The importance of genetic parenthood for infertile men and women

Driving factors in treatment decision-making of patients seeking medical assistance for infertility: a systematic review

BACKGROUND

ART differs in effectiveness, side-effects, administration, and costs. To improve the decision-making process, we need to understand what factors patients consider to be most important.

OBJECTIVE AND RATIONALE

We conducted this systematic review to assess which aspects of ART treatment (effectiveness, safety, burden, costs, patient-centeredness, and genetic parenthood) are most important in the decision-making of patients with an unfulfilled wish to have a child.

SEARCH METHODS

We searched studies indexed in Embase, PubMed, PsycINFO, and CINAHL prior to November 2023. Discrete choice experiments (DCEs), surveys, interviews, and conjoint analyses (CAs) about ART were included. Studies were included if they described two or more of the following attributes: effectiveness, safety, burden, costs, patient-centeredness, and genetic parenthood.Participants were men and women with an unfulfilled wish to have a child. From each DCE/CA study, we extracted the beta-coefficients and calculated the relative importance of treatment attributes or, in case of survey studies, extracted results. We assessed the risk of bias using the rating developed by the Grading of Recommendations Assessment, Development and Evaluation working group. Attributes were classified into effectiveness, safety, burden, costs, patient-centeredness, genetic parenthood, and others.

OUTCOMES

The search identified 938 studies of which 20 were included: 13 DCEs, three survey studies, three interview studies, and one conjoint analysis, with a total of 12 452 patients. Per study, 47-100% of the participants were women. Studies were assessed as having moderate to high risk of bias (critical: six studies, serious: four studies, moderate: nine studies, low: one study). The main limitation was the heterogeneity in the questionnaires and methodology utilized. Studies varied in the number and types of assessed attributes. Patients' treatment decision-making was mostly driven by effectiveness, followed by safety, burden, costs, and patient-centeredness. Effectiveness was rated as the first or second most important factor in 10 of the 12 DCE studies (83%) and the relative importance of effectiveness varied between 17% and 63%, with a median of 34% (moderate certainty of evidence). Of eight studies evaluating safety, five studies valued safety as the first or second most important factor (63%), and the relative importance ranged from 8% to 35% (median 23%) (moderate certainty of evidence). Cost was rated as first or second most important in five of 10 studies, and the importance relative to the other attributes varied between 5% and 47% (median 23%) (moderate certainty of evidence). Burden was rated as first or second by three of 10 studies (30%) and the relative importance varied between 1% and 43% (median 13%) (low certainty of evidence). Patient-centeredness was second most important in one of five studies (20%) and had a relative importance between 7% and 24% (median 14%) (low certainty of evidence). Results suggest that patients are prepared to trade-off some effectiveness for more safety, or less burden and patient-centeredness. When safety was evaluated, the safety of the child was considered more important than the mother's safety. Greater burden (cycle cancellations, number of injections, number of hospital visits, time) was more likely to be accepted by patients if they gained effectiveness, safety, or lower costs. Concerning patient-centeredness, information provision and physician attitude were considered most important, followed by involvement in decision-making, and treatment continuity by the same medical professional. Non-genetic parenthood did not have a clear impact on decision-making.

WIDER IMPLICATIONS

The findings of this review can be used in future preference studies and can help healthcare professionals in guiding patients' decision-making and enable a more patient-centered approach.

'Doing' kinship: heterosexual parents' experiences of non-genetic parenthood through donor conception

RESEARCH QUESTION

How do Dutch heterosexual parents who achieved parenthood through donor conception navigate non-genetic parenthood and kinship?

DESIGN

A qualitative in-depth semi-structured interview study was performed between September 2018 and January 2019 with both partners of 13 Dutch heterosexual couples where the male partner suffered from infertility and who conceived a child with the help of a sperm donor. Interview questions were based on literature and clinical experiences of experts in the field of donor conception. Interviews were transcribed and analysed using thematic analysis.

RESULTS

All parents navigated non-genetic parenthood through 'doing' kinship: they negotiated the importance of nature versus nurture with regards to donor conception and non-genetic parenthood. Most parents perceived genetics as irrelevant for experiencing parenthood, bonding with their children and the preferred role of the donor in their future lives. Yet most of them found genetics relevant for generating similarities between the father and the child, and for wanting the same donor for all their children to ensure a full genetic relation among them. Additionally, based on the donor's genetic bond with the child, some men were anxious about the donor's role in the child's future life and the consequences for their position as a non-genetic father. A few women perceived genetics as relevant in terms of possible inherited illnesses from the donor.

