Embryo donation: Counselling practice issues and dilemmas within the context of identity-release donor programmes.

Embryo donation (ED) involves the donation of surplus embryos post family formation to others in need. Commensurate with Australian and New Zealand legislation and policy, ED is practiced as an identity-release programme shaped by four paramount principles. These include: the need to consider the longitudinal health and well-being of donor-conceived children born from assisted reproductive technologies (ART); recognition that offspring should be made aware of and be able to access information about their genetic origins; awareness that the short and long-term health and psychological welfare of other stakeholders (i.e., recipients and donors) should be ensured; and finally, that all donations are altruistic. Whilst embedded in ART legislation or professional guidelines, how these principles are operationalized through counselling in both countries remains variable. In this paper, we draw upon Australian and New Zealand research, legislation and policy shaping the counselling milieu. We highlight some of the key clinical issues that counsellors need to explore with participants of an ED arrangement and the implications of these as they apply to dilemmas within counselling practice such as counsellor roles and responsibilities.

Assessment of patients' perceptions towards embryo disposition after donation of embryos to a research biobank.

PURPOSE: To explore perceptions towards embryo disposition among patients donating excess embryos to a research biobank. METHODS: Cross-sectional study of survey responses collected as part of enrollment in a research biobank. Patients are asked questions regarding the difficulty of their disposition decision, their alternative disposition choice if donation to research was not available, quality of the counseling they received, and if additional counseling throughout their treatment would have been beneficial. Survey responses use 5-point Likert scales, with "1" being lowest/least and "5" being highest/most. RESULTS: A total of 157 men and 163 women enrolled in the biobank. Median scores for difficulty of disposition decision were 3 for females and 2 for males, and for quality of counseling, the median scores were 4 for females and 3 for males. Seventy percent of patients would have chosen to discard their excess embryos had donation to research not been an option. Statistical analyses showed no significant difference in responses based on variations in race, religion, sexual orientation, and infertility diagnoses. Concordance of responses within heterosexual couples was tested and found to be poor to moderate. CONCLUSIONS: Assessing patients' perceptions towards embryo disposition after donation of their excess embryos to a research biobank affords a unique perspective. The difficulty of the disposition decision, the tendency to discard embryos in the absence of a means for donation to research, and the poor agreement between heterosexual partners highlight the importance of donation to research as an accessible disposition option and the need for a personalized approach to counseling and consenting for embryo disposition.

