legislation in this extremely specialised and complex field.

Attitudes toward posthumous assisted reproduction in China: a multi-dimensional survey

BACKGROUND

Professional legislation and ethics guidelines for posthumous assisted reproduction (PAR) are lacking in China. This study aims to measure the attitudes of the general public, IVF couples, and assisted reproductive technology (ART) practitioners toward PAR in China.

METHODS

A multi-dimensional survey was designed, and electronic questionnaires were used. General demographic data, reproductive viewpoints, attitudes toward PAR, interactive ability to predict the partner's attitude toward PAR, and the legal attributes and rights to the disposal of posthumous embryos were evaluated.

RESULTS

The study found that the traditional Chinese viewpoints of fertility had changed. The approval rates for PAR were 79.10%, 55.32%, and 58.89%, in the general public, IVF couples, and ART practitioners, respectively. Most participants agreed that the psychological well-being of offspring should be previously considered before making a PAR decision (81.84%, 73.61%, and 76.98%, respectively). Multivariable logistic regression analysis showed that age, marital status, and gender were common influencing factors, while occupation, religion, and pregnancy history showed no influence on support for PAR. Males and females showed similar predictive abilities for their partners' attitudes toward PAR (57.87% for males, 61.12% for females). Intracouple agreement analysis showed that the consistent rate of consistency in attitudes toward PAR was 65.28%.

CONCLUSION

The findings suggested that the approval rate of PAR was relatively high in China. Legislation and ethics guidelines for PAR may be considered in China. The psychological well-being of offspring should be considered before the implementation of PAR. Due to the very large regional and demographic differences in China, investigation of a larger samples of participants is necessary.

Perimortem and postmortem sperm acquisition: review of clinical data

PURPOSE

To provide the clinicians with the most comprehensive medical information about sperm acquisition peri/postmortem.

METHODS

The review was conducted according to the PRISMA statement. MEDLINE and Cochrane databases were searched up to January 2021. All studies reporting post or perimortem harvesting of sperm with any indication of an outcome, recognition and viability of sperm, and its utilization and treatment outcome were included. Studies that recorded cases but discussed only the ethical or legal issues without any information about the medical details were excluded.

RESULTS

Twenty-four studies were included in this review. One hundred forty-eight cases were described; in 113 of them, sperm was retrieved. A variety of techniques for sperm acquisition were used. The data collected are limited and comparing the efficacy of the different approaches is not feasible. The longest time interval described between the death and viable sperm acquisition was 3 days. The sperm quality varies between the studies. One hundred thirty-six mature oocytes were injected with the retrieved sperm; the fertilization rate was 41%. Transfer cycles of 25 embryos and 8 live births are reported in the medical literature.

CONCLUSION

The overall low quality and high heterogeneity of the available data impair the ability to draw definitive conclusions. However, it can be stated that sperm acquisition up to at least 3 days postmortem can result in the live birth of healthy offspring. Further studies are needed to clarify the medical questions regarding the best techniques, success rates, and wellbeing of the parties involved.

Fertility Preservation for Pediatric and Adolescent Patients With Cancer: Medical and Ethical Considerations

Many cancers presenting in children and adolescents are curable with surgery, chemotherapy, and/or radiotherapy. Potential adverse consequences of treatment include sterility, infertility, or subfertility as a result of gonad removal, damage to germ cells as a result of adjuvant therapy, or damage to the pituitary and hypothalamus or uterus as a result of irradiation. In recent years, treatment of solid tumors and hematologic malignancies has been modified in an attempt to reduce damage to the gonadal axis. Simultaneously, advances in assisted reproductive technology have led to new possibilities for the prevention and treatment of infertility. This clinical report reviews the medical aspects and ethical considerations that arise when considering fertility preservation in pediatric and adolescent patients with cancer.

Oncofertility Decision Making: Findings from Israeli Adolescents and Parents

PURPOSE

To date, few studies qualitatively investigate adolescent oncofertility decision making. This qualitative study seeks to understand the experiences of adolescents and parents in making oncofertility decisions within the pronatalist context of Israeli society.

