The point of no return: Up to what point should we be allowed to withdraw consent to the storage and use of embryos and gametes?

This article discusses when it is ethically acceptable to withdraw consent for the storage and use of embryos and gametes. Currently, the law in the UK states that consent to use of a gamete or embryo can be withdrawn up to the point of the embryo's transfer to the recipient's uterus or when the gamete is used in providing treatment services; that is, the 'point of no return'. In this article, we will consider other points of no return and argue that having a single point of no return, a one size fits all form of consent can, in some cases, lead to restrictions on individuals' autonomy and cause particular types of harm. Therefore, having different points of no return that fit different circumstances could extend autonomy and allow people to enter into agreements that are tailored more to their own particular needs and circumstances.

Secrets and disclosure in donor conception

This article considers the disclosure, sharing and exchange of information on being donor conceived within families, drawing on data from a study undertaken with donor-conceived adults registered with UK Donor Link (a voluntary DNA-linking register). This paper considers the narratives of how respondents found out they were donor-conceived and what events triggered disclosure of this information. This paper then goes on to examine the role secrecy played in their family life and uses the concept of 'display' to explore how secrecy affected their relationships with their immediate and extended family. Secrets are notoriously 'leaky' and we found complex patterns of knowing and uncertainty about whom in the family knew that the person was donor-conceived. We argue that what is kept secret and from whom provides insights into the multifaceted web of social relationships that can be created by donor-conception, and how knowledge can be managed and controlled in attempts to display and maintain family narratives of biogenetic connection.

Gamete donors' reasons for, and expectations and experiences of, registration with a voluntary donor linking register

This paper reports on a study of the views and experiences of 21 sperm donors and five egg donors registered with UK DonorLink (UKDL), a voluntary DNA-based contact register established to facilitate contact between adults who wish to identify and locate others to whom they are genetically related following donor conception. Specifically, the paper examines donors' reasons for searching for, or making information about themselves available to donor-conceived offspring. Their expectations of registration with UKDL, experiences of being registered and finally, the experiences of those who had contacted donor-conceived offspring and other genetic relatives are investigated. While most respondents reported largely positive experiences of registration, the study found significant issues relating to concerns about donation, DNA testing, possible linking with offspring and expectations of any relationship that might be established with offspring that have implications for support, mediation and counselling. Research that puts the experiences, perceptions and interests of gamete donors as the central focus of study is a relatively recent phenomenon. This study contributes to this debate and highlights directions for future research in this area.

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.

Cross-border-assisted reproduction: a qualitative account of UK travellers' experiences

Surveys on patients' experiences of cross-border fertility treatment have reported a range of positive and challenging features. However, the number of such studies is limited, and there is no detailed qualitative account of the experiences of UK patients who travel overseas for fertility treatment. The present study used a cross-sectional, qualitative design and in-depth interviews. Fifty-one participants (41 women and 10 men, representing 41 treatment 'cases') participated in semi-structured interviews. The experiences reported were broadly positive with a large proportion of participants (39 cases, 95%) citing a favourable overall experience with only two cases (5%) reporting a more negative experience. Thematic analysis revealed 6 major categories and 20 sub-categories, which described the positive and challenging aspects of cross-border fertility travel. The positive aspects were represented by the categories: 'access', 'control' and 'care and respect'. The more challenging aspects were categorized as 'logistics and coordination of care', 'uncertainty' and 'cultural dissonance'. The study confirms findings from others that despite some challenges, there is a relatively high level of patient satisfaction with cross-border treatment with participants able to extend the boundaries of their fertility-seeking trajectories and in some cases, regain a sense of control over their treatment.

Adoptive T cell immunotherapy for treatment of ganciclovir-resistant cytomegalovirus disease in a renal transplant recipient

Cytomegalovirus (CMV) is a significant cause of morbidity, mortality and graft loss in solid organ transplantation (SOT). Treatment options for ganciclovir-resistant CMV are limited. We describe a case of ganciclovir-resistant CMV disease in a renal transplant recipient manifested by thrombotic microangiopathy-associated glomerulopathy. Adoptive T cell immunotherapy using CMV-specific T cells from a donor bank was used as salvage therapy. This report is a proof-of-concept of the clinical and logistical feasibility of this therapy in SOT recipients.