CONCLUSIONS

Parents experienced several ambiguities regarding the role of genetics in donor conception and navigated 'doing' kinship in various ways. These aspects need to be taken into consideration during the counselling of prospective parents planning to conceive with donor conception.

“Spiritual distress (00060)” in patients under fertility treatment: Clinical validation study

PURPOSE

This study aimed to clinically validate the NANDA-I nursing diagnosis of "Spiritual distress (00066)" in people under assisted reproductive technologies, and to determine the sensitivity, specificity, and predictive value of the defining characteristics.

METHODS

Cross-sectional study that was conducted between September 2019 and June 2020. Recruitment happened by invitation posted in fertility-related websites. Those who accepted to participate were asked to fill the consent form and the online questionnaire. Statistical analysis was based on Rasch's model. The study was approved by the Ethics Committee.

FINDINGS

The sample comprised 104 Portuguese individuals undergoing assisted reproductive techniques. The "Spiritual distress (00066)" was validated and 22 defining characteristics were confirmed as representative. No item showed differential item functioning. "Perceived suffering" was the most sensitive defining characteristic and had the highest negative predictive value. "Insufficient courage" had the highest positive predictive value, and "Anger toward power greater than self" was the most specific.

CONCLUSIONS

Results validated the presence of the NANDA-I nursing diagnosis of "Spiritual distress (00066)" in a sample going through assisted reproductive technologies, improving accuracy of this nursing diagnosis in such population.

IMPLICATIONS FOR NURSING PRACTICE

This is a crucial step to raise the level of evidence of such nursing diagnosis and to increase the level of evidence on NANDA-I terminology. Furthermore, this study has contributed to raising the quality of nurse's critical judgement and clinical reasoning and allow an early spiritual and a more holistic and personalized patient-centered intervention in the reproductive field.

OUP accepted manuscript

STUDY QUESTION

What information and support should be offered to donors, intended parents and donor-conceived people, in general and in consideration of the availability of direct-to-consumer genetic testing and matching services?

SUMMARY ANSWER

For donors, intended parents and donor-conceived offspring, recommendations are made that cover information needs and informed consent, psychosocial implications and disclosure.

WHAT IS KNOWN ALREADY

Trends indicate that the use of donor-assisted conception is growing and guidance is needed to help these recipients/intended parents, the donors and offspring, navigate the rapidly changing environment in which donor-assisted conception takes place.

STUDY DESIGN, SIZE, DURATION

A working group (WG) collaborated on writing recommendations based, where available, on evidence collected from a literature search and expert opinion. Draft recommendations were published for stakeholder review and adapted where relevant based on the comments received.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Papers retrieved from PUBMED were included from 1 January 2014 up to 31 August 2020, focusing on studies published since direct-to-consumer genetic testing has become more widespread and accessible. The current paper is limited to reproductive donation performed in medically assisted reproduction (MAR) centres (and gamete banks): donation outside the medical context was not considered.

MAIN RESULTS AND THE ROLE OF CHANCE

In total, 32 recommendations were made for information provision and support to donors, 32 for intended parents and 27 for donor-conceived offspring requesting information/support.

LIMITATIONS, REASONS FOR CAUTION

The available evidence in the area of reproductive donation is limited and diverse with regards to the context and types of donation. General conclusions and recommendations are largely based on expert opinion and may need to be adapted in light of future research.

WIDER IMPLICATIONS OF THE FINDINGS

These recommendations provide guidance to MAR centres and gamete banks on good practice in information provision and support but should also be considered by regulatory bodies and policymakers at a national and international level to guide regulatory and legislative efforts towards the protection of donors and donor-conceived offspring.

STUDY FUNDING/COMPETING INTEREST(S)

The development of this good practice paper was funded by European Society of Human Reproduction and Embryology (ESHRE), covering expenses associated with the WG meetings, the literature searches and dissemination. The WG members did not receive any payment. The authors have no conflicts of interest to declare.

DISCLAIMER

This document represents the views of ESHRE, which are the result of consensus between the relevant ESHRE stakeholders and where relevant based on the scientific evidence available at the time of preparation.

The recommendations should be used for informational and educational purposes. They should not be interpreted as setting a standard of care, or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. They do not replace the need for application of clinical judgement to each individual presentation, nor variations based on locality and facility type.

^†ESHRE pages content is not externally peer reviewed. The manuscript has been approved by the Executive Committee of ESHRE.

