Medical research and reproductive medicine in an ethical context: a critical commentary on the paper dealing with uterine lavage published by Munné et al

A recent study published in Human Reproduction claimed that uterine lavage offers a non-surgical, minimally invasive strategy for the recovery of human embryos from fertile women who do not want or need IVF for medical reasons but who desire preimplantation genetic testing (PGT) for embryos. To prove this hypothesis, the researchers recruited dozens of young Mexican women. The prospective oocyte donors underwent ovarian stimulation to induce the production of multiple mature oocytes. Subsequently, these women were inseminated by donor semen. A few days later, the developing embryos were collected by uterine lavage (uterine flushing) and subjected to genetic testing for aneuploidies (PGT-A). Oocyte donors with persistently elevated hCG levels, indicating the implantation of one or more embryos after uterine lavage, had to undergo uterine curettage and/or treatment with methotrexate. A critical opinion paper discussing the aforementioned study was published by De Santis and colleagues and has raised critical issues that are largely technical in nature. However, this opinion paper neglects-from our point of view-critical issues of the Mexican study regarding ethical principles and moral standards in human research. These aspects are summarized below.

A moral argument for frozen human embryo adoption

Some people (e.g., Drs. Paul and Susan Lim) and, with them, organizations (e.g., the National Embryo Donation Center) believe that, morally speaking, the death of a frozen human embryo is a very bad thing. With such people and organizations in mind, the question to be addressed here is as follows: if one believes that the death of a frozen embryo is a very bad thing, ought, morally speaking, one prevent the death of at least one frozen embryo via embryo adoption? By way of a three-premise argument, one of which is a moral principle first introduced by Peter Singer, my answer to this question is: at least some of those who believe this ought to. (Just who the "some" are is identified in the paper.) If this is correct, then, for said people, preventing the death of a frozen embryo via embryo adoption is not a morally neutral matter; it is, instead, a morally laden one. Specifically, their intentional refusal to prevent the death of a frozen embryo via embryo adoption is, at a minimum, morally criticizable and, arguably, morally forbidden. Either way, it is, to one extent or another, a moral failing.

Disclosure of sex when incidentally revealed as part of preimplantation genetic testing (PGT): an Ethics Committee opinion

Clinics may develop a policy to disallow selecting which embryos to transfer based on sex and choose to use only embryo quality as selection criteria. Clinics may also develop a policy to use randomization to select those embryos for transfer if more embryos suitable for transfer are available than can be transferred.

Dealing with treatment and transfer requests: how PGD-professionals discuss ethical challenges arising in everyday practice

How do professionals working in pre-implantation genetic diagnosis (PGD) reflect upon their decision making with regard to ethical challenges arising in everyday practice? Two focus group discussions were held with staff of reproductive genetic clinics: one in Utrecht (The Netherlands) with PGD-professionals from Dutch PGD-centres and one in Prague (Czech Republic) with PGD-professionals working in centres in different European countries. Both meetings consisted of two parts, exploring participants' views regarding (1) treatment requests for conditions that may not fulfill traditional indications criteria for PGD, and (2) treatment and transfer requests involving welfare-of-the-child considerations. There was general support for the view that people who come for PGD will have their own good reasons to consider the condition they wish to avoid as serious. But whereas PGD-professionals in the international group tended to stress the applicants' legal right to eventually have the treatment they want (whatever the views of the professional), participants in the Dutch group sketched a picture of shared decision-making, where professionals would go ahead with treatment in cases where they are able to understand the reasonableness of the request in the light of the couple's reproductive history or family experience. In the international focus group there was little support for guidance stating that welfare-of-the child considerations should be taken into account. This was different in the Dutch focus group, where shared decision-making also had the role of reassuring professionals that applicants had adequately considered possible implications for the welfare of the child.

Oncofertility: Fertile Ground for Conflict Between Patient Autonomy and Medical Values

Oncofertility is a unique, multidisciplinary field that serves to bridge the gap between available fertility resources and the special reproductive needs of cancer patients. Oncofertility is a growing field due to the increasing number of survivors, development of new oncologic therapies, extension of duration of therapies, and development and refinement of reproductive therapies. While the technologies and demand for services expand, clinicians need to be appropriately prepared for dealing with various clinical scenarios that may require ethical deliberation. Three real cases are presented in which the patient wishes to pursue reproductive assistance, but her decision is met with hesitance or uncertainty by her care team. Discussion of these clinical scenarios highlights ethical implications of oncofertility practice and serves to highlight the need for the establishment of multidisciplinary care teams and guidelines to support both clinicians and patients.

