Non-identified and directed embryo donation: a questionnaire study on donor and recipient perspectives

With the growing challenge of abandoned surplus embryos in the ART arena, and the limited traction of embryo donation as a viable embryo disposition choice, it is important to better understand barriers to wider adoption of this opportunity. We aim to learn about perspectives and experience of participants in directed and non-identified embryo donation programmes. This was a longitudinal cohort survey study, of all participants in an embryo donation programme in a single university affiliated clinic between 2016 and 2020. Clinical data were extracted from counselling reports. Based on these data, non-identified online questionnaires were constructed and refined via Delphi procedure for face and content validity. Sixty-five online questionnaires were emailed between March-April 2021. Descriptive statistics, cross-tabulation, Fisher's exact test and t-test were used for analyses. Source of patient awareness, factors influencing the decision-making process, patient perspective and satisfaction were explored. The response rate was 67.2%. Most participants in the non-identified programme learned of it through their treating physicians, whereas most participants in the directed programme learned of it online. The main driver to donate across both cohorts was wanting to give others the opportunity to experience the joy of parenthood. Overall, 45% described moderate to marked difficulty in decision making related to donating their embryos, and this did not differ between cohorts. Non-identified donors reported feeling highly attached to the donated embryos more often than directed donors. Level of satisfaction was higher in the directed donation programme. Participants were more satisfied following directed than non-identified donation, and some even consider their counterparts as extended family. Our findings should be validated in various settings, and on larger samples.

Experiences of women undergoing infertility treatment from embryo transfer until pregnancy test and their conceptualization of their embryo

AIM

This study aims to explore women's experiences with embryo transfer (ET) until pregnancy test and their conceptualization of their embryo.

METHOD

The sample of this descriptive phenomenology study consists of 17 women with ET. The data were collected through in-depth interviews. The thematic analysis developed by Braun and Clarke was used for data analysis.

RESULTS

Analysis of the interviews led to the emergence of five themes and 14 sub-themes. The theme "pregnancy in biological terms" has two sub-themes: "considering herself pregnant" and "the first moment with the baby". The theme "not an embryo, my child" has three sub-themes: "world of hope", " unnatural but normal" and "attachment to embryo". The theme "daily life after ET" has three sub-themes: "living life in the usual way", "process of self-listening", and "the negative effects of drugs on the body". The theme "seeking ways to ensure fertility" has four sub-themes: "complete bed rest", "the search for information: the internet", "practice an infertility diet" and "spiritual support with prayer". Finally, the theme "caring after the transfer" has two sub-themes: "need more information" and "unmet women-oriented care".

CONCLUSION

In this study, it was determined that women had intense physical and emotional experiences during the waiting period after ET and their daily lives were affected. It was also understood that the embryo means "baby/child/son/daughter" to them and that they establish a close bond with their embryos. Women's needs are not sufficiently known until post-ET pregnancy testing. Explaining the experiences of women after IVF-ET and the meanings of their embryo will help determine the issues they need in holistic care.

OUP accepted manuscript

STUDY QUESTION

What information and support should be offered to donors, intended parents and donor-conceived people, in general and in consideration of the availability of direct-to-consumer genetic testing and matching services?

SUMMARY ANSWER

For donors, intended parents and donor-conceived offspring, recommendations are made that cover information needs and informed consent, psychosocial implications and disclosure.

WHAT IS KNOWN ALREADY

Trends indicate that the use of donor-assisted conception is growing and guidance is needed to help these recipients/intended parents, the donors and offspring, navigate the rapidly changing environment in which donor-assisted conception takes place.

STUDY DESIGN, SIZE, DURATION

A working group (WG) collaborated on writing recommendations based, where available, on evidence collected from a literature search and expert opinion. Draft recommendations were published for stakeholder review and adapted where relevant based on the comments received.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Papers retrieved from PUBMED were included from 1 January 2014 up to 31 August 2020, focusing on studies published since direct-to-consumer genetic testing has become more widespread and accessible. The current paper is limited to reproductive donation performed in medically assisted reproduction (MAR) centres (and gamete banks): donation outside the medical context was not considered.

MAIN RESULTS AND THE ROLE OF CHANCE

In total, 32 recommendations were made for information provision and support to donors, 32 for intended parents and 27 for donor-conceived offspring requesting information/support.

LIMITATIONS, REASONS FOR CAUTION

The available evidence in the area of reproductive donation is limited and diverse with regards to the context and types of donation. General conclusions and recommendations are largely based on expert opinion and may need to be adapted in light of future research.

WIDER IMPLICATIONS OF THE FINDINGS

These recommendations provide guidance to MAR centres and gamete banks on good practice in information provision and support but should also be considered by regulatory bodies and policymakers at a national and international level to guide regulatory and legislative efforts towards the protection of donors and donor-conceived offspring.

STUDY FUNDING/COMPETING INTEREST(S)

The development of this good practice paper was funded by European Society of Human Reproduction and Embryology (ESHRE), covering expenses associated with the WG meetings, the literature searches and dissemination. The WG members did not receive any payment. The authors have no conflicts of interest to declare.

DISCLAIMER

This document represents the views of ESHRE, which are the result of consensus between the relevant ESHRE stakeholders and where relevant based on the scientific evidence available at the time of preparation.

The recommendations should be used for informational and educational purposes. They should not be interpreted as setting a standard of care, or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. They do not replace the need for application of clinical judgement to each individual presentation, nor variations based on locality and facility type.

