Single men's attitudes towards posthumous use of their sperm cryopreserved due to illness in Israel

BACKGROUND

Banking of frozen spermatozoa by single men opens the possibility of procreation long after their death. Requests for posthumous reproduction by the families of the deceased are growing, raising an ethical debate, especially when written instructions were not left by the patients and in cases of unplanned perimortem collection. The issue of the progenitors' intention to procreate after death is the key to ethically based decision-making in these cases.

OBJECTIVES

To evaluate the attitude of single men cryopreserving spermatozoa before life-threatening medical situations towards post-mortem usage of their cryopreserved spermatozoa.

MATERIALS & METHODS

Adult single men prior to sperm cryopreservation before cytotoxic therapy were asked to sign a structured form declaring their will and instructions for the usage of their cryopreserved spermatozoa in case of their demise.

RESULTS

Four hundred fifty-two men of diverse ethnicity, religious and cultural backgrounds signed the form providing instructions for the use of their cryopreserved spermatozoa in case of mortality. Their age was 27.4 ± 8.06 years. Seven (1.5%) patients willed their spermatozoa for posthumous reproduction to a sibling, 22 (4.9%) to parents, and 26 (5.7%) to their informal female partners. The significant majority (n = 397; 87.8 %) of the single men were ordered to destroy their cryopreserved spermatozoa in case of their expiry. Note that, 26-39 years old men were less likely (81.8% vs. >90% in other ages) to order sperm destruction, as well as men with a poorer prognosis (83% vs. 90%).

DISCUSSION

In this study group, most single men cryopreserving spermatozoa in the face of future life-threatening morbidity do so for their own future live parenthood, and are not interested in posthumous reproduction.

CONCLUSION

Our results doubt the claim that single men who had an unplanned perimortem sperm collection can be universally presumed to have wished to father a child posthumously. Any claimed assumed consent in these cases should be considered for each case individually based on its specific circumstances.

Leaving a Legacy: Allied Health Professionals' Perceptions of Fertility Preservation and Posthumous Reproduction for Adolescent and Young Adults with a Poor Cancer Prognosis

Purpose: To explore Allied Health Professionals' (AHPs) experiences with and perceptions of posthumous assisted reproduction (PAR) among adolescent and young adults (AYA, ages 15-39) with a poor cancer prognosis. Methods: We conducted a qualitative analysis of video-based 90-minute focus groups (FGs) of AHPs who participated in the Enriching Communication Skills for Health Professionals in Oncofertility (ECHO) training program from May to August 2021. Moderator-facilitated discussions were guided by topics related to experiences around discussions and utilization of PAR among AYA with a poor cancer prognosis. Thematic analysis was conducted using the constant comparison method. Results: Forty-three AHPs participated in one of seven FGs. Three themes emerged: (1) PAR as palliative care: preserving patient's legacy for their partner, siblings, and parents; (2) ethical and legal considerations for balancing patient's time-sensitive needs; and (3) barriers AHPs encounter navigating complex dynamics of care in this population. Subthemes included an emphasis on patient autonomy, a multidisciplinary approach to counseling, early initiation of fertility discussions continuing over time, documenting reproductive desires, and concerns for family and offspring after patient death. Conclusions: AHPs desired timely conversations on reproductive legacy and family planning. In the absence of institutional policies, training, and resources, AHPs emphasized feeling ill-equipped to navigate the complex dynamics between patients, families, and colleagues. The development of transparent institutional policies, implementation of multidisciplinary care teams, and oversight with ethics committees may improve the provision of reproductive health care and/or end-of-life care for AYA with a poor cancer prognosis and their families.

Ethical and Practical Considerations of Perimortem Gamete Procurement for Palliative Care Providers

Requests for perimortem gamete procurement (PGP) typically arise by a surrogate decision maker after the unexpected death or incapacitation of a reproductive-aged individual. Palliative care clinicians should have a working knowledge of the medical, ethical, and practical considerations pertaining to such requests. In this paper, we describe a case in which the PGP request originated from an incapacitated patient's parents. We review the technologies associated with PGP and posthumous assisted reproduction (PAR) and discuss the ethical and legal issues involved in such cases, including recent position statements from national and international reproductive health groups. Finally, we provider readers with a stepwise approach for considering requests for PGP.