Exploring Swedish single women's decision to choose motherhood through medically assisted reproduction - a qualitative study

New legislation was introduced in Sweden in 2016, giving single women access to medically assisted reproduction (MAR). While Swedish single women's characteristics and motivations for choosing motherhood through MAR were assessed in our previous pilot survey, their experience of considering and making the decision to undergo MAR has not been assessed through a qualitative approach. Thus, the aim of this study was to explore Swedish single women´s experience of making the decision to choose motherhood through MAR. The study design was a qualitative method with a semi-structured interview guide used for individual face-to-face interviews. Sixteen single women accepted for MAR were interviewed individually during their waiting time to start treatment. Qualitative content analysis was used to analyse the data. The data analyses resulted in three main categories: (i) longing and belonging; (ii) social exclusion and support; and (iii) evaluation and encounter. The overarching theme reflects the decision to become a single mother by choice: motherhood through MAR - an emotional and ambivalent decision to make on your own. In conclusion, to reach motherhood, by giving birth to one's child and not deviating from the norm as childless, was considered important among these women when making the decision to become a single mother by choice.

Motherhood and assisted reproduction in a religious context: Genes, stigma and supports in Utah, United States

Six percent of cisgender (i.e. not transgender) women aged 15-44 are considered infertile in the United States, and 12% are unable to carry a pregnancy to term. For those who yearn to create a family despite these circumstances, assisted reproductive technology (ART) is an often-utilised resource. Though faith-based institutions have been referenced as a source of support for involuntarily childless adults, it is unclear how religious doctrine, especially that which prizes 'traditional' gender roles and genetic parenthood, may be a catalyst for distress. More research is needed to understand how the socio-cultural environment affects those who are unable to conceive without assistance. Therefore, the purpose of this research study was to understand the lived experiences of women who have utilised assisted reproduction in a particularly pronatalist, religious cultural context in the United States. From March to September 2017, in-depth interviews were conducted with 10 cisgender women who had utilised ART. Data analysis was conducted in NVivo 10 and consisted of line-by-line analysis, identifying themes, coding categories and developing matrices to uncover relationships between themes and categories. The quest for motherhood was truly a journey for the study participants who experienced rumination and self-blame due to their inability to become pregnant. This was rooted in their socio-cultural context. Thus, the study findings suggest that culture and stigma are linked with women's distress regarding their inability to become pregnant and results in distancing from other women. Genetic parenthood was prized initially, but this desire decreased over time. While past research suggests that infertility strains relationships, our study found that the turmoil of infertility and assisted reproduction actually strengthened couple relationships. Counselling was described as particularly helpful, but it is needed throughout the assisted reproduction process. The inclusion of religion and spirituality, for those who identify as such, in counselling would be beneficial.

Fair allocation of cryopreserved donor oocytes: towards an accountable process

A growing number of people desire ART with cryopreserved donor oocytes. The allocation of these oocytes to couples and mothers to be is a 2-fold process. The first step is to select a pool of recipients. The second step is to decide who should be treated first. Prioritizing recipients is critical in settings where demand outstrips supply. So far, the issue of how to fairly allocate cryopreserved donor oocytes has been poorly addressed. Our ethical analysis aims to support clinics involved in allocation decisions by formulating criteria for recipient selection irrespective of supply (Part I) and recipient prioritization in case supply is limited (Part II). Relevant criteria for recipient selection are: a need for treatment to experience parenthood; a reasonable chance for successful treatment; the ability to safely undergo an oocyte donation pregnancy; and the ability to establish a stable and loving relationship with the child. Recipients eligible for priority include those who: have limited time left for treatment; have not yet experienced parenthood; did not undergo previous treatment with cryopreserved donor oocytes; and contributed to the supply of donor oocytes by bringing a donor to the bank. While selection criteria function as a threshold principle, we argue that the different prioritization criteria should be carefully balanced. Since specifying and balancing the allocation criteria undoubtedly raises a moral dispute, a fair and legitimate allocation process is warranted (Part III). We argue that allocation decisions should be made by a multidisciplinary committee, staffed by relevant experts with a variety of perspectives. Furthermore, the committees' reasoning behind decisions should be transparent and accessible to those affected: clinicians, donors, recipients and children born from treatment. Insight into the reasons that underpin allocation decisions allows these stakeholders to understand, review and challenge decisions, which is also known as accountability for reasonableness.

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.