^†ESHRE pages content is not externally peer reviewed. The manuscript has been approved by the Executive Committee of ESHRE.

An Examination into the Embryo Disposal Practices of Human Fertilization and Embryology Authority Licenced Fertility Centers in the United Kingdom

When fertility centers dispose of embryos, how should this be done? Current regulatory guidelines by the Human Fertilisation and Embryology Authority state that, when terminating the development of human embryos, a clinic should act with sensitivity, taking account of the embryo's "special status" and respecting the interests of the gamete providers and recipients. As yet, it is unclear as to how and to what extent this achieved within fertility clinics in the UK. Resultantly, this paper examines the largely undocumented domain of embryo disposal practice. By undertaking an empirical study into policy and procedure and noting divergence in clinic practice, it then comments on the ethical implications of these protocols for patients and practitioners. Specifically, this paper argues for a more holistic approach to embryo disposal. An approach that effectively meets the requirements of the lab, is respectful of the "special status" of the human embryo, and, perhaps most importantly, reflects the multifaceted needs of the patient.

'Our family picture is a little hint of heaven': race, religion and selective reproduction in US 'embryo adoption'

People use selective reproductive technologies (SRT) in various family-making practices to assist with decisions about which children should be born. The practice of 'embryo adoption', a form of embryo donation developed by white American evangelical Christians in the late 1990s, is a novel site for reconceptualizing SRT and examining how they function among users. Based on ethnographic research conducted between 2008 and 2018 on US 'embryo adoption', this study provides an anthropological analysis of media produced by and about one white evangelical couple's race-specific preferences for embryos from donors of colour. This article shows how racializing processes and religious beliefs function as mutually reinforcing SRT for some 'embryo adoption' participants. Evangelical convictions justify racialized preferences, and racializing processes within and beyond the church reinforce religious acts. Race-specific preferences for embryos among white evangelicals promote selective decision-making not for particular kinds of children, a current focus in studies of SRT, but for particular kinds of families. This study expands the framework of SRT to include selection for wanted family forms and technologies beyond biomedical techniques, such as social technologies like racial constructs and religious convictions. Broadly, this article encourages greater attention to religion within analyses about race and reproduction by revealing how they are deeply entwined with Christianity, especially in the USA. Wherever constructions of race and religious convictions co-exist with selective reproductive decision-making, scholars should consider race, reproduction and religion as inextricable, rather than distinct, domains of analysis.

Making the Ethnic Embryo: Enacting Race in US Embryo Adoption

How are frozen embryos donated for procreation racialized as "ethnic" subjects and what are the political implications of these enactments? Based on ethnographic research within an embryo adoption program in the United States, I examine the practices through which staff and participants produce "ethnicity" in embryos and trace its multiple permutations. Strategies used to stabilize race in embryos also disturb, fracture, and confound the bases for designating race. Analyzing race-making practices in embryo adoption reveals the interplay between practical challenges in assisted family-making practices and their wider political implications for reproductive politics.

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.

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.

Family building using embryo adoption: relationships and contact arrangements between provider and recipient families-a mixed-methods study

STUDY QUESTION

What contact arrangements are established between providers and recipients of embryos using Snowflakes® Embryo Adoption Program?

SUMMARY ANSWER

Contact arrangements varied considerably and were generally positively described, although some challenges were acknowledged.

WHAT IS KNOWN ALREADY

Reproductive technologies create new and diverse family forms, and the ways in which families created by embryo adoption are negotiated in practice have not been extensively investigated.

STUDY DESIGN, SIZE, DURATION

This exploratory, mixed-methods study had two phases: (i) an online survey (open May-September 2013) and (ii) qualitative semi-structured interviews by email (conducted between 2014 and 2015), exploring participants' experiences of contact with their embryo provider or recipient.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Phase I included 17 providers (14 women and 3 men) and 28 recipients (27 women and 1 man). Phase II included 8 providers (5 women and 3 men) and 12 recipients (10 women and 2 men). All participants, except one, were located in the US.

MAIN RESULTS AND THE ROLE OF CHANCE

This study illustrates how embryo adoption in the US, as a form of conditional donation, can operate and how the participants define and negotiate these emerging relationships. All families were open with their children about how they were conceived and early contact between recipients and providers (frequently before birth) was valued. On the whole, participants were happy with the amount and type of contact they had, and where the current contact did not involve the children, it was seen as a way of keeping the channels open for future contact when the children were older. Participants often portrayed the opportunities for contact as being in the best interests of the child.

LIMITATIONS, REASONS FOR CAUTION

The study participants are a particular group who had chosen to either receive or give their embryos via a conditional embryo adoption agency in the US and had established contact. Therefore, this is not a representative sample of those who provide or receive embryos for family building.

WIDER IMPLICATIONS OF THE FINDINGS

This embryo adoption model clearly fulfils a need; some people want to use a conditional embryo donation programme such as Snowflakes®. Some form of 'ongoing support mechanism' such as counselling could be useful for those negotiating the complex sets of new kinship patterns and balancing these relationships with their children's welfare.

STUDY FUNDING/COMPETING INTEREST(S)

The authors have no conflict of interest to declare. Snowflakes is a commercial adoption agency and the authors have no relation to the organization, other than requesting that they participate in this research project.

TRIAL REGISTRATION NUMBER

N/A.

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 INTEREST(S)

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.