1
|
Graham ME, Jelin A, Hoon AH, Wilms Floet AM, Levey E, Graham EM. Assisted reproductive technology: Short- and long-term outcomes. Dev Med Child Neurol 2023; 65:38-49. [PMID: 35851656 PMCID: PMC9809323 DOI: 10.1111/dmcn.15332] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 06/06/2022] [Accepted: 06/07/2022] [Indexed: 01/05/2023]
Abstract
Assisted reproductive technology (ART) includes fertility treatment in which either eggs or embryos are handled outside a female's body to promote successful pregnancies and healthy offspring. Current ART procedures encompass in vitro fertilization with or without intracytoplasmic sperm injection. The most common complication of ART is related to the consequences of multiple pregnancy, which can be prevented or minimized by reducing the number of embryos transferred to the uterus, commonly single embryo transfer. ART has been shown to be variably associated with adverse short- and long-term perinatal outcomes, including cerebral palsy, autism, neurodevelopmental imprinting disorders, and cancer. However, there is uncertainty as to whether reported problems are related to the ART procedure itself, to factors related to infertility, to other medical and environmental factors, or a combination thereof. From a pathophysiological perspective, whether ART alters epigenetic mechanisms of gene expression, leading to later developmental, medical, and behavioral disorders, is an area of active investigation. With the meticulously conducted short- and long-term outcome studies completed so far, overall, and after controlling for multiple gestations and preterm delivery, the results suggest that ART is a safe procedure, offering hope to many parent(s) wishing for a healthy child. This paper highlights ART methods and the risk factors and confounders in the interpretation of short- and long-term outcome data, providing the reader with a means to evaluate findings and conclusions of outcome studies. WHAT THIS PAPER ADDS: Assisted reproductive technology (ART) is a relatively safe procedure. Single embryo implantation optimizes outcome. Informed consent, including the risks and benefits of ART, should be required. Ongoing longitudinal studies are necessary to fully understand ART outcomes.
Collapse
Affiliation(s)
- Mary Elaine Graham
- College of Arts and Sciences, Washington and Lee University, Lexington, VA, USA
| | - Angie Jelin
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA,Department of Gynecology and Obstetrics, Division of Maternal-Fetal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alexander H. Hoon
- Department of Pediatrics, Division of Developmental Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA,Phelps Center for Cerebral Palsy and Neurodevelopmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA
| | - Anna Maria Wilms Floet
- Department of Pediatrics, Division of Developmental Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA,Center for Autism and Related Disorders, Kennedy Krieger Institute, Baltimore, MD, USA,Center for Development and Learning, Kennedy Krieger Institute, Baltimore, MD, USA
| | - Eric Levey
- Health Services for Children with Special Needs, Washington, DC, USA
| | - Ernest M. Graham
- Department of Gynecology and Obstetrics, Division of Maternal-Fetal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA,Neuroscience Intensive Care Nursery Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
2
|
Schofield G, Dittborn M, Selman LE, Huxtable R. Defining ethical challenge(s) in healthcare research: a rapid review. BMC Med Ethics 2021; 22:135. [PMID: 34587950 PMCID: PMC8479723 DOI: 10.1186/s12910-021-00700-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 09/03/2021] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Despite its ubiquity in academic research, the phrase 'ethical challenge(s)' appears to lack an agreed definition. A lack of a definition risks introducing confusion or avoidable bias. Conceptual clarity is a key component of research, both theoretical and empirical. Using a rapid review methodology, we sought to review definitions of 'ethical challenge(s)' and closely related terms as used in current healthcare research literature. METHODS Rapid review to identify peer-reviewed reports examining 'ethical challenge(s)' in any context, extracting data on definitions of 'ethical challenge(s)' in use, and synonymous use of closely related terms in the general manuscript text. Data were analysed using content analysis. Four databases (MEDLINE, Philosopher's Index, EMBASE, CINAHL) were searched from April 2016 to April 2021. RESULTS 393 records were screened, with 72 studies eligible and included: 53 empirical studies, 17 structured reviews and 2 review protocols. 12/72 (17%) contained an explicit definition of 'ethical challenge(s), two of which were shared, resulting in 11 unique definitions. Within these 11 definitions, four approaches were identified: definition through concepts; reference to moral conflict, moral uncertainty or difficult choices; definition by participants; and challenges linked to emotional or moral distress. Each definition contained one or more of these approaches, but none contained all four. 68/72 (94%) included studies used terms closely related to synonymously refer to 'ethical challenge(s)' within their manuscript text, with 32 different terms identified and between one and eight different terms mentioned per study. CONCLUSIONS Only 12/72 studies contained an explicit definition of 'ethical challenge(s)', with significant variety in scope and complexity. This variation risks confusion and biasing data analysis and results, reducing confidence in research findings. Further work on establishing acceptable definitional content is needed to inform future bioethics research.