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

OBJECTIVE: To examine the disposition outcomes and disposition intentions of elective egg freezers (EEFs) toward their surplus frozen oocytes and the psychosocial determinants underlying these. DESIGN: A systematic review and meta-analysis. SETTING: Not applicable. PATIENT(S): Actual EEFs (women with oocytes in storage), potential EEFs (women investigating elective oocyte cryopreservation or about to freeze their oocytes), and women of reproductive age (women in the community aged ≥18 years). INTERVENTION(S): A systematic review was undertaken and electronically searched MEDLINE, Embase, and PsycINFO on the Ovid platform for conference abstracts and peer-reviewed articles, published in English after January 1, 2010. A search strategy combined synonyms for oocyte, cryopreservation, donation, disposition, elective, and attitude. Eligible studies assessed disposition outcomes (how an oocyte was disposed of) and disposition intentions (how women intend to dispose of an oocyte) and/or the psychosocial determinants underlying disposition outcomes and intentions. The Joanna Briggs Institute Prevalence Tool was used to assess the risk of bias. A meta-analysis using random effects was applied to pool proportions of women with similar disposition intentions toward their oocytes. MAIN OUTCOME MEASURE(S): Disposition outcomes and intentions toward surplus frozen oocytes: donate to research; donate to others; discard; unsure. Psychosocial determinants (beliefs, attitudes, barriers, and facilitators) of disposition outcomes and intentions. RESULT(S): A total of 3,560 records were identified, of which 22 (17 studies) met the inclusion criteria (8 studies from Europe, 7 from North America, and 2 from Asia). No studies reported on past oocyte disposition outcomes. Seventeen studies reported on the future disposition intentions of 5,446 women. Only 2 of the 17 studies reported on the psychosocial determinants of oocyte disposition intentions. There was substantial heterogeneity in the pooled results, which was likely a result of the significant variation in methodology. Actual EEFs were included in eight studies (n = 873), of whom 53% (95% confidence interval [CI], 44-63; I2, 87%) would donate surplus oocytes to research, 31% (95% CI, 23-40; I2, 72%) were unsure, 26% (95% CI, 17-38; I2, 92%) would donate to others, and 12% (95% CI, 6-21; I2, 88%) would discard their eggs. Psychosocial determinants: One study reported that 50% of these women were aware of friends and/or family having difficulty conceiving, which may have contributed to their willingness to donate to others. Potential EEFs were included in 4 studies (n = 645), of whom 38% (95% CI, 28-50; I2, 84%) would donate to research, 32% (95% CI, 17-51; I2, 91%) would donate to others, 29% (95% CI, 17-44; I2, 89%) would discard, and 7% (95% CI, 1-27; I2, 77%) were unsure. Psychosocial determinants: No studies. Women of reproductive age were included in 5 studies (n = 3,933), of whom 59% (95% CI, 48-70; I2, 97%) would donate to research and 46% (95% CI, 35-57; I2, 98%) would donate to others. "Unsure" and "discard" were not provided as response options. Psychosocial determinants: One study reported that the facilitators for donation to others included a family member or friend in need, to help others create a family, financial gain, to further science, and control or input over the selection of recipients. Barriers for donation included fear of having a biological child they do not know or who is raised by someone they know. CONCLUSION(S): No studies reported on the disposition outcomes of past EEFs. Disposition intentions varied across the three groups; however, "donating to research" was the most common disposition preference. Notably, the second disposition preference for one-third of actual EEFs was "unsure" and for one-third of potential EEFs was "donate to others." There were limited studies for actual and potential EEFs, and only two studies that explored the psychosocial determinants of oocyte disposition intentions. Additionally, these data suggest that disposition decisions change as women progress on their egg freezing journey, highlighting the importance of ongoing contact with the fertility team as intentions may change over time. More research is needed to understand the psychosocial determinants of oocyte disposition decisions so fertility clinics can provide EEFs with the support and information they need to make informed decisions about their stored eggs and reduce the level of uncertainty reported among EEFs and the potential risk of psychological distress and regret. CLINICAL TRIAL REGISTRATION NUMBER: PROSPERO 2020: CRD42020202733.

Consenting and ethical considerations in embryo cryopreservation.

PURPOSE OF REVIEW: An emerging body of literature has elucidated the growing burden of surplus embryos left in storage without any clear disposition. An out dated consent process is a significant but easily remedied contributor to this problem. We propose a novel approach to consenting for disposition of surplus embryos. RECENT FINDINGS: Decisional conflicts that stem from the moral status of embryos and from evolving personal values contribute to surplus embryos being left in storage. Barriers to donation of embryos to research or to other patients also discourage embryo disposition decisions. A flawed informed consent process compromises the physician--provider relationship and complicates decision-making. SUMMARY: Centralizing the process of donating embryos to research and to patients would lower barriers to these disposition options. The informed consent protocol must be redesigned as a longitudinal, narrative process compatible with the evolving values and fertility outcomes of patients. Counselors should be integrated into all discussions regarding embryo disposition from the onset of fertility treatment through its conclusion to facilitate the decision-making process.

Formal and informal support and counselling for embryo donation and receipt: An Australian qualitative study.

Despite growing numbers of people engaging in embryo donation for the purposes of family building, public access to information about the process may be limited. As such, support and counselling - both formal (i.e. through clinics) and informal (i.e. through online communities) - can play an important role in information provision. This article draws on a sub-sample of nine people from a qualitative study of embryo donation and receipt in Australia undertaken in 2017-2018. Themes developed suggest that formal support and counselling provided by clinics can be useful, though can require persistence to access and may not sufficiently address needs. In terms of informal support, themes developed suggest that sharing lived experiences in online communities can be important; however, there may also be challenges associated with differing viewpoints and threats to anonymity. The article concludes with a discussion of the ongoing importance of formal support and counselling while also suggesting that informal support is an avenue requiring further investigation.

Current perceptions and decisions of patients about cryopreserved embryos in Argentina. / [Percepciones actuales y decisiones de pacientes acerca de embriones criopreservados en Argentina.]

