Motivation to donate or not donate surplus embryos for stem-cell research: literature review

Survey of Japanese researchers and the public regarding the culture of human embryos in vitro beyond 14 days

The International Society for Stem Cell Research (ISSCR) has eliminated its prohibition on research involving the culturing of human embryos beyond 14 days within the updated 2021 guidelines. We conducted a survey of Japanese researchers working in stem cell- or embryo-related research (n = 535) and the public (n = 3,000) about their attitudes toward the 14-day rule. Among the researchers, 46.2% agreed that embryos could be cultured beyond 14 days, a result that was slightly lower among the public (37.9%). Among those that disagreed with embryo culturing beyond 14 days, 9.5% of researchers and 5.1% of the public agreed with culturing embryos within 14 days. Among the public, higher comprehension levels correlated with both agreement and disagreement with the culture of embryos beyond 14 days compared with "cannot judge." Further research and pubic discourse are necessary in order to better understand the factors informing participant decisions regarding the 14-day rule.

Patients' views on using human embryonic stem cells to treat Parkinson's disease: an interview study

BACKGROUND

Human embryonic stem cells (hESC) as a source for the development of advanced therapy medicinal products are considered for treatment of Parkinson's disease (PD). Research has shown promising results and opened an avenue of great importance for patients who currently lack a disease modifying therapy. The use of hESC has given rise to moral concerns and been the focus of often heated debates on the moral status of human embryos. Approval for marketing is still pending.

OBJECTIVE

To Investigate the perspectives and concerns of patients with PD, patients being the directly concerned stakeholders in the ethical discussion.

METHODS

Qualitative semi-structured interviews related to this new therapy in seventeen patients from two Swedish cities.

RESULTS

The participants expressed various interests related to the use of human embryos for development of medicinal therapies; however, overall, they were positive towards the use of hESC for treatment of PD. It was deemed important that the donating woman or couple made the choice to donate embryos voluntarily. Furthermore, there were concerns that the industry does not always prioritise the patient over profit; thus, transparency was seen as important.

Recent trends in embryo disposition choices made by patients following in vitro fertilization

PURPOSE

To assess longitudinal trends in in vitro fertilization (IVF) patients' choices for disposing of cryopreserved embryos.

METHODS

This is a retrospective cohort study of embryo disposition forms submitted between January 2000 and February 2020 at a university-based fertility clinic. Primary outcome was disposition decision. Binary and multivariable logistic regression were performed to determine odds ratios (OR) for decisions according to female age, education, race, religion, state of residence, area deprivation index based on zip code, and IVF pregnancy history. We also assessed disposition year, storage duration, and number of stored embryos.

RESULTS

Forms were reviewed from 615 patients; 50.6% chose to discard embryos, 45.4% donated to research, and 4.1% chose reproductive donation. In the regression model, two factors were significantly associated with donation to research: female listing "no preference" or declining to list religious preference (OR 2.56, 95%CI 1.44-4.54) and live birth of multiples after IVF (OR 1.58, 95%CI 1.05-2.36). Before 2012, females younger than age 30 at storage were equally likely to choose to donate embryos to research as discard them. However, between 2013 and 2020, females younger than 30 were significantly more likely to discard than donate embryos for research (OR 2.87, 95%CI 1.13-7.28).

CONCLUSION

Since 2013, the majority of patients younger than 30 at storage have chosen to discard cryopreserved embryos. Before then, patients were more likely to donate embryos for research. To ensure sufficient embryos are available for research, young patients, who are most likely to have cryopreserved embryos, should be counseled about options for donation.

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.

