Cryopreservation of embryos: medical, ethical, and legal issues

Fifteen year follow-up of embryos cryopreserved in cancer patients for fertility preservation

PURPOSE

Determine the outcome of embryo cryopreservation in female oncology patients

METHODS

The outcomes of IVF/ICSI cycles in oncology patients over 15 years in a University Teaching Hospital.

RESULTS

Forty-two oncology patients (mean 31.9 ± 3.9 years) underwent embryo cryopreservation treatment (n = 33 IVF, n = 6 ICSI). Controlled ovarian stimulation with GnRH antagonist protocol (n = 34; 81 %) yielded fewer oocytes than GnRH agonist protocol (n = 8; 19 %) (9.4 ± 6.3 vs. 15.3 ± 8.9; p = 0.04) respectively. There was no significant difference in mean (±SD) duration of ovarian stimulation (11.6 ± 2.6 vs.10.6 ± 2.7), median gonadotrophin dose (1950 vs. 1670 IU), median day 5-6 oestradiol level (1124 vs.1129 pmol/l) or embryo yield (6.2 ± 4.1 vs. 8.8 ± 4.3; p = 0.07) between GnRH antagonist and agonist treatment cycles respectively. Thirty-nine patients cryopreserved embryos and three had their cycle cancelled. During this study period, of those who cryopreserved embryos, 5 patients underwent 9 frozen-thaw cycles (13 %), resulting in 2 live births (1 twin, 1 singleton, live birth rate 22 %). Six patients died (15 %), 3 conceived naturally (8 %) and 2 couples separated (5 %). Fourteen patients discarded their embryos (36 %). Twenty-two patients' (56 %) have embryos remaining in storage.

CONCLUSIONS

This study demonstrates that embryo cryopreservation in female oncology patients gives a satisfactory live birth rate. However, there are concerns regarding cost-effectiveness, resulting from high disposal/non-usage of embryos, and further studies are required.

Frozen hope: fertility preservation for women with cancer

Young women diagnosed with cancer have the option of preserving their fertility by using assisted reproductive technology (ART) techniques prior to undergoing cancer treatment. This article presents a composite case of a young woman with cancer who had many unanswered emotional and ethical questions about her future as a parent. Fertility preservation techniques, including preimplantation genetic diagnosis (PGD), and related patient education are described. Current literature regarding reproductive counseling for cancer survivors is reviewed. Resources for providing psychosocial support for decisions about fertility preservation are lagging behind the rapid pace of scientific advancements in cancer treatment and ART. As more young women are surviving cancer and taking steps to preserve fertility, there is great need for the provision of psychologic support services and the establishment of ethical guidelines to aid them on this path. Women's health care providers can provide support to cancer survivors facing fertility and parenting issues by becoming knowledgeable about the long-term aspects of decision making and developing educational materials and guidelines for these patients.

The added value of embryo cryopreservation to cumulative ongoing pregnancy rates per IVF treatment: is cryopreservation worth the effort?

PURPOSE

To calculate the added benefit of a cryopreservation program to the cumulative ongoing pregnancy rate over a maximum of three cycles of IVF.

METHODS

A total of 1251 couples beginning their first IVF treatment between January 1995 and December 1999 were evaluated. Ongoing pregnancies from fresh and subsequent cryopreserved embryo transfer cycles were analyzed. Pregnancies arising from the cryopreservation cycle were considered to augment the cumulative pregnancy rate when no ongoing pregnancy arose from the fresh embryo transfer cycle.

RESULTS

The ongoing pregnancy rate per cryopreserved embryo transfer was 11.7%. The cumulative ongoing pregnancy rate following three successive started fresh IVF cycles was 42.5%. When pregnancies arising from the transfer of thawed cryopreserved embryos were included, the cumulative ongoing pregnancy rate increased to 43.8%, rising to 44.8% when extrapolated data from as yet unthawed embryos was included.

CONCLUSIONS

When analyzed in these terms, the supplementary benefit of cryopreserving supranumerical embryos appears limited.