Barriers for domestic surrogacy and challenges of transnational surrogacy in the context of Australians undertaking surrogacy in India

The ethical, social, psychological, legal and financial complexities associated with cross-border travel for reproductive services are gaining attention internationally. Travel abroad for surrogacy, and the transfer of gametes or embryos between countries for use in a surrogacy arrangement, can create conflict in relation to the rights of the parties involved: commissioning parents, surrogates and their families, gamete and embryo donors, and children born as a result of the arrangement. Australian surrogacy laws are restrictive and limit access to domestic surrogacy. Despite the introduction of laws in some Australian jurisdictions that penalise residents entering into international commercial surrogacy arrangements, hundreds of Australians resort to surrogacy arrangements in India and other countries each year. This article discusses legislation, policy and practice as they relate to Australians' use of surrogacy in India. It reviews current surrogacy-related legislation and regulation in Australia and India and existing evidence about the challenges posed by transnational surrogacy, and considers how restrictive Australian legislation may contribute to the number of Australians undertaking surrogacy in India.

Freezing the Biological Clock: A Viable Fertility Preservation Option for Young Singaporean Women?

In March 2012, an article in The Straits Times entitled ‘Freezing eggs could reverse falling birth rate’ suggested that employing the latest oocyte cryopreservation techniques could both foster individual women’s reproductive autonomy and impact Singapore’s fertility rate, which in recent years has consistently been among the world’s lowest. The article cited both local and international fertility specialists’ approval of elective oocyte cryopreservation for young women wishing to protect their reproductive potential against ageing and as a potential antidote to the contemporary ‘delay and defer’ model of family-building. Later in 2012, the Ministry of Health announced a review of oocyte cryopreservation policy taking into account related medical, scientific and ethical issues, while the Singapore College of Obstetricians and Gynaecologists endorsed oocyte cryopreservation as an “important, safe and efficient technology”. This paper outlines and analyses the arguments and empirical evidence used both to support and oppose offering elective oocyte cryopreservation as a routine fertility service, before concluding that this remains unjustifiable on the basis of insufficient evidence of its clinical efficacy and safety as regards either pregnancy rates or birth outcomes. If it is to be made available at all for these reasons in Singapore, it should be subjected to rigorous clinic-specific evaluation in accordance with accepted clinical and ethical norms. Key words: Elective oocyte cryopreservation, Outcomes

Freezing the biological clock: a viable fertility preservation option for young Singapore women?

In March 2012, an article in The Straits Times entitled 'Freezing eggs could reverse falling birth rate' suggested that employing the latest oocyte cryopreservation techniques could both foster individual women's reproductive autonomy and impact Singapore's fertility rate, which in recent years has consistently been among the world's lowest. The article cited both local and international fertility specialists' approval of elective oocyte cryopreservation for young women wishing to protect their reproductive potential against ageing and as a potential antidote to the contemporary 'delay and defer' model of family-building. Later in 2012, the Ministry of Health announced a review of oocyte cryopreservation policy taking into account related medical, scientific and ethical issues, while the Singapore College of Obstetricians and Gynaecologists endorsed oocyte cryopreservation as an "important, safe and efficient technology". This paper outlines and analyses the arguments and empirical evidence used both to support and oppose offering elective oocyte cryopreservation as a routine fertility service, before concluding that this remains unjustifiable on the basis of insufficient evidence of its clinical efficacy and safety as regards either pregnancy rates or birth outcomes. If it is to be made available at all for these reasons in Singapore, it should be subjected to rigorous clinic-specific evaluation in accordance with accepted clinical and ethical norms.