Using Surplus Embryos and Research Embryos in Stem Cell Research: Ethical Viewpoints of Buddhist, Hindu and Catholic Leaders in Malaysia on the Permissibility of Research

The sources of embryos for Embryonic Stem Cell Research (ESCR) include surplus embryos from infertility treatments, and research embryos which are created solely for an ESCR purpose. The latter raises more ethical concerns. In a multi-religious country like Malaysia, ethical discussions on the permissibility of ESCR with regard to the use surplus and research embryos are diversified. Malaysia has formulated guidelines influenced by the national fatwa ruling which allows the use of surplus embryos in ESCR. Input from other main religions is yet to be documented. In light of this, this study addresses (i) the ethical viewpoints of Buddhist, Hindu and Catholic leaders on the permissibility of using surplus and research embryos; and (ii) the moral standpoints of religious leaders towards attaining a consensus on the practice of ESCR in Malaysia. Responses from the religious leaders were obtained via semi-structured, face-to-face interviews. The findings show that generally the Buddhist and Hindu leaders approve the use of surplus embryos. Their responses on the creation of research embryos for ESCR are varied. Meanwhile, the Catholic leaders distinctively objected to ESCR regardless of the embryo sources, referring to it as the destruction of life. Taking into account the diverse views, this study explores the response of the religious leaders for a general consensus wherever possible. The ethical discourse surrounding ESCR in a multi-religious setting offers new perspective, which needs to be explored in a broader global community.

The Fate of Unused Embryos: Discourses, Action Possibilities, and Subject Positions

Although in vitro fertilization (IVF) has offered hope to those struggling with infertility, it has also had some unintended consequences, including the fate of embryos that may be "surplus" to requirement following IVF treatment. The number of embryos in storage across the world is high, creating a dilemma for patients who need to make disposal decisions, as well as presenting an administrative and practical dilemma for clinics. Research has suggested that patients' views of the status of their embryo/s may affect their disposal decisions, and yet the nature of the links between views of the embryo and decisions to either donate or discard remain unclear. In this article, we engage in a discursive analysis of literature on disposal decisions. We discuss the range of ways in which embryos may be constructed, and demonstrate how these discourses make available or constrain particular action possibilities, and offer particular subject positions for patients. The analysis highlights the complexity of the relationship between embryo status and decision making, and may assist clinicians in supporting and guiding patients' decisions.

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.

Patient Decision-Making About the Disposition of Surplus Cryopreserved Embryos in Canada

OBJECTIVE

The objective of this study was to identify factors that contribute to patient decision-making for disposition of surplus cryopreserved embryos in Canada.

METHODS

In 2013, interviews were conducted with 45 IVF patients from three clinic sites, representing a total of 33 households. Patients interviewed all had unused cryopreserved embryos in storage in 2010. Initial demographic data collection was followed by one in-depth semi-structured interview conducted in 2013. Data were managed and coded thematically.

RESULTS

Most patients (21 patients, representing 16 households) renewed storage agreements to keep embryos in storage at the time of the interview. Among patients who did not renew their storage agreements at some point between 2010 and 2013, six patients (representing 5 households) had since used all their embryos, two patients (representing one household) had decided to keep their embryos in storage in perpetuity, three patients (representing 3 households) discarded their embryos outright, and 13 patients (representing 9 households) donated their embryos to research or clinical training. Among patients who donated to research or clinical training, three key themes emerged: a desire to "give back," to contribute to scientific progress, and to avoid "wasting" embryos. These patients were not always certain about whether they had chosen research or clinical training.

CONCLUSION

This study demonstrates the applicability of international findings about embryo disposition decision-making to the Canadian setting. Moreover, it identifies that while patients making disposition decisions often choose to donate embryos to research and/or clinical training, they are not always certain about what these options entail. Clinicians, counsellors, and others must ensure that patients are not only aware of their embryo disposition options, but that they understand the nature of these options as well.