Posthumous Reproduction and the Law: Tissue Transplantation, Property Rights and the Reproductive Relational Autonomy

This paper examines the history of Australian superior court decisions on the retrieval of gametic material from deceased men. It examines the history of case law and legislation on the issue and then provides a summary of the current operative principles. The paper concludes with some reflections on the harms caused by posthumous retrieval of gametes, the role of property rights and the nature of reproductive autonomy.

Australia after Cresswell and Chapman: A Legal and Regulatory Paradox, or an Opportunity for Uniformity?

Australia, like many overseas jurisdictions, has recognised the need to cope with advancing medical technology and changing community attitudes towards assisted reproductive technology (ART). Despite this, several States in Australia still do not have legislative instruments regulating ART, and those that have legislated have done so in a non-uniform way. In 2018/2019, four cases came before State Supreme Courts, where the female applicants had to endure significant legal battle in order to utilise their late partner's gametes, highlighting the inability of the law to provide an appropriate clinical framework. This article outlines and discusses the current position of Australian States on the utilisation of posthumous gametes and how the recent decisions of the Supreme Courts of New South Wales, Queensland and Western Australia augment the current law and National Health and Medical Research Council Guidelines, and finally, considers how future legislation might account for the potential posthumous utilisation of oocytes.

Children of the Dead: Posthumous Conception, Critical Interests and Consent

Artificial Reproductive Technology now enables the conception of children after the death of their genetic father. There is little consensus on how posthumous conception should be dealt with by the law and this article examines alternative approaches to such regulation. The goal of any such regulatory regime should be the vindication of the deceased's critical or objective interests after death. Alternative approaches risk instrumentalising the dead to serve the interests of the living, or weigh too heavily the deceased's past decisional autonomy at the cost of respecting his or her likely wishes after death. Separate requirements should apply to applications for posthumous sperm retrieval and its subsequent use, with the former being less onerous given the emergency nature of the procedure and the latter involving a tribunal whose function is to consider how best to give effect to the deceased's reproductive autonomy after death.

MEDICAL-LEGAL PROBLEMS OF INTERFERENCE IN THE RIGHT TO HUMAN AUTONOMY IN POSTMORTEM REPRODUCTION

OBJECTIVE

The aim is a theoretical and methodological substantiation of revealing the possibility of interfering in the autonomy of a person during posthumous reproduction and establishing the existing protection of the rights and interests of postmortem children.

PATIENTS AND METHODS

Materials and methods: The legislation of the European Union, the USA, Great Britain, New Zealand, Spain, Germany, Ukraine, the statistical data published by the internationalorganizations are analyzed. In the course of the research a systemic, axiological approach and methods of analysis, synthesis, generalization were used.

CONCLUSION

Conclusions: It is proved that reproductive interference in the autonomy of the deceased in order to have a child is possible only on law basis, and in its absence - by a joint decision of the council of doctors, family lawyers, relatives of the deceased, taking into account the moral principles of society, public interests, rights and interests and other constituents (other heirs). It is emphasized that the origin of a postmortem child can be established based on a court decision. It is emphasized that post-mortem children should not have any discrimination; they are equal with other children. It was found that the system of rights of postmortem children includes personal non-property rights of a child (right to life, health, name, surname of biological parents); property rights (right to inheritance, right to social security). The primary is the system of non-property rights that ensure the physical and social life of the postmortem child.

Social security survivors benefits: the effects of reproductive pathways and intestacy law on attitudes

Most minor children are eligible for Social Security survivors benefits if a wage-earning parent dies, but eligibility of children not in utero at the time of death is more nuanced. The purpose of this study was to examine attitudes concerning access to Social Security survivors benefits in the context of posthumous reproduction. A probability sample of 540 Florida households responded to a multiple-segment factorial vignette designed to examine the effects of state intestacy laws and five reproductive pathways - normative, posthumous birth, cryopreserved embryo, cryopreserved gametes, and posthumous gamete retrieval - on attitudes toward eligibility for the Social Security survivors benefits. Broad support was found for the survivors benefits following normative and posthumous birth pathways, but attitudes were decidedly less favorable when the child was not in utero at the time of parental death. In addition, in stark contrast to the recent U.S. Supreme Court decision in Astrue v. Capato, the vast majority of respondents did not believe state intestacy laws should determine eligibility for Social Security survivors benefits.

Physicians' undecided attitudes toward posthumous reproduction: fertility preservation in cancer patients with a poor prognosis

BACKGROUND

The American Society for Clinical Oncology (ASCO) established guidelines for fertility preservation for cancer patients. In a national study of US oncologists, we examined attitudes toward the use of fertility preservation among patients with a poor prognosis, focusing on attitudes toward posthumous reproduction.