Introduction: Worldwide there is an increase in the number of assisted reproduction treatments. The developments in culture media and drugs, associated with the occurrence of rapid freezing or vitrification techniques has improved the procedures encouraging transfers of a single embryo per cycle. This generates a greater number of viable surplus embryos. An embryo disposition decision making is a complex phenomenon. Method: Method: This descriptive exploratory study investigates the perceptions and opinions of a sample of 60 participants who have started an assisted reproduction treatment in a specialized Fertility Center of the City of Buenos Aires. Results: The absence of children in the majority of the sample (70.6% still have no children) makes the prevailing option to "continue cryopreservation" (36.67%). The majority, 38.4% (23 people), considers that the option that best represents the embryo is "a child". Although there are relatively few people who have decided to donate their embryos (5 participants), several study participants report having reflected on it (35%). The vast majority (86.6%) of respondents would not be willing to face the costs of maintaining a long-term cryopreservation. Conclusion: After more than three decades of assisted reproduction, Argentinean patients still face a high degree of uncertainty regarding what to do with the surplus embryos. Gaining more in-depth knowledge regarding the decision-making process can help to improve the communication strategies. The normative absences generate that the ARTs users are "disengaged" from their embryos; this hinders the decision making, increasing the risk of accumulating more "abandoned" embryos

Introducción: A nivel mundial se registra un aumento en la cantidad de tratamientos de reproducción asistida. La optimización en medios de cultivo y fármacos, asociado al advenimiento de técnicas de congelamiento rápido o vitrificación han logrado mejorar los procedimientos alentando las transferencias de un único embrión por ciclo, generando un mayor número de embriones excedentes viables. La toma de las decisiones sobre la disposición de los embriones supernumerarios es un fenómeno complejo. Método: Este estudio exploratorio descriptivo indaga las percepciones y opiniones de una muestra de 59 participantes que han comenzado un tratamiento de reproducción asistida en un Centro de Fertilidad especializado de la Ciudad de Buenos Aires. Resultados: La ausencia de hijos en la mayoría de la muestra (70.6% aún no tiene hijos) hace que la opción prevalente sea continuar la criopreservación (35,6%). La mayoría, 40.7% (24 personas) considera que la opción que mejor representa al embrión es "un hijo/a". Si bien son relativamente pocas las personas que han decidido donar sus embriones (5 personas) varios participantes del estudio refieren haber reflexionado sobre ello (43%). La gran mayoría (86,5%) de los encuestados no estaría dispuesta a enfrentar los gastos del mantenimiento de la criopreservación a largo plazo. Conclusión: Se constata que, luego de más de tres décadas de desarrollo de las tecnologías reproductivas, aún existe en Argentina un alto grado de incertidumbre en los pacientes respecto de qué hacer con sus embriones excedentes. Conocer más en profundidad el proceso de toma de decisiones puede contribuir a implementar estrategias comunicacionales.

Attitudes towards embryo donation among healthcare professionals working in child healthcare: a survey study.

BACKGROUND: The aim of this study was to investigate attitudes towards embryo donation and embryo donation families among professionals working in primary child healthcare, and their experiences of these families. METHODS: A cross-sectional online survey was conducted in Sweden between April and November 2016. A total of 712 primary healthcare physicians, registered nurses and psychologists were approached to participate in this study. The study-specific questionnaire measured attitudes and experiences in the following four domains: legalisation and financing, the family and the child's health, clinical experience of meeting families following embryo donation, and knowledge of embryo donation. RESULTS: Of the 189 women and 18 men who completed the questionnaire (response rate 29%), relatively few (13%) had clinical experience of caring for families following embryo donation. Overall, 69% supported legalisation of embryo donation for infertile couples, and 54% agreed it should be publicly funded. The majority (88%) agreed the child should have the right to know the donors' identity. Respondents did not believe that children conceived through embryo donation are as healthy as other children (50%), citing the risks of poor mental health (17%) and social stigmatization (18%). Approximately half reported low confidence in their own knowledge of embryo donation (47%) and wanted to know more (58%). CONCLUSIONS: These results indicate relatively large support among healthcare professionals in Sweden for the legalisation of embryo donation. In order to provide adequate healthcare to families following embryo donation, there is a need to develop educational resources to increase knowledge about the medical and psychosocial consequences of embryo donation among healthcare professionals working in primary healthcare.