Of research and reproduction: defining embryo 'Research' in Canada

This article traces how embryo research has been theorized in Canada from the late 1980s to the current day. We find that research on human embryos has gradually come to be viewed in dichotomous terms, with scientific research pulled apart from experimentation to improve assisted reproduction procedures within fertility clinics. This distinction has been made manifest most clearly in the federal government's 2007 consent regulations. The distinction between 'improvement of assisted reproduction procedures' and 'research' is problematic on two accounts. First, interviews reveal that many Canadian IVF patients do not distinguish between the improvement of assisted reproduction and broader conceptions of 'research'. This suggests that patients may be consenting to participate in embryo experimentation even where they do not understand its purposes. Second, the dichotomy may allow researchers and clinicians to evade research protocols that might otherwise apply in Canadian law. This could permit fertility clinics to conduct what might in other contexts fall under the category of 'research' without prescribed oversight, and may even enable clinicians and researchers to engage in practices that policymakers deliberately sought to proscribe. We call for a re-evaluation of the legal distinctions on embryo experimentation built into Canadian law, and indeed built into broader discussions of embryo research.

Patients' attitudes toward the donation of biological materials for the derivation of induced pluripotent stem cells

Although academics have raised ethical issues with iPSCs, patients' perspectives on them and their attitudes toward donating biological materials for iPSC research are unclear. Here, we provide such information to aid in developing policies for consent, collection, and use of biological materials for deriving iPSCs based on patient focus groups.

The influence of patient and cohort parameters on the incidence and developmental potential of embryos with poor quality traits for use in human embryonic stem cell derivation

BACKGROUND

Human embryonic stem cells (hESCs) are most commonly derived from the inner cell mass (ICM) of blastocyst stage embryos. While the majority of hESC lines originate from good-quality embryos donated after cryogenic storage, poor-quality embryos (PQEs) not suitable for clinical use have also been shown to generate hESC. This provides a newfound function for embryos that would otherwise be discarded following IVF or ICSI. Owing to their lack of clinical importance, however, data on the poorest embryos in a cohort go largely unreported in the literature. It is therefore of interest to better understand the availability of PQEs from IVF/ICSI cycles and to determine their ability to develop into blastocysts with good-quality ICMs for use in hESC derivation. In this study, we investigate the influence of patient parameters and embryo cohort on PQE incidence, blastocyst development, ICM quality and successful hESC derivation from donated PQEs.

METHODS

PQEs from 736 patient cycles that did not meet our clinical criteria for transfer or cryopreservation were cultured until Day 6 of development and assessed for blastocyst formation and ICM quality. A subset of blastocysts with good-quality ICMs were then used for hESC derivation attempts. Anonymous patient data such as maternal age, embryo history and cohort parameters were then retrospectively compiled and analysed.

RESULTS

PQEs made up 46.8% of two pronucleate embryos created from IVF/ICSI. Including embryos with abnormal fertilization, a mean of 3.6 ± 2.8 embryos were donated per cycle with 32.6% developing to the blastocyst stage. Good-quality ICM were produced in 13.9% of PQEs cultured. Of good-quality ICM, 15.4% of those used in hESC derivation attempts resulted in a novel line. The PQEs that originated from older patients (>37 year) or from cycles that did not result in pregnancy had significantly diminished blastocyst development and ICM quality. Maternal age was also shown to further influence the ability of good-quality ICMs to generate hESC.

CONCLUSIONS

PQEs are an abundant source of embryos capable of developing to blastocysts with good-quality ICMs and subsequently generating novel hESC. We have shown that prognostic variables used to predict IVF/ICSI outcome can also help predict which PQEs have the best hESC developmental potential. Owing to the diversity of PQE origin, experiments designed to compare hESC derivation techniques or efficiency using PQEs should consider clinical IVF/ICSI parameters to establish groups with equal developmental competence. Additional investigation is needed to determine if these results are applicable to hESC derivation using good-quality embryos.

Donating embryos to stem cell research

This paper is based on linked qualitative studies of the donation of human embryos to stem cell research carried out in the United Kingdom, Switzerland, and China. All three studies used semi-structured interview protocols to allow an in-depth examination of donors' and non-donors' rationales for their donation decisions, with the aim of gaining information on contextual and other factors that play a role in donor decisions and identifying how these relate to factors that are more usually included in evaluations made by theoretical ethics. Our findings have implications for one factor that has previously been suggested as being of ethical concern: the role of gratitude. Our empirical work shows no evidence that interpersonal gratitude is an important factor, but it does support the existence of a solidarity-based desire to "give something back" to medical research. Thus, we use empirical data to expand and refine the conceptual basis of bioethically theorizing the IVF-stem cell interface.