Moral women, immoral technologies? Romanian women's perceptions of assisted reproductive technologies versus adoption

The present study explored how Romanian women perceive in-vitro fertilization (IVF), surrogacy, and adoption as alternative pathways to traditional parenthood. Previous studies suggested that both men and women generally prefer a full genetic link, followed by a partial genetic link and, finally, no genetic link (i.e. adoption). We explored these findings by testing a series of predictors in a sample of women aged 18-45-years. We found that adoption was the most preferred option among Romanian women, while surrogacy was the last. Older women, with children, rather non-religious, and in a steady relationship, had a more positive perception of IVF. Older women and less religious had a more positive perception of surrogacy as a pathway to parenthood. In hypothetical scenarios, the most preferred option was adoption, followed by IVF and surrogacy. Results are discussed within the Romanian context regarding various methods of ART.

Reproductive trajectories and social-biological dimensions in parenthood: Portuguese version of the Meaning of Parenthood scale

BACKGROUND

Public meanings attributed to parenthood may shape individuals' family planning and how involuntary childlessness is supported by governmental policies. This study aimed to evaluate the influence of reproductive trajectories and gender in the meanings attributed to parenthood, and to assess the psychometric characteristics of the Portuguese version of the Meaning of Parenthood (MOP) scale.

METHODS

The sample comprised 754 participants: 246 young adults without children; 51 fathers and 159 mothers of adolescent children conceived spontaneously; and 149 infertile heterosexual couples. The scale was self-administered. Higher scores indicate attributing greater importance to parenthood to fulfill identity needs at individual, marital and social levels. Psychometric characteristics were analyzed through exploratory factor analysis; Cronbach alpha (α) assessed internal consistency.

RESULTS

Two dimensions of the MOP scale emerged, with good internal consistency (α ≥ 0.70): biological (importance of parenthood to fulfill reproductive needs as a biological being); social (importance of parenthood arising from social reproduction). Young adults attributed less importance to parenthood to fulfill both biological and social needs. The biological dimension was valued more than the social dimension in all subsamples; men highly valued the biological dimension compared to women.

CONCLUSIONS

Family planning needs to focus on a reasonable balance between biological and social dimensions of parenthood. The reinforcement of public policies providing the necessary conditions for human reproduction is essential to reverse declining fertility rates.

The relative importance of genetic parenthood

RESEARCH QUESTION

How much do patients with severe infertility and their gynaecologists value genetic parenthood relative to other key treatment characteristics?

DESIGN

A discrete choice experiment included the following treatment characteristics: genetic parenthood, pregnancy rate, curing infertility, maternal health, child health and costs. The questionnaire was disseminated between 2015 and 2016 among Dutch and Belgian patients with severe infertility and their gynaecologists.

RESULTS

The questionnaire was completed by 173 patients and 111 gynaecologists. When choosing between treatments that varied in safety, effectiveness and costs, the treatment's ability to lead to genetic parenthood did not affect the treatment preference of patients with severe infertility (n = 173). Genetic parenthood affected the treatment preference of gynaecologists (n = 111) less than all other treatment characteristics. Patients indicated that they would switch to a treatment that did not enable genetic parenthood in return for a child health risk reduction of 3.6%, a cost reduction of €3500, an ovarian hyperstimulation risk reduction of 4.6%, a maternal cancer risk reduction of 2.7% or a pregnancy rate increase of 18%. Gynaecologists made similar trade-offs.

CONCLUSIONS

While awaiting replication of this study in larger populations, these findings challenge the presumed dominant importance of genetic parenthood. This raises questions about whether donor gametes could be presented as a worthy alternative earlier in treatment trajectories and whether investments in novel treatments enabling genetic parenthood, like in-vitro gametogenesis, are proportional to their future clinical effect.

Lesbian motherhood and mitochondrial replacement techniques: reproductive freedom and genetic kinship

In this paper, we argue that lesbian couples who wish to have children who are genetically related to both of them should be allowed access to mitochondrial replacement techniques (MRTs). First, we provide a brief explanation of mitochondrial diseases and MRTs. We then present the reasons why MRTs are not, by nature, therapeutic. The upshot of the view that MRTs are non-therapeutic techniques is that their therapeutic potential cannot be invoked for restricting their use only to those cases where a mitochondrial DNA disease could be 'cured'. We then argue that a positive case for MRTs is justified by an appeal to reproductive freedom, and that the criteria to access these techniques should hence be extended to include lesbian couples who wish to share genetic parenthood. Finally, we consider a potential objection to our argument: that the desire to have genetically related kin is not a morally sufficient reason to allow lesbian couples to access MRTs.