The main will of the patients of a private Italian IVF clinic for their aneuploid/affected blastocysts would be donation to research: a currently forbidden choice.

PURPOSE: Surplus cryopreserved affected/aneuploid blastocysts may be obtained after in vitro fertilization (IVF) treatments with preimplantation genetic testing (PGT). These embryos are considered not suitable for transfer and may be discarded. Currently, in Italy, an embryo disposition decision (EDD) is not allowed and the frozen/vitrified blastocysts (even if affected/aneuploid) should be kept cryopreserved indefinitely. In this peculiar clinical, social, and legislative scenario, we aimed at assessing the attitudes of the patients towards the fate of these embryos, in case the local regulation would be changed and allow an EDD regarding the surplus affected/aneuploid embryos obtained after PGT. METHODS: A questionnaire with multiple answers was submitted to 832 patients who obtained affected/aneuploid embryos during a PGT cycle at our private IVF center. They were asked to choose between three putative options with related reasons: everlasting cryopreservation (only option currently available); discard or donate them to research. RESULTS: Overall, 149 patients (18%; 85 women and 64 men) answered the questionnaire. Among them, 84% (n = 126) would choose to donate their affected/aneuploid blastocysts to research, 9% (n = 13) would discard them and only 7% (n = 10) would keep them cryopreserved indefinitely. CONCLUSIONS: Donation of the affected/aneuploid blastocysts is the option chosen from most of the respondents (84%; 15% of the eligible patients). These patients are motivated from the altruistic will of incentivating the progress in IVF and/or stem cell research and supporting future couples to limit/solve their infertility/health issues.

'Compassionate transfer': an alternative option for surplus embryo disposition.

Compassionate transfer is a procedure wherein in vitro-created embryos are placed in a patient's cervix, vagina or uterus at an infertile period in the menstrual cycle where they are expected to perish. Patients report that they feel this procedure is a more natural means of disposition and provides them with the opportunity to grieve the loss of a potential child. However, some have argued that the procedure is an unnecessary, and illogical, addition to fertility treatment and that it detracts resources from medical care. Here, we introduce compassionate transfer as an alternative disposition option and argue that, for certain patients, it may constitute an ethical extension of fertility care that respects patient autonomy and psychosocial health.

We wanted to choose us: how embryo donors choose recipients for their surplus embryos.

OBJECTIVE: This study aimed to explore factors affecting donors' choice of recipients for their surplus embryos in the New Zealand context of conditional, known donations. BACKGROUND: Internationally, embryo donation has a low uptake in spite of large numbers of cryopreserved embryos. Possible reasons include a lack of knowledge about and concern for the future welfare of the resultant offspring. In New Zealand, donors and recipients meet prior to donation and legislation supports disclosure and access to genetic knowledge. METHOD: Twenty-two embryo donors (10 couples, two individuals) were interviewed between March 2012 and February 2013 about their experiences of donation and factors affecting their donation. Interview data were analysed thematically. RESULTS: In the interests of the welfare of the child resulting from donation, donors were invested in choosing recipients who would make suitable parents. They attempted to choose recipients similar to themselves, as well as those that they trusted to disclose the manner of conception and facilitate agreed-upon information exchange and contact. CONCLUSION: The interest of donors in ensuring offspring well-being may lend support to conditional forms of open donation, allowing for assessment of recipients' suitability to parent, and for negotiation around information exchange and contact.

Percepciones y creencias sobre criopreservación embrionaria en mujeres y hombres que se realizan técnicas de reproducción asistida en Santiago, Chile / Perceptions and beliefs about embryo cryopreservation in women and men who have assisted reproductive techniques in Santiago, Chile