IMPLICATIONS FOR PRACTICE

The growing field of oncofertility is ripe for conflict between patient autonomy and medical values due to the nature of cancer and associated threat on an individual's health and survival, as well as the personal significance of childbearing. Cases are presented and ethical implications are discussed to further explore the inherent difficulties in oncofertility practice and guide clinicians in similar situations. Developing guidelines and establishing multidisciplinary teams to facilitate oncofertility discussions and care, as well as training of clinical team members, may improve patient safety, well-being, and satisfaction within the context of fertility decision making, care, and outcomes.

A case report of embryo donation: ethical and clinical implications for psychologists

Third-party reproduction is a growing field, and an increasing body of literature considers the ethics of embryo donation. Due to the psychosocial complexities that generally accompany the donation and/or use of donor embryos, psychologists can play a pivotal role in these specialised fertility cases. While laws in the USA are in place to regulate the medical procedures involved in embryo donation, only unenforceable guidelines exist for psychologists specialising in fertility cases. The presentation of this case study aims to: (1) clarify the ethical concerns that fertility psychologists should consider in similar situations by assessing whether American Society of Reproductive Medicine (ASRM) and the American Psychological Association (APA) guidelines compete or complement one another within this case of embryo donation and (2) consider the interests, obligations and rights of all parties involved. Several principles, standards and guidelines that must be considered are described. Overall, the APA Ethics Code and the ASRM Guidelines appear to complement one another for most aspects of this case. Fertility psychologists should consider the clinical implications of the interests, rights and duties of all involved parties, including themselves.

[POST MORTEM PATERNITY]

Post mortem paternity, namely the procreation after the death of the man whom is part of the couple, is one of the questions which raised the most hesitations since the first bioethics laws of 1994. The National Assembly, encouraged by several opinions of the CCNE (National advisory committee of ethics) had let itself convince that the transfer had, at least, to be authorized in utero embryos preserved at the regard of which no one could not claim to have rights equal or higher than those of the woman concerned. However, the Senate always ended up obtaining the maintenance of an absolute prohibition of posthumous procreation (starting) from the spermatozoids or frozen embryos. This indifference with the cruelty of the application of the law to the women plunged into mourning--based on a paradoxical appreciation of the interest of the child not to be born orphan, and on a not very glorious taking into account of the interest of the Body of notaries not to change its practices--is particularly debatable. One can, nevertheless, try to understand it according to the obsession of the legalization of surrogate motherhood by application of the principle of nondiscrimination which could justify the requests of the men who, thanks to a surrogate mother, would wish to become fathers starting from gametes or embryos taken or created before the death of their wife or partner.

Double trouble: should double embryo transfer be banned?

What role should legislation or policy play in avoiding the complications of in-vitro fertilization? In this article, we focus on single versus double embryo transfer, and assess three arguments in favour of mandatory single embryo transfer: risks to the mother, risks to resultant children, and costs to society. We highlight significant ethical concerns about each of these. Reproductive autonomy and non-paternalism are strong enough to outweigh the health concerns for the woman. Complications due to non-identity cast doubt on the extent to which children are harmed. Twinning may offer an overall benefit rather than burden to society. Finally, including the future health costs for children (not yet born) in reproductive policy is inconsistent with other decisions. We conclude that mandatory single embryo transfer is not justified and that a number of countries should reconsider their current embryo transfer policy.

[The Cryopre-servation: history and the ethical issue of storing embryos]

This review article deals with the technique which is called cryopreservation. Text describes the principle of this method, history and ethical problems in assisted reproduction.

The post-humanist embryo: genetic manipulation, assisted reproductive technologies and the Principle of Procreative Beneficence

Drawing from Julian Savulescu's argument for the obligation to use technological interventions for the enhancement human life, the Principle of Procreative Beneficence (PPB) states that parents have a moral obligation to use available reproductive technologies, including techniques of genetic manipulation, to create children who have the best chance of enjoying the best possible life. The aim of this study is to analyse the extent to which the possibility of using genetic manipulation to promote specific personality traits and thereby enhance human life is actually supported by current scientific knowledge and to determine whether the techniques employed in embryo selection comply with the PPB. In light of this analysis, the importance of involving the scientific community in the enhancement debate will be made clear. Moreover, when current knowledge of genetic and epigenetic processes and evidence of the risks of assisted reproductive technologies are taken into account, we find sufficient reason - even when guided by the PPB - to abstain from the use of current techniques of genetic manipulation and embryonic selection.