The ethical, legal, and social issues impacted by modern assisted reproductive technologies

Background. While assisted reproductive technology (ART), including in vitro fertilization has given hope to millions of couples suffering from infertility, it has also introduced countless ethical, legal, and social challenges. The objective of this paper is to identify the aspects of ART that are most relevant to present-day society and discuss the multiple ethical, legal, and social challenges inherent to this technology. Scope of Review. This paper evaluates some of the most visible and challenging topics in the field of ART and outlines the ethical, legal, and social challenges they introduce. Major Conclusions. ART has resulted in a tectonic shift in the way physicians and the general population perceive infertility and ethics. In the coming years, advancing technology is likely to exacerbate ethical, legal, and social concerns associated with ART. ART is directly challenging society to reevaluate the way in which human life, social justice and equality, and claims to genetic offspring are viewed. Furthermore, these issues will force legal systems to modify existing laws to accommodate the unique challenges created by ART. Society has a responsibility to ensure that the advances achieved through ART are implemented in a socially responsible manner.

Deciding the fate of supernumerary frozen embryos: parents' choices

Embryo cryopreservation is a routine procedure in assisted reproductive technologies. Although couples have been informed about all potential procedures, some of them face the dilemma of what to do with surplus frozen embryos. The purpose of this qualitative study was to evaluate the attitude of patients toward their surplus cryopreserved embryos. Fifty patients who had undergone successful IVF cycles, and had surplus embryos cryopreserved were selected from a clinical database. We could contact twenty two patients agreed to participate in the study and responded the interview. Seventeen participants (77.3%) believed that cryostoraged embryos were 'life'. Patients who would discard embryos rather than donate to research expressed their concern about the misuse of embryos. Those who would discard rather than donate to other couples considered that donating an embryo would be like giving away a child. Seven patients were unsure whether life had begun at this stage of development. Although some couples thought of their embryos as little more than biological material, others envisioned them as living entities or 'virtual' children. The decisions on whether to donate embryos to another couple, or discard them were coloured by strong values about human life and equated with child abandonment.

Fresh embryo donation for human embryonic stem cell (hESC) research: the experiences and values of IVF couples asked to be embryo donors

BACKGROUND

This article reports on an investigation of the views of IVF couples asked to donate fresh embryos for research and contributes to the debates on: the acceptability of human embryonic stem cell (hESC) research, the moral status of the human embryo and embryo donation for research.

METHODS

A hypothesis-generating design was followed. All IVF couples in one UK clinic who were asked to donate embryos in 1 year were contacted 6 weeks after their pregnancy result. Forty four in-depth interviews were conducted.

RESULTS

Interviewees were preoccupied with IVF treatment and the request to donate was a secondary consideration. They used a complex and dynamic system of embryo classification. Initially, all embryos were important but then their focus shifted to those that had most potential to produce a baby. At that point, 'other' embryos were less important though they later realise that they did not know what happened to them. Guessing that these embryos went to research, interviewees preferred not to contemplate what that might entail. The embryos that caused interviewees most concern were good quality embryos that might have produced a baby but went to research instead. 'The' embryo, the morally laden, but abstract, entity, did not play a central role in their decision-making.

CONCLUSIONS

This study, despite missing those who refuse to donate embryos, suggests that debates on embryo donation for hESC research should include the views of embryo donors and should consider the social, as well as the moral, status of the human embryo.

'Not taken in by media hype': how potential donors, recipients and members of the general public perceive stem cell research

BACKGROUND

Views of embryo donors, scientists and members of the general public on embryonic stem cell research (eSCR) have been widely reported. Less is known about views of potential beneficiaries of stem cell therapy and the influence of media 'hype' on perceptions of eSCR among different groups of stakeholders. This study aimed to examine the perceptions of members of the general public as well as two patient groups likely to benefit from eSCR and to explore the role of the media in shaping these views.