METHODS

Semi-structured interviews were conducted in Israel with adolescents between the ages of 12 and 19 years who were in remission for at least 2 months and had been offered fertility preservation (FP) of sperm, ova, or ovary cryopreservation, and their parents, separately. Transcripts were thematically analyzed.

RESULTS

Thirty-five interviews were conducted-16 with adolescents and 19 with parents-representing 20 cases of FP decision making. Adolescents and parents do not necessarily view decision making in the same way. Both parties mention a variety of factors in and justifications for FP decisions. Although most participants imagine the adolescent will use cryopreserved biological materials only if s/he experiences reproductive difficulties, nearly all participants do not recall having discussed what to do with these materials in the case of death. Many adolescents and parents feel comfortable waiting to take further action regarding adolescent fertility until the topic has greater relevance to the adolescent's life. Satisfaction with FP decision making is nearly unanimous, regardless of whether FP was pursued.

CONCLUSION

As in other cultural contexts, Israeli adolescents and parents demonstrate multifaceted decision making with respect to oncofertility. A significant finding from this study suggests that health professionals shy from discussing posthumous planning of cryopreserved materials with adolescent cancer patients and their parents. Further investigation is warranted to determine whether this is a uniquely Israeli phenomenon, the cause for it, and how to overcome it.

A cross-cultural analysis of posthumous reproduction: The significance of the gender and margins-of-life perspectives

The scholarly discussion of posthumous reproduction (PHR) focuses on informed consent and the welfare of the future child, for the most part overlooking cultural differences between societies. Based on a cross-cultural comparison of legal and regulatory documents, analysis of pivotal cases and study of scholarly and media discussions in Israel and Germany, this paper analyses the relevant ethical and policy issues, and questions how cultural differences shape the practice of PHR. The findings challenge the common classifications of PHR by highlighting the gender perspective and adding brain-dead pregnant women to the debate. Based on this study's findings, four neglected cultural factors affecting social attitudes towards PHR are identified: (i) the relationship between the pregnant woman and her future child; (ii) what constitutes the beginning of life; (iii) what constitutes dying; and (iv) the social agent(s) seeking to have the future child. The paper argues that PHR can be better understood by adding the gender and margins-of-life perspectives, and that future ethical and practical discussions of this issue could benefit from the criteria emerging from this cross-cultural analysis.

Pregnancy and childhood health and developmental outcomes with the use of posthumous human sperm

Although there is now considerable experience in obtaining sperm from a cadaver, there is little or no published data regarding pregnancy, birth and long-term childhood health and development outcomes when posthumous sperm is used in in vitro fertilisation (IVF). We report the results from treatment of four women undergoing IVF treatment using posthumously acquired human sperm from their deceased partners. In all cases, testicular tissue was obtained in a mortuary setting, and the duration from death to posthumous sperm retrieval ranged from 12 to 48 h. The age of women treated ranged from 31 to 41 years. Fertilization rates ranged from 40 to 100%. Singleton pregnancies were obtained for each of the four women. One pregnancy was complicated by preterm birth at 31 weeks; the other three delivered at term. One baby was growth restricted but morphologically normal; the other children had term birthweights in the normal range. All four children were have shown normal health and developmental outcomes, with the follow-up ranging from 1 to 7 years.

Blurring the line between life and death: a review of the psychological and ethical concerns related to posthumous-assisted reproduction

Posthumous-assisted reproduction (PAR), though viewed unfavourably by some, is desirable to many individuals whose partners die prior to the completion of family building. PAR is technically feasible for males and females both pre- and post-mortem and these procedures have previously been completed on numerous occasions. However, such treatment is associated with three primary ethical concerns: autonomy; beneficence; and justice for the living, the deceased, and the soon-to-be conceived. Further, there are many psychological risks of PAR which may affect all involved parties. As such, early psychological counselling of patients and surviving family members is warranted.

Postmortem sperm retrieval in context of developing countries of Indian subcontinent

There was a request for postmortem sperm retrieval (PMSR) from the wife of a deceased, but we had to decline. We have no guideline in place for the procedure in such cases. When we explored the international scenario on the issue of PMSR, we found that most of the developed countries have their guidelines about it, whether to allow or not to. There is not guideline available in developing countries, as such, for the procedure and various medical, legal, and social issues related thereto. In this article, we have explored the status of postmortem retrieval and feasibility of the procedure in developing countries of Indian subcontinent.