Adoption first? The disposition of human embryos

Anja Karnein has suggested that because of the importance of respect for persons, law and policy should require some human embryos created in vitro to be available for adoption for a period of time. If no one comes forward to adopt the embryos during that time, they may be destroyed (in the case of embryos left over from fertility medicine) or used in research (in the case of embryos created for that purpose or left over from fertility medicine). This adoption option would increase the number of embryos available for couples looking for help in having children, but that effect is less important--Karnein argues--than the observance of respect for human persons. As possible persons, she holds that embryos ought to be treated, as if they will become children, if only for a while. If enacted as a matter of law and policy, an 'adoption option' would wrongly interfere with the dispositional rights women and men ought to have over embryos they create in the course of trying to have children. Karnein's proposal would also deprive researchers of certainty that the embryos they create for research would actually be available that way, leading to increased burdens of time and money and maybe even to more embryos than would otherwise be produced. Karnein's analysis does not show, moreover, that any duty of rescue applies to embryos. No woman is required to adopt any embryo, which significantly undercuts the justification for an obligatory adoption period.

Opinion of obstetricians and gynaecologists on ethical issues in the practice of in-vitro fertilisation and embryo transfer in Nigeria

The objective of this study was to bring ethical issues in the practice of in-vitro fertilisation (IVF) in Nigeria to the fore, to determine and articulate the views of Obstetricians and Gynaecologists on treatment modalities and to drive regulation of this specialised field. A plenary session was organised by The Bridge Clinic at the 2010 Society of Gynaecology and Obstetrics of Nigeria (SOGON) annual general meeting. Participants self-administered a 33-point questionnaire on their views on ethical issues in IVF. The results buttress the conclusions of an earlier publication, clearly indicating that even amongst specialised medical professionals; there are varying views which really cannot be challenged as being either right or wrong as they represent the individuals' position and his culture. Within the context of our society, ethics and morality especially as they affect patient care can and must be hinged on a code or framework which should be developed, implemented and its implementation monitored by a legally bound regulatory body for the protection of the rights and safety of our patients, their unborn children and for the integrity of our health care systems.

Cryopreserved embryos and Dignitas personae: another option?

Many of the thousands of human embryos currently in cryogenic storage will sooner or later be discarded, often after being experimented upon. Others will remain in storage indefinitely, left there by parents who have no plans either to bring them to term or to offer them for adoption. These facts, coupled with a commitment to the basic moral equality of all human beings at all stages of development, generate a pressing question: What should be done for these embryos whose vital activities have been suspended and whose futures look so bleak? This paper offers a case that allows some of these cryogenically stored embryos to thaw and die, allows disposal of their remains in a manner that reflects their status, and is morally acceptable in that it is consistent with the principles that many accept as governing the removal of life-sustaining treatment in end-of-life cases.

Ethical concerns for maternal surrogacy and reproductive tourism

Reproductive medical tourism is by some accounts a multibillion dollar industry globally. The seeking by clients in high income nations of surrogate mothers in low income nations, particularly India, presents a set of largely unexamined ethical challenges. In this paper, eight such challenges are elucidated to spur discussion and eventual policy development towards protecting the rights and health of vulnerable women of the Global South.

Donation of 'spare' fresh or frozen embryos to research: who decides that an embryo is 'spare' and how can we enhance the quality and protect the validity of consent?

This paper analyses elements of the legal process of consent to the donation of 'spare' embryos to research, including stem-cell research, and makes a recommendation intended to enhance the quality of that process, including on occasion by guarding against the invalidity of such consent. This is important in its own right and also so as to maximise the reproductive treatment options of couples engaged in in vitro fertilisation (IVF) treatment and to avoid possible harms to them. In Part 1, with reference to qualitative data from three UK IVF clinics, we explore the often delicate and contingent nature of what comes to be, for legal purposes, a 'spare' embryo. The way in which an embryo becomes 'spare', with its implications for the process of consent to donation to research, is not addressed in the relevant reports relating to or codes of practice governing the donation of embryos to research, which assume an unproblematic notion of the 'spare' embryo. Significantly, our analysis demonstrates that there is an important and previously unrecognised first stage in the donation of a 'spare' embryo to research, namely: consent to an embryo being 'spare' and so, at the same time, to its disuse in treatment. This is not explicitly covered by the Human Fertilisation and Embryology (HFE) Act 1990, as amended by the HFE Act 2008. Having identified this important initial stage in the process of consent to the donation of a 'spare' embryo to research in conclusion to Part 1, in Part 2 we analyse the idea of consent to an embryo's disuse in treatment on the basis that it is 'spare' with reference to the legal elements of consent, namely information as to nature and purpose, capacity, and voluntariness. We argue that there are in fact three related consent processes in play, of which the principal one concerns consent to an embryo's disuse in treatment. If the quality of this first consent is compromised, in turn this will impact on the quality of the consent to the donation of that 'spare' embryo to research, followed by the quality of consent to future cycles of assisted reproduction treatment in the event that these are needed as a result of a donation decision. The analysis overall is of central relevance to the debate as to whether, and if so when, it should be permissible to request the donation of fresh embryos for research, as opposed to those that have been frozen and, for instance, have reached the end of their statutory storage term. This has a particular bearing on the donation of embryos to stem-cell research since there is a debate as to whether fresh embryos are most useful for this.