Collapse
Affiliation(s)
- Guy Schofield
- Centre for Ethics in Medicine, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK.
- Palliative and End of Life Care Research Group, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK.
| | - Mariana Dittborn
- Paediatric Bioethics Centre, Great Ormond Street Hospital, London, WC1N 3JH, UK
| | - Lucy Ellen Selman
- Palliative and End of Life Care Research Group, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK
| | - Richard Huxtable
- Centre for Ethics in Medicine, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK
| |
Collapse
|
3
|
Golboni F, Jalali A, Dinmohammadi M, Taghizadeh Z, Nouri P, Salahsoor MR. Iranian model of decision making to use surrogacy: A grounded theory Study. Health Care Women Int 2020; 41:853-865. [PMID: 32357079 DOI: 10.1080/07399332.2020.1758107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Identifying the process of making the decision to use a surrogate mother can create a broad knowledge of this concept. In this grounded theory study, participants were selected through snowball sampling method and obtaining an informed consent, in-depth interviews were conducted face to face and recorded. Then, all the interviews, field notes, and memos were analyzed using Strauss-Corbin 1998 method. Analysis of the statements of the participants boiled down to 487 initial codes, 311 codes, 14 subcategories, and six categories. In the conceptual model of this process, "the hope to have a child" was an influential concept that interacted with other concepts.
Collapse
Affiliation(s)
- Farzaneh Golboni
- Dept. of Midwifery, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Amir Jalali
- Substance Abuse Prevention research Center, Research Institute for Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mohammadreza Dinmohammadi
- Dept. of Nursing, School of Nursing and Midwifery, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Ziba Taghizadeh
- Dept. of Midwifery and Reproductive Health, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
| | - Parichehr Nouri
- Dept. of Midwifery, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mohammad Reza Salahsoor
- Dept. of Anatomy, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| |
Collapse
|
4
|
Dual consent? Donors' and recipients' views about involvement in decision-making on the use of embryos created by gamete donation in research. BMC Med Ethics 2019; 20:90. [PMID: 31791312 PMCID: PMC6889541 DOI: 10.1186/s12910-019-0430-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 11/21/2019] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Reasonable disagreement about the role awarded to gamete donors in decision-making on the use of embryos created by gamete donation (EGDs) for research purposes emphasises the importance of considering the implementation of participatory, adaptive, and trustworthy policies and guidelines for consent procedures. However, the perspectives of gamete donors and recipients about decision-making regarding research with EGDs are still under-researched, which precludes the development of policies and guidelines informed by evidence. This study seeks to explore the views of donors and recipients about who should take part in consent processes for the use of EGDs in research. METHODS From July 2017 to June 2018, 72 gamete donors and 175 recipients completed a self-report structured questionnaire at the Portuguese Public Bank of Gametes (response rate: 76%). Agreement with dual consent was defined as the belief that the use of EGDs in research should be consented by both donors and recipients. RESULTS The majority of participants (74.6% of donors and 65.7% of recipients) were willing to donate embryos for research. Almost half of the donors (48.6%) and half of the recipients (46.9%) considered that a dual consent procedure is desirable. This view was more frequent among employed recipients (49.7%) than among non-employed (21.4%). Donors were less likely to believe that only recipients should be involved in giving consent for the use of EGDs in research (25.0% vs. 41.7% among recipients) and were more frequently favourable to the idea of exclusive donors' consent (26.4% vs. 11.4% among recipients). CONCLUSIONS Divergent views on dual consent among donors and recipients indicate the need to develop evidence-based and ethically sustainable policies and guidelines to protect well-being, autonomy and reproductive rights of both stakeholder groups. More empirical research and further theoretical normative analyses are needed to inform people-centred policy and guidelines for shared decision-making concerning the use of EGDs for research.