A survey of 1700 women who formed their families using donor spermatozoa

This paper reports the results of an online survey of 1700 recipients of donor spermatozoa conducted by the Donor Sibling Registry, aiming to understand the perspectives of respondents who had used donor spermatozoa. The survey examined: choice of sperm bank and donor; reporting of births and genetic disorders; disclosure; contact with donor and half-siblings; regulation of sperm donor activity and genetic testing; and access to medical information. The respondents formed three groups: single women; women in a same-sex relationship; and women in a heterosexual relationship. Some differences between the three cohorts were observed: preinsemination counselling; acceptance of donors without medical records or with chronic or late-onset diseases; awareness of choice of bank and type of donor; and views on the right of offspring to know their genetic origins. However, important areas of common ground were identified: the wish by those who had used an anonymous donor that they had used an open-identity donor; support for, and willingness to pay for, comprehensive genetic testing of donors; and desire for access to their donor's family health information. The implications of these results for policies concerning the use and management of donor spermatozoa will be discussed. This paper reports the results of a survey of 1700 women who used donor spermatozoa to conceive a child. The survey considers their views on the following areas: choice of sperm bank and donor; reporting of births and genetic disorders; disclosure; contact with donor and half-siblings; regulation of sperm donor activity and genetic testing; and access to medical information. This was an online survey was designed and conducted by the Donor Sibling Registry (DSR), a US-based non-profit organization that supports donor sperm recipients, donors and donor-conceived people. The survey aimed to understand the experiences, perspectives and concerns of women who had used donor spermatozoa. The respondents formed three groups: single women; women in a same sex relationship; and women in a heterosexual relationship. Some differences between the three groups were observed: preinsemination counselling; acceptance of donors without medical records or with chronic or late-onset diseases; awareness of choice of bank and type of donor; and the right of offspring to know their genetic origins. However, despite these differences, important areas of common ground were identified: the wish by those who had used an anonymous donor that they had used an open-identity donor; support for, and a willingness to pay for, comprehensive genetic testing of donors; and desire for access to their donor's family health information. The implications of these results for policies concerning the use and management of donor spermatozoa will be discussed.

They can't have my embryo: the ethics of conditional embryo donation

There are substantial numbers of frozen embryos in storage that will not be used by those who produced them for their own fertility treatment. One option for such embryos is to donate them to others to use in their fertility treatment. There has been considerable debate about how this process should be organized. In the US, there are embryo adoption programmes that mediate between those relinquishing embryos and potential recipients. This is a form of conditional embryo donation, where the relinquishing couple can choose the recipient of their embryo. This article examines the ethical debate over conditional embryo donation for family building and explores the question of whether those who have unused frozen embryos should be able to determine who receives their embryos. The main objections to conditional embryo donation are examined: first, the embryo is not a person and therefore such concern over the placement of an embryo is unwarranted; secondly, potential donors might impose morally problematic conditions on who should receive their embryo; and thirdly, there are practical difficulties regarding organizational arrangements and the associated costs involved. It will be concluded that these objections can be countered and that if people wish to donate and receive embryos in this way there is no ethical objection to them doing so.

Donor-conceived people's views and experiences of their genetic origins: a critical analysis of the research evidence

This article reports on a systematic review of English language, peer-reviewed publications from 13 empirical studies with donor-conceived children and adults regarding their experiences and perceptions of donor conception. A total of 19 articles that met the inclusion criteria were reviewed. These were identified by means of a bibliographic search of four electronic databases for the period 1990-2011 and supplemented by the authors' personal knowledge of work in this field. No reports from such studies appeared prior to 2000, and more than half have been published since 2008, demonstrating the relative novelty of research in this field. Much of the reviewed research evidence concerns individuals conceived through sperm donation conducted under a regime promoting both anonymity and nondisclosure. Consequently, there is little research that pertains to individuals conceived through other forms of collaborative reproduction, nor to those conceived under arrangements and regimes in which early parental disclosure is both advocated and practised and the identity of the donor and of other genetic relatives may be accessible to donor-conceived individuals. The studies consistently report that most donor-conceived people have an interest in securing information about their genetic and biographical heritage - more information than most of them have been able to obtain. Although a number of methodological limitations in the research base are identified, the authors conclude that the evidence is sufficiently robust to promote the implementation of policies and practices that promote transparency and openness in collaborative reproduction, thus reflecting the importance of maximising future choices and opportunities for donor-conceived people.