RESUMEN Introducción y objetivos: Aunque la criopreservación embrionaria es frecuentemente utilizada como parte de las técnicas de reproducción asistida, no existe información cuantitativa de cómo las parejas infértiles viven la experiencia de tener embriones criopreservados en Chile. El objetivo del estudio fue examinar las percepciones y creencias que tienen mujeres y hombres respecto de sus embriones criopreservados, sus perspectivas respecto de la donación reproductiva y destino de los embriones remanentes. Metodología: 153 mujeres y hombres con embriones criopreservados provenientes de un hospital público, Instituto de Investigaciones Materno Infantil y un centro privado, Clínica Las Condes, en Santiago, Chile, respondieron durante mayo 2015 a mayo 2016 un cuestionario en línea, anónimo, respecto de sus percepciones y creencias sobre criopreservación embrionaria. Resultados: Los encuestados reconocen a sus embriones criopreservados como un hijo (53.2%) o un proyecto de hijo (40.7%). Sólo 8% los considera un grupo organizado de células; sobre el 60% rechaza la opción de descartarlos o usarlos para investigación. Los participantes del hospital público tenían mayor disposición a donar sus embriones remanentes a otras parejas que aquellos del privado (61% vs 40%; P=0.016). Un 34% de las personas encuestadas estuvo de acuerdo con donar embriones a parejas de un mismo sexo. Conclusión: Este estudio muestra que las personas chilenas tienen un vínculo emocional con sus embriones criopreservados y no consideran descartarlos. Los resultados de este estudio pueden servir para dar adecuada consejería a las personas que se realizan técnicas de reproducción asistida, de tal modo de tomar decisiones informadas respecto de la criopreservación.

ABSTRACT Background and objetive: Although embryo cryopreservation is frequently used as part of assisted reproductive technology, quantitave information addressing how infertile couples live the experience of having cryopreserved embryos is lacking in Chile. The aim of this study is to examine men and women's perception and beliefs regarding their cryopreserved embryos, as well as their perspective on embryo donation and disposition. Methods: 153 women and men with frozen embryos from a public hospital, Instituto de Investigactiones Materno Infantil, and a private clinic, Clínica Las Condes, in Santiago, Chile, responded between May 2015 and May 2016 to an anonymous online survey addressing their perceptions and beliefs concerning their cryopreserved embryos. Results: Respondents considered their frozen embryos to be equivalent to a child (53.2%) or a potential child (40.7%). Only 8% regard them as an organized group of cells. Over 60% of respondents disagree with destroying surplus embryos or using them for research. Participants from the public hospital are more willing to donate their embryos to another couple than those from the private center (61% vs 40%; P=0.016); 34% of respondents agreed to donate surplus embryos to same sex couples. Conclusion: This study reveals that Chilean couples are emotionally bound to their frozen embryos, and that discarding them is not an option. The results from this survey will help strengthen counseling for couples to enable them to make informed decisions regarding their surplus embryos.

Interprofessional spanning and building boundaries when supporting potential embryo donors to stem cell research.

When patients undergo fertility treatment, it is likely that a surplus of embryos will be created. The existence of these surplus embryos creates responsibilities for the clinics where they are stored and for the people who own them. Since 2001, the owners of the surplus embryos in the UK have the option to donate them to be used in stem cell research (SCR). This development has generated a new population-potential embryo donors to SCR-who have unique support needs as they are neither fertility patients nor donors. However, little is known how lay and professional stakeholders associated with fertility treatment and SCR have conceptualised the support needs of potential embryo donors to SCR or have responded to the additional task once the option became available. In this article, we draw on Gieryn's concept of boundary-work to explore how the emergence of donating embryos to SCR has provided opportunities for embryologists, counsellors, and scientists to shift, adapt, or confirm their roles, knowledge base, and areas of expertise. We present a thematic analysis of 21 in-depth, semi-structured interviews conducted with UK lay and professional stakeholders associated with fertility treatment and SCR. We conclude with reflections on the implications this boundary-work has for those contemplating donating embryos to SCR and the care they receive when making their decision. Such insights are pertinent given the current policy and practice discussions led by the National Donation Strategy Group to improve the care of donors in the UK.

Death in the clinic: women's perceptions and experiences of discarding supernumerary IVF embryos.

Perspectives on the status of human embryos and whether they should be discarded differ globally. Some countries protect embryos in law while in other countries embryos 'die' or 'succumb' in assisted reproductive technology clinics on a daily basis. This study analyses interview data drawn from a larger qualitative study conducted in South Australia from 2004-2007. 21 women and 12 of 21 partners were interviewed about the decision they made to discard their embryos. The analysis reported here sought to examine the ways in which women constructed and experienced the decision to discard embryos. The article highlights the ways in which embryo discard is a contested discursive space. Embryo death is sequestered through their confinement in the laboratory and their invisibility to the naked eye. The clinic treated embryo discard as disposal of biological waste and failed to acknowledge the meaning of the event. By contrast women experienced emotional bereavement described as similar to early pregnancy loss, and described experiences of attachment and grief. For sensitive and compassionate care these differences in perceptions of embryo discard need to be addressed.