Posthumous Reproduction (PHR) in Israel: Policy Rationales Versus Lay People's Concerns, a Preliminary Study

Israeli policy concerning PHR has been decided upon in an expertocratic manner, leaving the voice of the public unheard. Based on 26 semi-structured in-depth interviews with 13 Jewish-Israeli young couples, this preliminary study provides the first empirical data regarding lay attitudes toward PHR in Israel. Findings suggest major dissimilarities between the policy and lay people's wishes and rationales. While policy is built on the "presumed wish" assumption, supposing all men living in a loving relationship wish to have their partner carry their child post-mortem, this was empirically unsupported. However, the findings suggest that many interviewees were willing to defer to their surviving spouse's wishes to have their post-mortem child, sometimes even against their own wish, indicating a support for presumed consent. Respecting the wishes of the dead, a dominant argument in the bioethical discussion in Israel and beyond, was mainly irrelevant to informants, whereas interviewees considered the future child's welfare, a concern overlooked by Israeli policy. Likewise, while posthumous grandparenthood is on the rise in Israel, it clearly contradicts the wishes of the majority of this study's informants. Nonetheless, existing policy is not expected to raise any opposition, due to the extreme liberalism of the participants and their support of reproductive autonomy.

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.

Oocyte cryopreservation beyond cancer: tools for ethical reflection

PURPOSE

This article offers physicians a tool for structured ethical reflection on challenging situations surrounding oocyte cryopreservation in young healthy women.

METHODS

A systematic literature review offers a comprehensive overview of the ethical debate surrounding the practice. Ethical Counseling Methodology (ECM) offers a practical approach for addressing ethical uncertainties. ECM consists of seven steps: (i) case presentation; (ii) analysis of possible implications; (iii) presentation of ethical question(s); (iv) explanation of ethical terms; (v) presentation of the ethical arguments in favor of and against the procedure; (vi) examination of the individual patient's beliefs and wishes; and (vii) conclusive summary.

RESULTS

The most problematic aspects in the ethical debate include the distinction between medical and non-medical use of oocyte cryopreservation, safety and efficiency of the procedure, and marketing practices aimed at healthy women. Female empowerment and enhanced reproductive choices (granted oocyte cryopreservation is a safe and efficient technique) are presented as ethical arguments supporting the practice, while ethical reservations towards oocyte cryopreservation are based on concerns about maternal and fetal safety and wider societal implications.

CONCLUSIONS

Oocyte cryopreservation is gaining popularity among healthy reproductive age women. However, despite promised benefits it also involves risks that are not always properly communicated in commercialized settings. ECM offers clinicians a tool for structured ethical analysis taking into consideration a wide range of implications, various ethical standpoints, and patients' perceptions and beliefs.

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.

Prospective study of depression and anxiety in female fertility preservation and infertility patients

OBJECTIVE

To prospectively assess anxiety, depression, coping, and appraisal in female fertility preservation (FP) patients compared with infertile patients.

DESIGN

Prospective pre- and post-treatment survey.

SETTING

Academic medical center.

PATIENT(S)

Forty-seven women with cancer (FP patients) and 91 age-matched infertile patients.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Depression, anxiety, coping, infertility-related stress, appraisal of treatment, and medical outcomes.

RESULT(S)

FP patients reported more symptoms of anxiety and depression than infertile patients, but infertile patients' symptoms worsened over time; 44% of FP and 14% of infertile patients' scores exceeded the clinical cutoff for depression before treatment. The interval between surveys and medical treatment data did not predict changes in mood symptoms. Coping strategies and infertility-related stress did not differ between groups, and avoidant coping predicted higher depression and anxiety scores.

CONCLUSION(S)

FP patients reported more anxiety and depression than infertile patients at enrollment in treatment, with more than one-third of FP patients reporting clinically significant depressive symptoms. However, infertile patients' anxiety and depressive symptoms increased across treatment. This increase was not related to time between registration for IVF and oocyte retrieval or the medical aspects of treatment. FP and infertile patients should be provided psychologic consultation before treatment to identify mood and anxiety symptoms and to refer patients for counseling as needed to prevent worsening of symptoms.