The Human Responses and Nursing Diagnoses of Those Living With Infertility: A Qualitative Systematic Review

OBJECTIVE

To systematically retrieve, critique, and synthesize patients' human responses about living with infertility and identify possible related nursing diagnoses according to NANDA-I.

METHODS

Systematic review of qualitative nursing studies.

FINDINGS

A total of 39 papers were included, 49 human responses, and 77 potential infertility-related nursing diagnoses were identified across three themes. Main foci matching nursing diagnosis were related to spiritual well-being, spiritual distress, and resilience.

CONCLUSIONS

Patients respond to infertility in a variety of ways and this raises the need for a more effective, holistic, and accurate nursing diagnosis.

IMPLICATIONS FOR PRACTICE

The accuracy of the nursing diagnosis is critical in raising the quality of the nursing process and in meeting infertile patients' circumstances and care expectations.

The ethics of clinical applications of germline genome modification: a systematic review of reasons

STUDY QUESTION

What are the reasons for or against the future clinical application of germline genome modification (GGM)?

SUMMARY ANSWER

A total of 169 reasons were identified, including 90 reasons for and 79 reasons against future clinical application of GGM.

WHAT IS KNOWN ALREADY

GGM is still unsafe and insufficiently effective for clinical purposes. However, the progress made using Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR)- CRISPR-associated system (Cas) has led scientists to expect to overcome the technical hurdles in the foreseeable future. This has invited a debate on the socio-ethical and legal implications and acceptability of clinical applications of GGM. However, an overview of the reasons presented in this debate is missing.

STUDY DESIGN, SIZE, DURATION

MEDLINE was systematically searched for articles published between January 2011 and June 2016. Articles covering reasons for or against clinical application of intentional modification of the nuclear DNA of the germline were included.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Two researchers independently extracted the reported reasons from the articles and grouped them into categories through content analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

The systematic search yielded 1179 articles and 180 articles were included. Most papers were written by professionals in ethics, (science) journalism and biomedical sciences. Overall, 169 reasons were identified, including 90 reasons for, and 79 reasons against future clinical application of GGM. None of the included articles mentioned more than 60/169 reasons. The reasons could be categorized into: (i) quality of life of affected individuals; (ii) safety; (iii) effectiveness; (iv) existence of a clinical need or alternative; (v) costs; (vi) homo sapiens as a species (i.e. relating to effects on our species); (vii) social justice; (viii) potential for misuse; (ix) special interests exercising influence; (x) parental rights and duties; (xi) comparability to acceptable processes; (xii) rights of the unborn child; and (xiii) human life and dignity. Considerations relating to the implementation processes and regulation were reported.

LIMITATIONS, REASONS FOR CAUTION

We cannot ensure completeness as reasons may have been omitted in the reviewed literature and our search was limited to MEDLINE and a 5-year time period.

WIDER IMPLICATIONS OF THE FINDINGS

Besides needing (pre)clinical studies on safety and effectiveness, authors call for a sound pre-implementation process. This overview of reasons may assist a thorough evaluation of the responsible introduction of GGM.

STUDY FUNDING/COMPETING INTEREST(S)

University of Amsterdam, Alliance Grant of the Amsterdam Reproduction and Development Research Institute (I.D.), and Clinical Center, Department of Bioethics, National Institutes of Health Intramural Research Program (S.H.). There are no competing interests.

Attitudes towards family formation among men attending fertility counselling

Men and women are increasingly postponing childbearing until an age where fertility has decreased, meaning that they might have difficulties in achieving their desired family size. This study explored childless men's attitudes towards family formation. Data were collected through semi-structured qualitative interviews with 21 men attending the Fertility Assessment and Counselling Clinic in Copenhagen or Horsens, Denmark. Data were analysed using content analysis. The men envisioned a nuclear family with their own biological children, but they experienced doubts and ambivalence about parenthood and feeling 'ready'. Their lack of readiness was linked to their awareness of the sacrifices and costs involved with parenthood, and their belief that they could safely delay parenthood. The men did not consider that they may be unable to have their own biological children. This study highlights the importance of considering men's attitudes and preferences towards family formation when understanding couples' decision-making. Contrary to common understanding, the findings show that men are as concerned with the planning and timing of parenthood as women, but their knowledge of the age-related decline in fertility is poor. Men need to gain more awareness of the limitations of fertility and the impact of female and male age on the ability to achieve parenthood aspirations.