The Discourse of Gifting in Embryo Donation: The Understandings of Donors, Recipients, and Counselors.

In New Zealand, embryo donation (ED) is "open," allowing offspring to access genetic information. Donors and recipients meet prior to donation. Drawing on interviews with 15 recipients, 22 donors, and nine counselors, this article discusses how ED may be constructed as a form of gifting. This discourse may evoke expectations that recipients will express gratitude for the gift, including through honoring contact agreements. Donation becomes a relational practice of obligations and counter-obligations. However, the gift discourse may not adequately capture the emotional sacrifice experienced by donors. Donors describe significant attachment to their embryos, ambiguity about relinquishment, and interest in offsprings' welfare. Furthermore, embryos may be constructed as inalienable bodily gifts resulting in children with whom the donors share immutable social ties. A discourse of ED as mutual exchange, collaboration, and extended family building may be more useful to donors and recipients in managing ED.

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

STUDY QUESTION: What is the impact of law and policy upon the experience of embryo donation for reproductive use? SUMMARY ANSWER: Access to, and experience of, embryo donation are influenced by a number of external factors including laws that impose embryo storage limits, those that frame counselling and approval requirements and allow for, or mandate, donor identity disclosure. WHAT IS KNOWN ALREADY: To date only three qualitative studies in Australia and New Zealand have been completed on the experience of embryo donation for reproductive purposes, each with a small cohort of interviewees and divergent findings. STUDY DESIGN, SIZE, DURATION: Embryo donors, recipients, and would-be donors were interviewed between July 2010 and July 2012, with three additional interviews between September 2015 and September 2016, on their experiences of embryo donation. The sampling protocol had the advantage of addressing donation practices across multiple clinical sites under distinct legal frameworks. PARTICIPANTS/MATERIALS, SETTINGS, METHODS: Participants were recruited from five Australian jurisdictions and across 11 clinical sites. Twenty-six participants were interviewed, comprising: 11 people who had donated embryos for the reproductive use of others (nine individuals and one couple), six recipients of donated embryos (four individuals and one couple) and nine individuals who had attempted to donate, or had a strong desire to donate, but had been prevented from doing so. In total, participants reported on 15 completed donation experiences; of which nine had resulted in offspring to the knowledge of the donor. MAIN RESULTS AND THE ROLE OF CHANCE: Donors positively desired donation and did not find the decision difficult. Neither donors nor recipients saw the donation process as akin to adoption . The process and practice of donation varied considerably across different jurisdictions and clinical sites. LIMITATIONS, REASONS FOR CAUTION: Because the pool of donors and recipients is small, caution must be exercised over drawing general conclusions. Saturation was not reached on themes of counselling models and future contact. WIDER IMPLICATIONS OF THE FINDINGS: The differences between our findings and those of a previous study are attributable to varied legal and counselling regimes. Therefore, law and policy governing embryo storage limits, counselling protocols and identity disclosure shape the donation experience and how it is described. STUDY FUNDING/COMPETING INTERESTS: This research was supported by Discovery Project Grants DP 0986213 and 15010157 from the Australian Research Council and additional funding from UTS: Law. There are no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: Not applicable.