METHODS

A qualitative study carried out in Aberdeen, Scotland included 15 people living with Parkinson's disease (PD), 15 people living with diabetes mellitus (DM), 15 couples with infertility and 21 members of the general public who volunteered for the study. Interview transcripts were analysed thematically using grounded theory.

RESULTS

The two patient groups likely to benefit from eSCR in the future differed in their knowledge (mainly gained from the media) and understanding of eSCR. Those living with PD were older, more debilitated and better informed than those with DM who showed limited interest in potential future benefits of eSCR. Infertile couples learnt about eSCR from health professionals who explained the process of embryo donation to them, and had sought no further information. Most of the general public had accessed information on eSCR and believed themselves to be more discerning than others because of their objectivity, intelligence and 'scientific awareness'. Although, the media and internet were primary sources of information for all except couples with infertility, members of all four groups claimed not to be taken in by the media 'hype' surrounding eSCR.

CONCLUSIONS

Those who expected to benefit from eSCR in the future as well as members of the general public differ in their susceptibility to media 'hype', while believing that they are not taken in by exaggerated claims of benefits. As respondents were a selected group who were not drawn from a representative sample, the findings cannot be generalized to a wider population.

Report on the donation of supernumerary embryos from fresh IVF and ICSI treatment cycles for human stem cell research

BACKGROUND

Research involving human embryos promises exciting therapeutic advances but raises ethical and moral dilemmas for scientists and potential donors. The aim of this study is to report the proportion of couples donating supernumerary fresh embryos for development of stem cell lines from a single centre and the characteristics of those who donate.

METHODS

Couples undergoing assisted conception treatment in a teaching hospital received research information between January 2005 and July 2006. Counselling and consenting was performed by a dedicated research nurse. Demographic data was collected for couples who enrolled in the study.

MAIN OUTCOME MEASURES

To determine the proportion of couples willing to donate surplus embryos for stem cell derivation and to examine the characteristics of those who consent to donate.

RESULTS

Of 508 couples, 353 (69%) expressed an interest in research on their treatment consent forms. Sixty-six percent of those interested in research and 87% of counselled couples consented to donation. The demographic characteristics of those who agreed to donate were similar to those of all couples attending the unit.

CONCLUSIONS

Approximately half of couples consented to donate under the described system in our centre. Detailed information provision helps the majority of those counselled to proceed to donation.

Fertility patients' views about frozen embryo disposition: results of a multi-institutional U.S. survey

OBJECTIVE

To describe fertility patients' preferences for disposition of cryopreserved embryos and determine factors important to these preferences.

DESIGN

Cross-sectional survey conducted between June 2006 and July 2007.

SETTING

Nine geographically diverse U.S. fertility clinics.

PATIENT(S)

1020 fertility patients with cryopreserved embryos.

INTERVENTION(S)

Self-administered questionnaire.

MAIN OUTCOME MEASURE(S)

Likelihood of selecting each of five conventional embryo disposition options: store for reproduction, thaw and discard, donate to another couple, freeze indefinitely, and donate for research; likelihood of selecting each of two alternative options identified in previous research: placement of embryos in the woman's body at an infertile time, or a disposal ceremony; importance of each of 26 considerations to disposition decisions; and views on the embryo's moral status.

RESULT(S)

We found that 54% of respondents with cryopreserved embryos were very likely to use them for reproduction, 21% were very likely to donate for research, 7% or fewer were very likely to choose any other option. Respondents who ascribed high importance to concerns about the health or well-being of the embryo, fetus, or future child were more likely to thaw and discard embryos or freeze them indefinitely.

CONCLUSION(S)

Fertility patients frequently prefer disposition options that are not available to them or find the available options unacceptable. Restructuring and standardizing the informed consent process and ensuring availability of all disposition options may benefit patients, facilitate disposition decisions, and address problems of long-term storage.