Guidelines for infertility counselling in different countries: is there an emerging trend?

BACKGROUND

It is widely accepted that infertility and involuntary childlessness, and the decision to engage with assisted reproduction technology (ART) services as a patient, donor or surrogate can entail wide-ranging psychosocial issues. Psychosocial counselling has, therefore, become valued as an integral element of ART services. The objective of this study was to begin to map out what exists globally by the way of guidelines for infertility counselling.

METHODS

Data were analysed from formal guidelines produced by seven national infertility counselling bodies, onetransnational infertility counselling organization, reports of the American Society for Reproductive Medicine Ethics Committee and Practice Committee and the ESHRE Task Force on Ethics and Law. Additional sources of data were the International Infertility Counseling Organization and counselling colleagues internationally.

RESULTS

Four broad areas concerning contemporary practice in infertility counselling are identified: (i) the legal mandate for counselling; (ii) eligibility credentials for individuals carrying out professional counselling activities; (iii) different forms of counselling and (iv) counselling practice in relation to specific elements of assisted reproduction treatment.

CONCLUSIONS

Internationally, the development of infertility guidelines is best described as a 'work in progress', although key trends are evident.

Cross-border reproductive services--suggestions for ethically based minimum standards of care in Europe

Cross-border reproductive services (CBRS) is a phenomenon discussed worldwide. The major challenges associated with CBRS are the lack of data on the number of patients travelling for treatment and lack of transparency regarding the quality and safety of treatment procedures, especially in countries that have not yet introduced legislation or binding professional guidelines. This has given rise to practices that range from dubious to irresponsible treatment. Given that pan-European (let alone globally encompassing) legislation or guidelines are unlikely to appear quickly if at all, the authors suggest the implementation of ethically based minimum standards of care to which clinics and service providers can adhere on a voluntary basis. Such minimum standards of care can result in providing infertility treatment that is transparent, accountable and carried out responsibly for all parties involved.

Genes r us? Making sense of genetic and non-genetic relationships following anonymous donor insemination

This exploratory qualitative study investigates the experiences of eight adults conceived following anonymous sperm donation who had discovered the identity both of their donor and of donor half-siblings and had established contact with each other. It focuses primarily on participants' reflections on genetic and social kinship relationships. Data were collected from this group as well as from the son of the donor and the donor-conceived half-sister of one participant by means of semistructured interviews utilizing asynchronous email and digitalized voice recording. Participants discussed their experience of genetic disconnection resulting from learning of their donor-conceived status and of revising their personal biographies and developing new kinship networks as a result of discovering the identity of their donor and the existence of donor half-siblings. The study highlights participants' agency expressed through their ability to draw on both genetic and non-genetic elements of their inheritance to redefine their self-identity and extend their familial/kinship networks in meaningful ways.

CBRC and psychosocial counselling: assessing needs and developing an ethical framework for practice

Encountering infertility and involuntary childlessness and undergoing infertility treatment are acknowledged as stressful experiences that impact on individuals' psychological and emotional health – and for which access to psychosocial counselling by a skilled mental health professional may be beneficial. Evidence of patients', gamete donors' and surrogates' experiences indicates that utilization of infertility treatment in another country may not only exacerbate these psychosocial adversities, but may also pose additional risks to the psychological or physical health of participants, thus further emphasizing the need for competent psychosocial counselling services in cross-border reproductive care. However, this is a largely neglected topic in recent discussions of both CBRC itself and of infertility counselling practice. This paper extends the previous work undertaken by two of the authors to begin to map out practice issues within an ethical framework for counsellors when working with clients, donors, surrogates, individuals conceived following infertility treatment and existing children in clients', donor's and surrogates' families where cross-border reproductive treatment is considered or undertaken.