Correspondence Between Legislation and Public Opinion in Bulgaria about Accessto Assisted Reproductive Technologies (ART)

Introduction: This is the first study on the correspondence between the legislation and public opinion in Bulgaria regarding access to assisted reproductive technologies (ART).

Methods: We carried out a national on-line-based cross-sectional survey in the Bulgarian language from July 2010 until June 2011. Participants were 951 respondents from 18 to 65 years of age who independently completed the anonymous survey. We were interested in: 1) Attitudes about a woman’s age limit for ART, 2) the rate of acceptance of access of single women to ART, 3) the rate of approval of access of lesbian couples to ART, 4) the degree of acceptance of post-mortem assisted reproduction (PAR).

Results: Most of the respondents (54.9%) approved of a woman’s age limit of 43 years. The majority of the respondents (85.4%) supported access of single women to ART, while 45.1% of the participants approved of lesbians using assisted reproductive technologies (ART). Approximately 71.7% of the respondents stated they would permit PAR.

Conclusions: People prefer 43 years as a woman’s age limit for ART. The majority of the respondents accept access of single women to ART, but a two-fold lower percentage considers that lesbians should be allowed to use ART. The majority of the respondents are proponents of PAR.

[Posthumous assisted reproductive technologies]

Several types of posthumous ART, all exceptional, can be considered. Using frozen sperm by the wife or concubine results in a conception at a time when the father has been dead for longer or shorter. His ban is broadly consensual in France. Transferring frozen embryos after the man's death raises more questions. The only options in France for the surviving wife are donation to another couple, donation to research or destruction. The National Consultative Ethics Committee was several times favourable to allowing this practice under certain conditions, but it is still prohibited after the 2011 revision of the bioethics laws.

Preservation of fertility in females treated for cancer

Advancements of diagnosis and treatment have substantially improved cancer survival rates in the last few decades. The increasing number of survivors focuses attention on long-term effects caused by cancer treatment and its impact on quality of life. Ovarian failure is one of the major sequelae of cytotoxic chemotherapy and/or radiotherapy in female children and reproductive-age women. Oncologists should address the patients about fertility preservation options before therapy. Embryo cryopreservation is the only well-established method for females in preserving fertility; however other strategies including ovarian suppression, ovarian transposition and cryopreservation of oocytes and ovarian tissue are still experimental. Patients need advice and to know which are the most practical options for them. This article reviews the available fertility preservation methods in women, and the related issues including normal physiology of the ovary, effect of anticancer therapy on fertility, role of the oncologist and ethics. We performed a MEDLINE search from 1971 to 2011 in a similar way as Jensen et al. 2011, using the following MeSH terms: antineoplastic agents; ovarian failure; premature; infertility, female; fertility preservation; child and cancer; reproductive technologies, assisted.

Implications of oocyte cryostorage for the practice of oocyte donation

As the efficiency of oocyte cryopreservation has increased rapidly in recent years, oocytes are currently being stored either in the course of IVF treatments or as a fertility preservation measure. These practices may have an impact on the number of available donor oocytes due to two different dynamics: first, a certain percentage of women for whom oocytes were cryopreserved will eventually not use their oocytes and may decide to donate them to others; secondly, especially in the practice of social freezing, women may opt to donate a portion of the retrieved oocytes in 'freeze-and-share' schemes in order to reduce the costs. In this article, we aim to sketch the ethical implications of such developments in general and the issue of payment to oocyte donors in particular.

Guidelines for infertility counselling in different countries: is there an emerging trend?

BACKGROUND

It is widely accepted that infertility and involuntary childlessness, and the decision to engage with assisted reproduction technology (ART) services as a patient, donor or surrogate can entail wide-ranging psychosocial issues. Psychosocial counselling has, therefore, become valued as an integral element of ART services. The objective of this study was to begin to map out what exists globally by the way of guidelines for infertility counselling.

