Attitudes and policies regarding access to fertility care and assisted reproductive technologies in Israel

A study of the experience of Norwegian IVF physicians in evaluating the parenting capacity of patients

RESEARCH QUESTION

How do Norwegian fertility doctors assess the parenting capacity of applicants, and how do they experience and evaluate the assessment practice?

DESIGN

Qualitative interview study with 14 Norwegian fertility doctors. Interviews were analysed with systematic text condensation, a qualitative analysis framework.

RESULTS

Norwegian fertility doctors deem parenting capacity assessments of applicants to be straightforward and simple in most cases. Yet, some cases of doubt pose difficulties. Physicians can then draw on resources such as colleagues, physicians from other specialties who know the patient and patient records. All the participating physicians agreed with the principle of parenting capacity assessment for patients seeking fertility treatment. The assessment enabled physicians to refuse patients whom they thought should definitely not have responsibility for children. The physicians' main argument was their own felt responsibility for the future child. Even though assessments could be challenging, the participants all thought of themselves as competent to perform them. Indeed, some thought that delegating the assessments would imply abdicating a responsibility that was properly theirs. Although national guidelines might aid decision-making, the physicians would not want guidelines to curtail the significant discretion that they exercised.

CONCLUSIONS

Whether societies should assess applicants' capacity for parenthood before fertility treatment is an ethical and political question. Although sometimes a difficult task, Norwegian fertility doctors see it as important, and as something they are competent and suited to undertake.

Fertility Practitioners’ Coping Strategies When Faced with Intra-Role Conflict from Screening Aspiring Single Mothers by Choice

Women without a partner can become single mothers by choice through the use of fertility treatments. In Belgium, the decision to accept a candidate single mother by choice rests with the fertility clinic’s multidisciplinary team of fertility practitioners. As a result, the fertility practitioners fulfil a gatekeeping role. However, this can cause an intra-role conflict as the responsibility to select the best fitting candidates is at odds with the responsibility to help patients. In this explorative study, we examine how fertility practitioners cope with the strain resulting from intra-role conflict in the decision-making process regarding single motherhood by choice in Belgium. The findings showed that practitioners appear to mainly resort to problem-focused coping, by constructing a grassroots criteria list and by shifting their role from screening agent to counsellor. These results are based on ten open in-depth interviews with fertility practitioners employed in the multidisciplinary teams of fertility centers, using a reflexive interview lead.

Access to infertility evaluation and treatment in two public fertility clinics and the reasons for withholding it: a prospective survey cohort study of healthcare professionals

OBJECTIVES

Study the proportion of patients affected by involuntary childlessness who are denied fertility treatment and the reasons behind this in a publicly funded healthcare system.

DESIGN

Survey study using prospectively collected information by healthcare professionals.

SETTING

Two university-affiliated fertility clinics in Sweden.

PARTICIPANTS

Single women and couples in heterosexual and homosexual relationships seeking fertility evaluation and treatment between November 2017 and April 2018 (943 individual cases).

PRIMARY AND SECONDARY OUTCOME MEASURES

Number and proportion of individuals who were either denied, delayed or granted fertility treatment directly. Furthermore, the reasons behind delaying or completely withholding treatment.

RESULTS

The majority of those seeking evaluation were heterosexual couples (75%), while 14% were single women and 7.5% were same-sex couples. The great majority of those undergoing evaluation were granted treatment either directly (85%) or after in-depth evaluation (7.5%), while 7.5% were denied treatment. Among those who were denied treatment, there were a greater proportion of single women and couples seeking treatment with donated gametes. Among heterosexual couples, gamete origin was not associated with treatment refusal. Although age did not differ between those granted and denied treatment, a higher body mass index (in both recipient and partner, when applicable) was observed among those being refused treatment. Fertility specialists in Sweden focused their assessment on parental factors that may indirectly entail a risk of harm to the future child, such as medical and psychiatric conditions of the individuals involved, their financial constraints and other social reasons, substance abuse and female obesity.

CONCLUSION

Being single or receiving treatment with donated gametes can both be reasons for withholding fertility treatment. Although difficult to operationalise, parenting assessment in Sweden is employed interchangeably in treatments with donated gametes (legally mandated assessment) and even autologous gametes (non-legally mandated assessment)-making evident a need for clear official policy guidelines regulating these assessments and the provision of treatment.

The Meaning and Importance of Genetic Relatedness: Fertility Preservation Decision Making Among Israeli Adolescent Cancer Survivors and Their Parents

Background: With multiple options available today to become a parent, how does the matter of genetic relatedness factor into adolescent cancer patients’ fertility preservation (FP) decision making? This study reports on and normatively analyzes this aspect of FP decision making. Methods: A convenience sample of Israeli adolescent cancer survivors and their parents were invited to participate in individual, semi-structured interviews. Results: In discussing the importance of genetic relatedness to future children or grandchildren, participants repeatedly brought up the interrelated issues of nature, normalcy, and personal identity. Regardless of preference or ambivalence for genetic relatedness, the majority of participants were aware of alternative parenting options and noted both their advantages and disadvantages. However, knowledge of alternative parenting options was not uniform. Conclusions: To ensure that adolescent patients and their parents make informed FP decisions that meet their personal goals and values, it is important for physicians to discuss alternative parenting options with them in a culturally sensitive manner. Greater credence also should be given to those who question the importance of genetic relatedness.