Relinquishing frozen embryos for conception by infertile couples

This qualitative study sought to provide an in-depth understanding of the experiences of couples who have relinquished their stored frozen embryos to one or more infertile couples. All couples were recruited through a U.S. based not-for-profit, prolife, Christian "embryo adoption" agency. In-depth semistructured interviews were undertaken via e-mail. Implications for practice strategies, including effective ways for educating couples with surplus frozen embryos are offered.

Patient experiences of an "egg sharing" programme

INTRODUCTION

This paper reports on a qualitative empirical study of the experiences of women (and their partners) attending one UK assisted conception unit, who have considered egg sharing.

AIMS

In the absence of any published research of the experiences of people contemplating egg sharing and the considerable concerns that egg sharing had generated (for an overview see Blyth, 2002), the major purpose of the study was to examine the experiences not only of those who had considered and proceeded with egg sharing but also those who had considered, but had then decided against, egg sharing. In addition, since the views of male partners are frequently overlooked in studies of assisted conception treatment (cf. Ahuja, Mostyn, & Simons, 1997) the project actively sought the involvement of the women's partners. The study was designed to explore couples' motivation for egg sharing, their experiences of treatment, attitudes regarding information about egg sharing treatment and outcomes, and attitudes towards egg sharing.

METHODS

The centre sent a written invitation to participate in the study to all women who had indicated an interest in egg sharing and who had received both information and counselling in advance of proceeding (n = 60). Of these, 43 had decided to proceed after the counselling session and 17 had decided not to do so. Expressions of interest in participating in the study were received from 20 women: (a) five women had proceeded with egg sharing but had not been successful with their own treatment at the time of interview--all husbands/partners also participated (n = 10); (b) seven women had proceeded with egg sharing and had conceived (one of whom had conceived unexpectedly without assisted conception services)--5 couples and 2 women participated (n = 12); (c) six women decided to proceed with egg sharing, however an insufficient number of eggs were available following egg retrieval to enable egg sharing to take place--all husbands/partners also participated (n = 12); (d) two women decided not to proceed--and both husbands/partners participated (n = 4). The study data were derived from retrospective semi-structured interviews conducted by the author with these 20 women and 18 husbands/partners. Respondents also completed a paper exercise following the interview indicating their level of agreement or disagreement with a number of statements relating to egg sharing that were derived from responses to the HFEA's consultation on the withdrawal of payment to donors (HFEA 1998a.). While there was an overall 33% response rate, the response rate for those who had decided to proceed with egg sharing (41.9%) was greater than for those who had decided not to proceed (11.8%). Consequently, this study under-represents the views of women and their partners who had considered, but then rejected, egg sharing. Couples agreeing to participate in the research were given a choice of being interviewed together or separately and in their own home or at an alternative venue. This choice of separate or joint interviews was offered as part of the explicit effort to involve men in the study and to maximize participant choice. Twelve couples agreed to be interviewed separately; six couples were interviewed together and two women whose partners did not take part in the study were interviewed alone. There was no evidence of any significant differences in interview data between joint and separate interviews. Indeed, there was little disagreement between partners at all; this is probably not surprising, given that they will have discussed their decision about egg sharing together and will be aware of each other's views about at least some of the issues discussed during interview. All except four interviews took place in respondents' own homes. Two interviews took place in the centre at the respondents' requests and two interviews were conducted by telephone because of geographical considerations. All interviews were audio-recorded with respondents' permission and subsequently transcribed verbatim. The research was conducted in accordance with the British Psychological Society Statement of Ethical Principles for Conducting Research with Human Subjects (British Psychological Society, 2002). Ethical approval was given by the University of Huddersfield Ethics Committee.

Ethical objections to sex selection for non-medical reasons

This paper examines the main ethical argument used to support the use of sex selection for non-medical reasons, namely that sex selection for non-medical reasons should be allowed on the grounds of reproductive autonomy. A critique of this argument is offered, concluding that sex selection for non-medical reasons should not be permitted.