METHODS

Data were analysed from formal guidelines produced by seven national infertility counselling bodies, onetransnational infertility counselling organization, reports of the American Society for Reproductive Medicine Ethics Committee and Practice Committee and the ESHRE Task Force on Ethics and Law. Additional sources of data were the International Infertility Counseling Organization and counselling colleagues internationally.

RESULTS

Four broad areas concerning contemporary practice in infertility counselling are identified: (i) the legal mandate for counselling; (ii) eligibility credentials for individuals carrying out professional counselling activities; (iii) different forms of counselling and (iv) counselling practice in relation to specific elements of assisted reproduction treatment.

CONCLUSIONS

Internationally, the development of infertility guidelines is best described as a 'work in progress', although key trends are evident.

Physicians' undecided attitudes toward posthumous reproduction: fertility preservation in cancer patients with a poor prognosis

BACKGROUND

The American Society for Clinical Oncology (ASCO) established guidelines for fertility preservation for cancer patients. In a national study of US oncologists, we examined attitudes toward the use of fertility preservation among patients with a poor prognosis, focusing on attitudes toward posthumous reproduction.

METHOD

A cross-sectional survey was administered via mail and Internet to a stratified random sample of US oncologists. The survey measured demographics, knowledge, attitude, and practice behaviors regarding posthumous reproduction and fertility preservation with cancer patients of childbearing age.

RESULTS

Only 16.2% supported posthumous parenting, whereas the majority (51.5%) did not have an opinion. Analysis of variance indicated that attitudes toward posthumous reproduction were significantly related to physician practice behaviors and were dependent on oncologists' knowledge of ASCO guidelines.

CONCLUSIONS

Physician attitudes may conflict with the recommended guidelines and may reduce the likelihood that some patients will receive information about fertility preservation. Further education may raise physicians' awareness of poor-prognostic patients' interest in pursuing this technology.

Medical, ethical, and legal considerations in fertility preservation

The past 2 decades have seen a significant rise in cancer survival rates, and an increasing proportion of survivors at reproductive age are interested in childbearing. Although assisted reproduction provides physicians with an array of potential possibilities to help patients whose fertility is compromised by cancer treatment, there is still a dearth of regulation regarding the application of this technology. The present paper reviews the current options for fertility preservation, with a particular focus on the legal and ethical challenges that confront providers of this type of care.

Posthumous reproduction and palliative care

Posthumous reproduction is an issue fraught with legal, ethical, religious, and moral debate. The involvement of the hospice and palliative care community in this debate may be peripheral due to the fact that other health care professionals would be actually delivering the services. However, the hospice and palliative care community are more likely to treat patients considering posthumous reproduction as they near the end of their lives. This article provides the hospice and palliative care community with a review of the medical, ethical, and legal considerations associated with posthumous reproduction. Having knowledge of these issues, and a list of available resources, will be useful if hospice and palliative care staff find themselves facing a patient or family that is considering posthumous reproduction.

[Perimortem semen retrieval from comatose intensive care patients : Medico-legal, psychological and ethical aspects]

DEFINITION OF THE PROBLEM

Due to new technological advances in assisted reproduction, perimortem sperm retrieval has developed into a subject of increasing interest for families of comatose or dying male patients in critical care facilities. These requests raise a number of medical, ethical, legal and psychological issues. ARGUMENTS AND CONCLUSIONS: The case of a comatose dying male patient is used to illustrate the variety of positions and problems which have to be discussed. The importance of written consent of the donor, the interest of the unborn child and the legal limitations are highlighted.

Preservation of fertility in pediatric and adolescent patients with cancer

Many cancers that present in children and adolescents are curable with surgery, chemotherapy, and/or radiation therapy. Potential adverse consequences of treatment include sterility, infertility, or subfertility as a result of either gonad removal or damage to germ cells from adjuvant therapy. In recent years, treatment of solid tumors and hematologic malignancies has been modified in an attempt to reduce damage to the gonads. Simultaneously, advances in assisted reproductive techniques have led to new possibilities for the prevention and treatment of infertility. This technical report reviews the topic of fertility preservation in pediatric and adolescent patients with cancer, including ethical considerations.