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

BACKGROUND: The high number of IVF procedures performed in Israel has had an unforeseen consequence: accumulation of large amounts of surplus frozen embryos. After five years that the frozen embryos are kept for free, patients need to make an embryo disposition decision. One option is donation for research. The donation rate in Israel is very low. Our aim was to understand the attitudes, values and perceptions of female IVF patients that decided to donate their surplus frozen embryos to research. METHODS: The study setting was a tertiary IVF unit which during the 2000-2009 period treated 241 patients who had their frozen pre-embryos stored for more than five years. The study population consists of the 12 patients (from among the 241) who had decided to donate their excess frozen pre-embryos to research. In-depth interviews were carried out with 8 of those 12 patients. RESULTS: IVF patients who donated their surplus frozen pre-embryos to research viewed the frozen embryo as a valuable resource that does not have human identity yet. The majority expressed a gradualist approach to the human status of the embryo as requiring successful implantation and development in the uterus. All the respondents chose donation to research not because it was their first choice but because they did not want or were unable to use the pre-embryos in the future, in addition to not willing to thaw them. For many of the respondents, donation to research was accompanied by a sense of uncertainty. All would have preferred to donate their pre-embryos to infertile women or couples, an option which is currently prohibited in Israel. CONCLUSIONS: The moral reasoning behind decisions that patients make regarding excess pre-embryos is important for health care practitioners to consider when offering decision-making alternatives and counseling. For our respondents, the scarcity of donating excess frozen pre-embryos to research may reflect patients' preference for embryo donation to infertile couples. Recommended ways to increase donation to research may include public education and awareness, as well as targeted communication with IVF patients by multi-professional IVF unit teams comprised of a medical doctor and a professional trained in bioethics.

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.

Survey of 243 ART patients having made a final disposition decision about their surplus cryopreserved embryos: the crucial role of symbolic embryo representation.

STUDY QUESTION: In couples who have chosen and confirmed the fate of surplus frozen embryos, which factors influence their decision, with a special emphasis on their symbolic representation of the embryo(s)? SUMMARY ANSWER: Embryo representation and gamete donation use significantly influence the fate of surplus cryopreserved embryos. WHAT IS KNOWN ALREADY: Previous studies report difficulties for couples to decide whether or not to continue storing their frozen embryo(s) and different factors have been already highlighted which influence their decision, including embryo conceptualization, information and support provided by the medical institution, quality of embryo(s) and life events. Little is known, however, about couples who definitely decided to stop their parental project and finalized the process of decision-making about the fate of their cryopreserved embryo(s). STUDY DESIGN, SIZE, DURATION: This prospective study was conducted over a period of 3 years (2007-2010) and included IVF/ICSI patients with surplus frozen embryos, who made a final embryo disposition decision. Among the 280 eligible IVF/ICSI patients, 247 agreed to participate in the study. According to the available options, 91 persons chose to 'stop cryopreservation', 77 chose donation to 'research' and 48 'embryo donation' to infertile couples. Furthermore, 31 participants who chose embryo donation for a parental project were refused by the center as not compatible with their mandatory medical conditions. Among them, 27 participants then selected donation to research as a new option and were included in a fourth group: 'donation to research after Refusal of Embryo Donation for parental project' or 'research-RED' (n = 27). Four participants chose 'stop cryopreservation', however, given the small number of subjects this latter group was not included in the analysis. In all, 243 participants who made a final choice concerning the fate of their cryopreserved embryos were included in this study. PARTICIPANTS/MATERIALS, SETTING, METHODS: Participants were sent a letter of invitation to a semi-structured interview of 30 min with a psychologist. Interviews were conducted separately for each partner, including a questionnaire with a common part and a specific part, according to the chosen option, and allowing a quantitative evaluation. A multivariate logistic regression model was used to assess the link between their embryo representation and their decision about their embryos' fate. MAIN RESULTS AND THE ROLE OF CHANCE: After adjustment for age, gender, gamete donation, number of children and the different embryo representations, a choice to 'stop cryopreservation' is more frequent if the embryo is represented as a child [odds ratio (OR) adjusted = 3.29, 95% confidence interval (CI) = 1.62-6.66], P = 0.0009. Representing the embryo as a project prompts patients to choose 'donation to research' [OR adjusted = 3.76, 95% CI = 1.56-9.06], P = 0.0032. Respondents are more likely to choose 'embryo donation' if they represent the embryo as a potential person [OR adjusted = 3.77, 95% CI = 1.45-9.80], P = 0.0064. Furthermore, patients who benefited from gamete donation are ∼10 times more likely to donate their embryos to another couple [OR adjusted = 10.62, 95% CI = 3.99-28.30], P < 0.0001. For more than half the participants (57%) the decision-making was easy, however, deciding to stop cryopreservation was significantly more difficult than choosing research or embryo donation (P < 0.0001). LIMITATIONS, REASONS FOR CAUTION: Socio-economic status, moral and religious affiliations are known to influence the choice of couples but analyzing these factors was not an aim of the present study. WIDER IMPLICATIONS OF THE FINDINGS: When couples definitely decide to stop their parental project, the embryo symbolic representation remains the main factor that influences the fate of their frozen embryo(s). Moreover, this representation can evolve when influenced by external events and information provided. In order to support patients who are making this difficult decision, it could be helpful to explore this symbolic representation early in the IVF/ICSI procedure, before surplus embryo freezing, as a new tool enhancing the accuracy of counseling. STUDY FUNDING/COMPETING INTERESTS: this study was supported by a grant from the 'Agence de la biomedicine (ABM)', the national regulatory ART agency, under the authority of the French Ministry of Health. The authors have no conflict of interest to declare.