Collapse
|
5
|
Carr SV. Surrogacy and ethics in women with cancer. Best Pract Res Clin Obstet Gynaecol 2018; 55:117-127. [PMID: 30553717 DOI: 10.1016/j.bpobgyn.2018.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 11/02/2018] [Indexed: 10/27/2022]
Abstract
Women diagnosed with gynaecological cancer may face unwanted loss of fertility as well as all the other life-changing issues with which cancer and its treatments are associated. The decision to harvest and store gametes has to be made before commencement of treatment, and advances in these techniques have made this successful. Fertility sparing therefore must be discussed and offered at an early stage post diagnosis. Surrogacy is currently an evidence-based method of assisted reproduction, with mainly desirable outcomes for the commissioning mother, surrogate and child, without impacting on the cancer treatment and long-term survival. Surrogacy is therefore ethical as long as the autonomous rights of both the commissioning mother and gestational carrier are equally observed, they both have equal legal protection and due attention is paid to the short- and long-term welfare of any resulting offspring.
Collapse
Affiliation(s)
- Susan V Carr
- Faculty of Medicine, University of Melbourne, Parkville, Australia.
| |
Collapse
|
6
|
Siegel AM, Ravitsky V. Women With Mental Illness Seeking Assisted Reproduction Considerations in Ethical Candidate Selection. Curr Psychiatry Rep 2018; 20:70. [PMID: 30094584 DOI: 10.1007/s11920-018-0944-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE OF REVIEW This review aims to provide guidance to clinicians facing requests for assisted reproduction from women with mental illness. RECENT FINDINGS The paper explores the clinical and safety aspects of initiating fertility treatment in this context, including the use of psychotropic medication and the risk of untreated psychiatric mood or psychotic disorders. It also presents the ethical considerations involved in candidate selection, including treating similar cases equitably to avoid biased decisions based solely on "gut-feelings," respect for women's reproductive autonomy, and an effort to protect patients and prospective fetuses/children from harm by employing optimal strategies regarding medication and psychosocial support. Clinicians ought to be informed regarding recent evidence related to the safety and efficacy of psychopharmacologic treatment of women during pregnancy and the post-partum. They should also carry out a thoughtful ethical analysis to ensure minimal violation of women's reproductive autonomy.
Collapse
Affiliation(s)
- Andrew M Siegel
- University of Pennsylvania Perelman School of Medicine, 3535 Market Street, 2nd Fl, Philadelphia, PA, 19104, USA.