[An approach to the legal and ethical problem of surrogate motherhood]

Surrogate motherhood is an issue which currently gives rise to considerable complexity. Some consider that it is a justifiable practice which should be permitted by law. However, western legal systems have traditionally understood that whereas objects can be traded freely, persons, including the human body, its organs and most essential functions, cannot be the object of commerce. This means that the freedom of the individual to make contracts for mutual benefit is limited. Regarding the child, legalization of surrogate motherhood means converting the parent-child relationship into a commercial relationship, since in the last instance this would depend on a financial transaction. Moreover, experience has shown that the child is left in a very vulnerable position, since his or her situation depends on the clauses set forth in the contract, which in no sense guarantees that his or her interests and rights will be protected. For all these reasons, we must conclude that the wish on the part of infertile couples should be taken seriously by society. However, not all desires that adults have should be regarded as rights, particularly if this is detrimental to the dignity and rights of other subjects involved, particularly those of vulnerable women and their children.

Dignity, marriage and embryo adoption: a look at Dignitas Personae

The Catholic Church's 2008 Dignitas Personae discusses the moral implications of respecting the dignity of all human beings, regardless of the stage of development. In that text, the Vatican's Congregation for the Doctrine of the Faith argues that respect for this dignity is incompatible with the conception of embryos outside marriage as well as assisted reproduction treatments and certain kinds of human embryonic research. Not only that, but the Congregation also rejects efforts at embryo adoption. As a matter of secular moral philosophy, this view of dignity is disputable and this article shows how an alternate view of dignity--one that depends on interests as against status--serves as a better foundation for decisions about ways in which to help people have children. This view of dignity is entirely compatible with a wide array of assisted reproduction treatments and research and is compatible with the conception of embryos for single parents or opposite-sex couples looking to have children. Using its notion of human dignity, the Congregation makes a case against embryo adoption, but that case is unconvincing given the permissible exercise of individual conscience and the presumptive importance of rescuing human lives where they can be rescued.

Stakeholders' views on ethical issues in the practice of in-vitro fertilisation and embryo transfer in Nigeria

The provision of IVF for the specialized treatment of infertility has grown very rapidly in Nigeria in recent times, especially within the private sector. The objective of this study was to document the views of key stakeholders regarding salient ethical issues relating to the practice of in-vitro fertilisation (IVF) in Nigeria. A think-tank session was convened with participants drawn from different backgrounds and disciplines to deliberate on ethical issues in IVF. Ten key issues were discussed at this inaugural session. It was unanimously agreed that there are no right or wrong answers when considering the ethics and morality of IVF as these are principally dependent on choice and circumstances. However within the legal and socio-cultural dictates of the Nigerian society, right and wrong may be clearly determined on some issues. With the expansion of the IVF industry and technology in Nigeria, the need to address related ethical issues have become paramount. The forum recommended that it is important that regulatory guidelines are put in place to regulate the practice of IVF in Nigeria and to protect patients' rights and safety.

Saviour siblings and collective family interests

In this article, I will explore the ethical concerns arising out of the use of preimplantation tissue typing (PTT) to create saviour siblings. There are two main ethical concerns about the welfare of the child to be born as a result of PTT. The first is whether the child to be born is treated as a commodity, as simply a means to save the life of his or her sibling. The second is whether the child to be born will be harmed as a result of PTT, either physically, psychologically or socially. These two ethical concerns reflect an individualistic approach to the welfare of the child, whose interests are treated as largely separate to the interests of other family members. I will argue that the welfare of the child born as a result of PTT should be conceived more broadly to include not only the child's individual interests, but also the collective interests the child shares with his or her family. I base this broader conception of welfare on the notion of human flourishing, which recognises that the welfare of a child is inextricably connected to the welfare of the intimate collective that is his or her family. The collective interests of intimate family members are particularly relevant in the context of PTT, as the members are engaged in a shared journey to save the life of an ill child.