Menopausal women requesting egg/embryo donation: examining health screening guidelines for assisted reproductive technology.

OBJECTIVE: As more postreproductive women opt to pursue pregnancy with advanced assisted reproductive technologies (ART), the menopausal practitioner will become more involved in counseling, screening, and referral of premenopausal, perimenopausal, and postmenopausal women for these services. This review was conducted with the aim of (1) evaluating ART screening practices as they pertain to postreproductive women, and (2) reviewing the outcomes of ART using oocyte donation in postreproductive women. METHODS: A total of 950 unique records were found on PubMed, Clinical Key, and Google Scholar. Of these, 252 records were screened for relevance based on their titles and abstracts. With further review of these 252 records, 93 full-text articles were assessed for eligibility, and 63 were excluded based on relevance to our study. Finally, 30 studies were included in our qualitative synthesis. RESULTS: Despite the increasing use of ART in postreproductive women, there are limited guidelines for determining candidacy with regard to maternal health, the most comprehensive of which are the guidelines from the American Society for Reproductive Medicine (ASRM). Although the American Society for Reproductive Medicine guidelines state that healthy women over 50 who are prepared for parenthood are candidates for ART through oocyte donation, they note that older women should be counseled as to the increased obstetric risk associated with advanced maternal age. With aging, particularly for those women who are menopausal and postmenopausal, the woman and her fetus, however, are at risk of increased morbidity and mortality as compared with younger, healthy pregnant women. Because national trends suggest that women are delaying childbearing, the cohort of postreproductive women looking toward ART using donor oocytes as a fertility option will expand and menopausal practitioners will often participate in the ART counseling of these women. CONCLUSIONS: Because maternal and fetal morbidity and mortality increase in postmenopausal women who become pregnant through ART, practitioners caring for this cohort should provide input into developing standardized, comprehensive guidelines for this population so that screening is consistent for all older women seeking this intervention and risks are objectively outlined and considered.

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

INTRODUCTION: Decision-making on embryo disposition is a source of distress and is subject to change over time. This paper analyzes the willingness of couples undergoing in vitro fertilization to donate cryopreserved embryos for research from 15 days after embryo transfer to 12 months later, taking into account the influence of psychosocial, demographic, and reproductive factors. MATERIAL AND METHODS: Prospective longitudinal study, with 74 heterosexual couples undergoing in vitro fertilization in a public fertility centre in Portugal, recruited between 2011 and 2012. Participants were evaluated twice: 15 days after embryo transfer and 12 months later. RESULTS: A significant decrease in patients' willingness to donate embryos for research over time was observed [86.5% to 73.6%; relative risk (RR) = 0.85; 95% CI 0.76-0.95]. A higher education level (>12 years) [adjusted RR (RRadj ) = 0.79; 95% CI 0.64-0.96], considering research on human embryos to be important (vs. very important) (RRadj = 0.59; 95% CI 0.39-0.85) and practicing a religion less than once a month (vs. at least once a month) (RRadj = 0.73; 95% CI 0.53-1.00) seemed associated with unwillingness to donate embryos for research over time. Change towards non-donation happened mainly among couples who first considered that it was better to donate than wasting the embryos. Change towards donation occurred mostly among those stating that their priority at time 1 was to have a baby and who became pregnant in the meantime. CONCLUSIONS: Quality of care guided by patients' characteristics, values, preferences, and needs calls for considering the factors and reasons underlying couples' willingness to donate embryos for research over time as a topic in psychosocial guidelines for infertility and medically assisted reproductive care.