Fertility Physicians’ Opinions and Attitudes on Access to Assisted Reproductive Technology: An Asia-Pacific Perspective

Background: Fertility physicians are gatekeepers of assisted reproductive technology (ART) and have immediate control over access to fertility care. However, little is understood about their attitudes and willingness to provide and support different procedures. Therefore, we examined fertility physicians’ perspectives on support of public funding and willingness to provide care in various scenarios.

Methods: We invited fertility physicians attending the 8th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2018) to participate in a 10-minute survey. Participants completed the survey anonymously and in private.

Results: 78 out of 105 fertility physicians from 12 countries completed the survey (response rate = 74.3%). Mean age was 44.9 years (SD = 11.1). A majority of respondents supported public funding for ART: 76.3% for intrauterine insemination and 80.5% for in vitro fertilization. For controversial procedures, a majority agreed to provide social egg freezing (88.5%) compared to sex selection (25.6%) and gene editing for nonmedical reasons (19.2%), p < 0.001 for both comparisons. Support for public funding was also significantly higher for social egg freezing (51.3%) compared to sex selection (23.1%) and gene editing for nonmedical reasons (20.5%), p < 0.001 for both comparisons. For eligibility criteria, willingness to provide treatment to single women (50.0%) was significantly higher compared to other nontraditional family structures — single men (33.3%), p < 0.001, male homosexual couples (33.3%), p = 0.002, female homosexual couples (32.1%), p = 0.001 and unmarried heterosexual couples (32.1%), p = 0.004. Consistently, support for public finding was significantly higher for single women (32.1%) compared to single men (23.1%), p = 0.013, male homosexual couples (20.5%), p = 0.020, and unmarried heterosexual couples (20.5%), p = 0.006.

Conclusions: These results show support for public funding and conservative opinions toward ART for nontraditional family structures among physicians in the Asia-Pacific region.

Investigation of Each Society for Fertility Preservation in Asia

Fertility preservation (FP) remains a future direction for reproductive medicine. FP development is needed to keep up with advancements in other areas of medicine, such as cancer research that has successfully prolonged patients' survival. The demand for optimum FP is sought by both patients and practitioners alike. The American Society of Clinical Oncology has published and updated several FP guidelines. However, these guidelines need to be optimized for each country due to the nature of FP that interacts with the local policy, social decorum, and economic factors. Furthermore, the availability and success rate for each procedure might differ since there is a requirement for advanced and innovative technologies involved in FP. These guidelines should ideally be supported by the FP society to overcome unique barriers that may arise in each country. Here we try to illustrate the most recent update on the condition of FP practice in several countries in Asia. This hopefully will encourage future FP development and might become a useful reference for other countries, especially in Asia.

The acceptability of stem cell-based fertility treatments for different indications

STUDY QUESTION

What is the acceptability of using stem cell-based fertility treatments (SCFT) for different indications according to gynaecologists and the general public?

SUMMARY ANSWER

The majority of gynaecologists and the general public accept SCFT for the indications female or male infertility in young heterosexual couples, and female infertility in single women and same-sex couples.

WHAT IS KNOWN ALREADY

SCFT could result in genetic parenthood for intended parents with indications that cannot be treated using currently available methods, such as being in a same-sex relationship or female post-menopausal age. It is unclear whether the acceptability of SCFT differs between indications for treatment and whether gynaecologists and the general public differ in their assessments.

STUDY DESIGN SIZE, DURATION

In November 2015, a cross-sectional survey was disseminated among 179 gynaecologists and a panel of 1250 respondents comprising a representative sample of the Dutch general public.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The potential indications for future SCFT to achieve genetic parenthood were identified by literature review. A questionnaire was developed, reviewed by experts from different disciplines and tested among the general public. The questionnaire asked whether treating eight groups of intended parents with SCFT was acceptable or not. Regression analysis examined whether demographic characteristics influenced choices and whether the general public and gynaecologists differed in opinion.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 82 (46%) gynaecologists and 772 (62%) members of the general public completed the survey. The acceptability of using SCFT varied according to both gynaecologists and the general public between the eight groups of intended parents (P < 0.001). The majority of the Dutch general public accepts SCFT for six out of eight possible indications, namely female infertility in young heterosexual couples (94%), male infertility in young heterosexual couples (94%), unexplained infertility in young heterosexual couples (83%), female infertility in single women (69%), lesbian couples (68%) and gay couples (62%). The majority of gynaecologists also found treating these groups acceptable, except for the indication of unexplained infertility, which was only accepted by a minority of gynaecologists (43%). A minority of both the general public and gynaecologists accepted SCFT for fertile women who want a child that is genetically only her own (27 and 6%, respectively) and for female infertility in heterosexual couples in which the woman is over 50 years of age (17% and 26%, respectively). Attaching low importance to religion, having progressive political preferences, not having a university degree, having experienced infertility, being a woman, being older and not being of European ethnicity were positively associated with considering using SCFT acceptable for one or multiple indications.