Ethics and assisted reproduction

In vitro fertilization and assisted reproductive technology have made great progress during the last 20 years. Genetic material donation, human embryo cryopreservation, selective embryo reduction, preimplantation genetic diagnosis and surrogacy are currently practiced in many countries. On the other hand, embryo research is practiced only in a small number of nations, whereas human cloning has thus far been universally condemned. The rapid evolution and progress of all these techniques of assisted reproduction has revealed certain ethical issues that have to be addressed.

Maternal-fetal conflict

Advances in prenatal care have brought about a greater understanding as to the special status of the fetus to the point that it is considered a patient in its own regard. Pregnant women generally follow the medical recommendations of their physicians that are intended for the benefit of their baby. Any situation where maternal well-being or wishes contradict fetal benefit constitutes a maternal-fetal conflict. Such situations include a broad range of possible interventions, non-interventions, and coercive influences. In such cases, the attending physician is expected to attain an attitude that involves either the respect of the woman's autonomy and right to privacy, which precludes any approach other than to accept her decision, or to modify this absolute for the beneficence of the fetus. Current ethical viewpoints range from absolute respect for maternal autonomy with no persuasion allowed, to gentle persuasion and to others which permit intervention and overriding of the woman's autonomy. Court-ordered decisions enforcing the pregnant woman to undergo a procedure in order to improve fetal outcome have been criticized as an invasion of a woman's privacy, limitation of her autonomy, and taking away of her right to informed consent.

Establishment of a successful donor embryo program: medical, ethical, and policy issues

OBJECTIVE

To determine how couples prefer to dispose of their extra embryos and to establish a donor embryo program for the treatment of infertile couples.

DESIGN

Cohort study.

SETTING

University-based IVF program.

PATIENT(S)

Patients (n = 365) with cryopreserved embryos in storage for >2 years and eight patients who desired donated embryos for transfer.

INTERVENTION(S)

An IVF ethics committee was formed to discuss the ethical and policy issues involved in starting an embryo donation program and to establish program guidelines. Couples with embryos cryopreserved for > or = 2 years were contacted to determine their desires for disposition of embryos. Potential recipients of donated embryos were identified in our clinic, and donated embryos were transferred to these patients.

MAIN OUTCOME MEASURE(S)

Desires for embryo disposition and pregnancy rates.

RESULT(S)

Most couples elected either to continue storage of their embryos for future use (44%) or to discard their embryos (34%). A minority elected to donate their embryos either to infertile couples (11%) or for research (10%). Eight couples have had donated embryos transferred, and four have conceived ongoing pregnancies.

CONCLUSION(S)

Although only a small percentage of couples are willing to donate their embryos, the resulting number of embryos for use is substantial. Transfer of donated embryos results in a high pregnancy rate and is a cost-effective treatment of infertility.

Efficacy of postal communication with patients who have cryopreserved pre-embryos

OBJECTIVE

To compare the characteristics of patients who did and did not respond to a request for information regarding their cryopreserved pre-embryos.

DESIGN

Mail survey.

SETTING

Academic-assisted reproductive technology program.

PATIENT(S)

One hundred thirty-six patients with cryopreserved pre-embryos.

INTERVENTION(S)

Patients were surveyed by first-class mail regarding their plans for their cryopreserved pre-embryos and their interest in embryo donation.

MAIN OUTCOME MEASURE(S)

Age, number of stored pre-embryos, and duration of storage of responders and nonresponders at 6 weeks after mailing.

RESULT(S)

Eighty-three patients (62%) did not respond to the survey. Compared with responders, nonresponders were significantly older at the time of embryo cryopreservation, had fewer pre-embryos cryopreserved, and had the pre-embryos cryopreserved for a longer duration. Five responders (9%) expressed an interest in embryo donation. Three patients requested disposal of pre-embryos. Sixteen surveys (12%) were returned as undeliverable. As a group, these patients had the fewest pre-embryos cryopreserved and had the longest duration of storage.

CONCLUSION(S)

A disturbing number of patients with cryopreserved pre-embryos ignored efforts by our program to maintain contact. Older patients with few cryopreserved pre-embryos may require special attention to avoid abandonment.