| | - Vardit Ravitsky
- School of Public Health, University of Montreal, Montreal, Canada
| |
Collapse
|
7
|
Klitzman R. Impediments to communication and relationships between infertility care providers and patients. BMC Womens Health 2018; 18:84. [PMID: 29871622 PMCID: PMC5989459 DOI: 10.1186/s12905-018-0572-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 05/21/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Infertility patients generally see provider-patient communication and relationships as important, but as often insufficient, raising critical questions regarding why these gaps persist, and how they might best be addressed. METHODS Semi-structured interviews of approximately one hour each were conducted with 37 ART providers and patients (17 physicians, 10 other health providers, and 10 patients) and were thematically analyzed. RESULTS Patients see clinicians' interactions as ranging widely from good to bad, related to several specific barriers and factors. Patients and providers may differ in their physical and emotional experiences, expectations concerning treatment outcomes and uncertainties, and time frames and finances, generating dynamic processes and tensions. Characteristics of particular providers, clinics and patients can also vary. Infertility patients tend to find only one outcome acceptable - a "take home baby" - rather than partial success, as is the case with many other diseases. Yet most IVF cycles fail. Many patients must pay considerable out-of-pocket expenses for infertility treatment, exacerbating disappointments and frustrations. Providers often work in competitive, entrepreneurial markets, and "hype" their potential success. After treatment failures, providers may feel guilty and withdraw from patients. Yet these behaviors can antagonize patients more than physicians realize, aggravating patient stresses. Several providers described how they understood patients' needs and perceptions more fully only after becoming infertility patients themselves. Interactions with not only physicians, but other providers (e.g., nurses and staff) can play key roles. Patients may be willing to understand these impediments, but providers often communicate these obstacles and reasons poorly or not at all, furthering tensions. CONCLUSIONS These data, the first to examine several critical aspects of challenges that infertility providers and patients face in communication and relationships, suggest that several key dynamic processes and factors may be involved, and need to be addressed. While prior research has shown that infertility patients value, but often feel disappointed in relationships with clinicians, the present data highlight several specific impediments, and thus have critical implications for future practice, research, guidelines and education.
Collapse
Affiliation(s)
- Robert Klitzman
- Columbia University, 1051 Riverside Drive #15, New York, NY, 10032, USA.
| |
Collapse
|
8
|
Klitzman R. Gatekeepers for infertility treatment? Views of ART providers concerning referrals by non-ART providers. REPRODUCTIVE BIOMEDICINE & SOCIETY ONLINE 2018; 5:17-30. [PMID: 29774271 PMCID: PMC5952807 DOI: 10.1016/j.rbms.2017.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 06/27/2017] [Accepted: 08/10/2017] [Indexed: 05/07/2023]
Abstract
Many patients who might benefit from treatment using assisted reproductive technology (ART) do not receive it, raising critical questions of why, and how best to overcome existing barriers. In-depth interviews of approximately 1 h each were conducted with 27 ART providers (17 physicians and 10 other healthcare providers). These interviewees suggest that non-ART providers may serve as gatekeepers in a complex system, involving not only individual-level, but also dyadic and institutional, processes and factors related to provider-patient relationships. Differences emerge concerning 'who' refers patients for ART (e.g. what types of provider), 'how' (amount, type and specificity of information offered), 'when' (delayed or not) and 'why or why not', and how patients respond to referrals, once made. At least seven types of clinician (general practitioners, obstetricians/gynaecologists, paediatricians, geneticists, psychologists and oncologists) may refer patients. Barriers to referral include indistinct boundaries between specialties and provider discomfort discussing reproduction and sex. These data, the first to explore dynamic factors and processes related to provider-patient relationships and interactions in referrals of patients for ART, suggest several key issues (e.g. non-ART providers' roles as gatekeepers), and implications for future education, practice, guidelines and research, highlighting a research agenda, and the need for targeted education for different groups of clinicians.
Collapse
|
9
|
Klitzman R. How Infertility Patients and Providers View and Confront Religious and Spiritual Issues. JOURNAL OF RELIGION AND HEALTH 2018; 57:223-239. [PMID: 29189982 DOI: 10.1007/s10943-017-0528-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Questions arise concerning whether and how religion affects infertility treatment decisions. Thirty-seven infertility providers and patients were interviewed. Patients confront religious, spiritual, and metaphysical issues coping with treatment failures and religious opposition from clergy and others. Religion can provide meaning and support, but poses questions and objections that patients may try to avoid or negotiate-e.g., concealing treatment or changing clergy. Differences exist within and between religions. Whether and how much providers discuss these issues with patients varies. These data, the first to examine several key aspects of how infertility providers and patients confront religious/spiritual issues, have important implications for practice, research, guidelines, and education.