LARGE SCALE DATA

N/A.

LIMITATIONS REASONS FOR CAUTION

The generalizability of our findings to future decades or other countries might be limited as opinions about novel technologies change over time and might vary across cultures. Support among gynaecologists and the general public is interesting but not proof of ethical acceptability.

WIDER IMPLICATIONS OF THE FINDINGS

Once proven safe and effective, fear of limited acceptability by the general public is unwarranted, and thus should not stop gynaecologists from offering SCFT to single infertile women and same-sex couples in addition to young infertile heterosexual couples.

STUDY FUNDING AND COMPETING INTEREST(S)

Funded by the Young Academy of the Royal Netherlands Academy of Arts and Sciences and the Universities of Amsterdam and Leuven. No conflict of interest to declare.

Impact of egg donation deliveries from domestic and overseas sources on maternal care: a questionnaire survey of Japanese perinatal physicians

OBJECTIVES

Recent demographic changes, such as marriage at later ages and delayed childbearing, have contributed to the increased demand for ovum donation. The purpose of the present study was to evaluate the frequency and impact of egg donation deliveries on maternal care using a questionnaire survey of Japanese perinatal care providers.

METHODS

A quantitative survey was conducted from October to November 2012 using self-administered anonymous questionnaires. We asked 2,693 obstetrics clinics/hospitals throughout Japan to complete the survey: 679 questionnaires were returned (response rate, 25.2 %).

RESULTS

Of the respondents, 15.8 % answered that they had handled egg donation deliveries in the past. With regards to the country in which patients received egg donation services, the most frequent was the United States, including Hawaii. Asian countries, such as Thailand, Korea, and Singapore, were also reported; only two cases in Japan were reported. "Advanced age/menopause" was the most frequent reason for egg donation, and the mean age at egg donation delivery, because of advanced age/menopause, was 48.3 years.

CONCLUSIONS

Our findings will increase public awareness of the legal issues related to assisted reproductive technology and cross-border reproductive care, as well as care of the mother and child in pregnancies resulting from reproductive technologies such as egg donation overseas. People should be aware of the issues involved in egg donation abroad and the resulting deliveries, and should implement specific care for women bearing children at later ages.

Giving oocytes to women in need: permitted, forbidden, or pressured? A commentary

There can be no starker contrast in egg donation than between Austria, where it is forbidden, and Israel, where it is encouraged to the extent that some Israeli women go abroad in order to obtain these precious reproductive cells. There are grave ethical issues in some of the transactions involved, which may fall out with the definition of a gift. The ESHRE taskforce on cross-border reproductive care is keen to promote standards in this field, including the ethical standard of avoiding coercion.

This is a commentary on http://www.ijhpr.org/content/1/1/15/

Socializing the public: invoking Hannah Arendt's critique of modernity to evaluate reproductive technologies

The article examines the writings of one of the most influential political philosophers, Hannah Arendt, and specifically focuses on her views regarding the distinction between the private and the public and the transformation of the public to the social by modernity. Arendt's theory of human activity and critique of modernity are explored to critically evaluate the social contributions and implications of reproductive technologies especially where the use of such technologies is most dominant within Western societies. Focusing on empirical studies on new reproductive technologies in Israel, it is argued, powerfully demonstrates Arendt's theory, and broadens the perspectives through which society should evaluate these new technologies towards a more reflective understanding of its current laws and policies and their affect on women more generally.

Assisted reproductive technologies: a systematic review of safety and effectiveness to inform disinvestment policy

OBJECTIVE

Health policy relating to assisted reproductive technologies (ART) has been variably informed by clinical evidence, social values, political and fiscal considerations. This systematic review examined key factors associated with specific benefits and harms of ART to inform the development of a model for generating policy recommendations within an Australian disinvestment research agenda.

METHODS

Six databases were searched from 1994 to 2009. Included articles contained data on safety and/or effectiveness of in vitro fertilisation (IVF) or IVF with intracytoplasmic sperm injection with reference to female age, male age or cycle rank. Narrative descriptions of key outcomes (live birth, miscarriage) were constructed alongside tabular summaries.

RESULTS

Sixty-eight studies and one registry report were included. There was substantial heterogeneity present within the evidence-base which limited the strength and scope of conclusions that could be drawn. However, this review does affirm the differential effectiveness associated with the ageing of ART patients with regard to live birth and miscarriage.

CONCLUSION

From the available evidence, it was not possible to determine an explicit age or cycle rank that could be used to formulate defensible policy responsive to identified differential effectiveness. Stakeholder interpretation of this evidence-base may assist in developing policy that can incorporate uncertainty and reflect social values.