[Oocyte and embryo donation and surrogacy. Religious, medico-social, ethical, financial and legal problems]

The authors quote and discuss the postulates of the Orthodox, Jewish, Catholic and Islamic religions towards ART as well as worldwide legislations and standards and the attitude of female students of medicine in Varna. Indications of oocyte and embryo donation and surrogacy are proposed but all kinds or surrogacy should be permitted. The ART legislation and standards in Bulgaria should be thoroughly revised.

The number of embryos to transfer: current practices in Minnesota

Recent events have sparked interest in the scientific, medical, and ethical issues surrounding assisted reproductive technologies (ART), particularly related to the number of embryos to transfer. This article provides an update on current practices of Minnesota physicians who use ART in the treatment of infertile patients.

Issues and ethics related to embryo placement: a national discussion

There is growing debate over the transfer, or "placement," of embryos. During the first national conference on embryos (Emerging Issues in Embryo Adoption and Donation), funded by the U.S. Department of Health and Human Services, Thomas C. Atwood, President and CEO of the National Council for Adoption, expressed his views and concerns regarding embryo "adoption." This article will highlight Mr. Atwood's presentation, offering a chance to examine and reflect on the scientific questions and moral implications of this new procedure.

Coming soon to your clinic: patient-friendly ART

The current practice in medically assisted reproduction is still too exclusively focused on effectiveness and success rates. This has a number of considerable, and more importantly, avoidable drawbacks. Single embryo transfer was an important move away from this model to include safety and welfare of mother and child. Patient-friendly ART goes one big step further. It is composed of a mix of four criteria: cost-effectiveness, equity of access, minimal risk for mother and child and minimal burden for patients. All four components have a strong normative ethical basis: cost-effectiveness relies on the optimal use of community resources to maximise well-being; equity of access is based on justice, minimal risk is founded on the fundamental non-maleficence rule and minimal burden is largely based on the autonomy principle. The inclusion of the four criteria in decision-making about treatment would express these values in clinical practice.

Having a child to save a sibling: reassessing risks and benefits of creating stem cell donors

This manuscript assesses the risks, benefits, and ethical concerns regarding the use of assisted reproductive techniques (ART) to create a new donor for stem cell transplantation. We address ethical literature, the medical and psychosocial impact on patient, donor, family, and medical caregivers, and the appropriate decision-making process. We conclude that the use of ART to create a stem cell donor can be ethically acceptable. The decision to conceive a donor has medical and psychosocial implications. The family is the appropriate decision-maker and must consider risks and benefits to all parties with input from medical caregivers.

[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.

ACOG Committee on Ethics. ACOG Committee Opinion No. 347, November 2006: Using preimplantation embryos for research

Human embryonic stem cell research promises an increased understanding of the molecular process underlying cell differentiation. Transplantation of embryonic stem cells or their derivatives may, in the future, offer therapies for human diseases. In this Committee Opinion, American College of Obstetricians and Gynecologists (ACOG) Committee on Ethics presents an ethical framework for examining issues surrounding research using preimplantation embryos and proposes ethical guidelines for such research. The Committee acknowledges the diversity of opinions among ACOG members and affirms that no physician who finds embryo research morally objectionable should be required or expected to participate in such research. The Committee supports embryo research within 14 days after evidence of fertilization but limits it according to ethical guidelines. The Committee recommends that cryopreserved embryos be the preferred source for research but believes that the promise of somatic cell nuclear transfer is such that research in this area is justified. The Committee opposes reproductive cloning. Intended parents for whom embryos are created should give informed consent for the disposition for any excess embryos. The donors of gametes or somatic cells used in the creation of such tissue should give consent for donation of embryos for research. Potential research projects should be described to potential donors as much as possible. Donation of embryos for stem cell research requires specific consent. The Committee believes that compensation for egg donors for research is acceptable, consistent with American Society for Reproductive Medicine guidelines.

Rescuing human embryonic stem cell research: the Blastocyst Transfer Method

Despite the therapeutic potential of human embryonic stem (HES) cells, many people believe that HES cell research should be banned. The reason is that the present method of extracting HES cells involves the destruction of the embryo, which for many is the beginning of a person. This paper examines a number of compromise solutions such as parthenogenesis, the use of defective embryos, genetically creating a "pseudo embryo" that can never form a placenta, and determining embryo death, and argues that none of these proposals are likely to satisfy embryoists, that is, those who regard the embryo as a person. This paper then proposes a method of extracting HES cells, what might be called the Blastocyst Transfer Method, that meets the ethical requirements of embryoists, and it considers some possible concerns regarding this method. It concludes by encouraging future HES cell research to investigate this method.