Collapse
Affiliation(s)
- Robert Klitzman
- Columbia University, 1051 Riverside Drive; Mail Unit #15, New York, NY, 10032, USA.
| |
Collapse
|
10
|
Klitzman R. Challenges, Dilemmas and Factors Involved in PGD Decision-Making: Providers’ and Patients’ Views, Experiences and Decisions. J Genet Couns 2017; 27:909-919. [DOI: 10.1007/s10897-017-0173-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 11/06/2017] [Indexed: 12/29/2022]
|
11
|
Klitzman R. Infertility providers' and patients' views and experiences concerning doctor shopping in the USA. HUM FERTIL 2017; 22:238-245. [PMID: 29172797 DOI: 10.1080/14647273.2017.1406155] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Many questions arise concerning how infertility patients decide whether, how much and why or why not to consult more than one doctor and change physicians. To explore this issue, a total of 37 US in vitro fertilization (IVF) providers and patients were interviewed in-depth. Many infertility patients feel disappointed with infertility providers, especially after treatment failure, and then struggle to evaluate and weigh relative 'bedside manner' against technical skills, finances and hope, facing dilemmas of which doctor to choose, whether and how much, to 'shop around', how to do so, and whether and how much to give doctors 'second chances'. Complex, dynamic processes can ensue: shopping for initial or subsequent physicians and consulting and/or changing doctors multiple times, based on differing treatment approaches. Patients may alter perceptions of physicians over time. Providers are often busy and have difficulty addressing patients' emotional stresses; and may provide providing 'false hope', and/or criticize colleagues' approaches. These data, the first to explore how infertility patients decide whether, how and why to consult with more than one infertility doctor, suggest that patients may 'doctor shop,', engaging in dynamic processes, wrestling to weigh communication vs. other skills. These data have important implications for future practice, research, guidelines and education.
Collapse
Affiliation(s)
- Robert Klitzman
- Department of Psychiatry, Columbia University, New York, NY, USA
| |
Collapse
|
12
|
Klitzman R. "Will they be good enough parents?": Ethical dilemmas, views, and decisions among assisted reproductive technology (ART) providers. AJOB Empir Bioeth 2017; 8:253-265. [PMID: 29058532 DOI: 10.1080/23294515.2017.1394927] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Many adults may make less-than-ideal parents, but important ethical questions arise concerning whether assisted reproductive technology (ART) providers should thus ever refuse treatment to certain patients, and if so, when, and how to decide. METHODS In-depth interviews of approximately 1 hour each were conducted with 27 ART providers (17 physicians, and 10 other health providers). RESULTS Clinicians often struggle with whether to attempt to assess and predict patients' potential future parenting abilities, and if so, how, and how to proceed if doubts arise. Providers face profound ethical tensions between adults' rights to reproduce and best interests of the eventual children (i.e., to be born into "stable" homes), and questions about the extent of professional responsibilities toward potential parents versus toward future offspring. Providers generally feel uncomfortable with this role, and hence don't want it, partly since they lack training for it, but also because of inherent empirical and ethical uncertainties. Concerns about discrimination based on the mere presence or history of certain diagnoses or traits (e.g., single marital status or past depression) also arise. Clinicians frequently seek to resolve these tensions through various strategies-for example, referring these decisions to others; hoping that patients drop out of treatment; assessing and increasing social support (e.g., arranging for possible co-parents); assisting the patient psychotherapeutically; or seeking to communicate concerns to patients only indirectly or implicitly. Clinics vary in how they make and approach these decisions-whether they rely on a formal ethics or other committee. CONCLUSIONS These data, the first to explore several critical aspects of in vitro fertilization (IVF) providers' views and decision making about assessing the quality of patients' potential future parenting, have critical implications for future practice, education, research, and guidelines. Further empirical and normative scholarship and guidelines are needed to help clarify expectations, processes, and possible approaches to aid providers and patients.
Collapse
Affiliation(s)
- Robert Klitzman
- a Department of Psychiatry and Director , Bioethics Masters & Online Course Programs, Columbia University
| |
Collapse
|