METHOD

A cross-sectional survey was administered via mail and Internet to a stratified random sample of US oncologists. The survey measured demographics, knowledge, attitude, and practice behaviors regarding posthumous reproduction and fertility preservation with cancer patients of childbearing age.

RESULTS

Only 16.2% supported posthumous parenting, whereas the majority (51.5%) did not have an opinion. Analysis of variance indicated that attitudes toward posthumous reproduction were significantly related to physician practice behaviors and were dependent on oncologists' knowledge of ASCO guidelines.

CONCLUSIONS

Physician attitudes may conflict with the recommended guidelines and may reduce the likelihood that some patients will receive information about fertility preservation. Further education may raise physicians' awareness of poor-prognostic patients' interest in pursuing this technology.

Cancer and Fertility: Ethical and Legal Challenges

Preserving the fertility of younger cancer patients requires coordinated efforts and attention to ethical issues by oncologists and fertility specialists. Although sperm is easily stored, freezing eggs or ovarian tissue is still experimental and should not be offered except as part of an experimental protocol. When gametic material is stored for later use, written directives for posthumous use may be given effect, and subsequently born children may be recognized as legal offspring of the deceased. Concerns about the welfare of offspring resulting from an expected shortened life span of the parent are not sufficient reason to deny cancer survivors assistance in reproducing.

Factors associated with disposition of cryopreserved reproductive tissue

OBJECTIVE

To study patient characteristics associated with the preferences for the disposition of cryopreserved semen and embryos in the event of death or divorce.

DESIGN

Retrospective exploratory study.

SETTING

Tertiary care academic medical center.

PATIENT(S)

One hundred twelve men banking sperm, 54 female patients (partners of men banking sperm) undergoing in vitro fertilization (IVF), and 112 women undergoing IVF who were not partners of men banking sperm.

INTERVENTION(S)

Male patients banking sperm and couples undergoing IVF completed a standard consent form detailing their desired dispositions (disposal or release to a surviving party) of cryopreserved sperm and embryos in the event of death or divorce.

MAIN OUTCOME MEASURE(S)

Effect of marital status, age, reason for sperm banking, infertility diagnosis, partner status (single or significant-other partner) on sperm, and embryo disposition choice.

RESULT(S)

In the event of death, married men were 5.5 times more likely to release banked sperm to a surviving party than were single men. The estimated odds of giving sperm to a survivor were 1.07 times greater with every 1-year increase in age. The choice of sperm disposal was significantly related to the banking reason for the case of banking prior to chemotherapy and/or radiation for malignancy. In the case of male death, the decisions of couples undergoing IVF for embryo disposition agreed with choices of male patients for sperm disposition approximately 33% of the time more often than by chance alone.

CONCLUSION(S)

Decisions surrounding disposition of cryopreserved sperm are significantly associated with marital status, age, and reason for banking sperm. Respective choices of sperm and embryo disposition in couples undergoing IVF were similar in the situation of male death.

Live birth after posthumous testicular sperm aspiration and intracytoplasmic sperm injection with cryopreserved sperm: case report

PURPOSE

To determine if a viable pregnancy is possible after aspiration of sperm from the testes of a man several hours after his death.

METHOD

Following cryopreservation of the aspirated sperm, in vitro fertilization (IVF)-embryo transfer (ET) with intracytoplasmic sperm injection (ICSI) was used. The sperm selected were either those with motility or plumper non-motile sperm.

RESULTS

Fertilization of oocytes and ET occurred following all five IVF-ET cycles. A clinical pregnancy was achieved in cycle 1 with non-motile sperm and a viable pregnancy resulted from cycle 5 with ICSI performed with viable sperm.

CONCLUSION

Viable pregnancies following IVF-ET and ICSI are possible even when using testicular sperm obtained posthumously.

Fertility clinics: one Code of Practice?

Since the enactment of the Human Fertility and Embryology Act 1990, Fertility Clinics have been obliged to work within the HFEA guidelines to comply with the requirements of their licences. However the recent media focus on certain aspects of assisted conception calls into question the degree of subjective interpretation that is applied by individual clinics with regard to the guidelines. This paper is the result of an empirical study examining how clinics interpret the guidelines, and will examine the question of whether the existing guidelines should be tightened to remove some of the inherent ambiguities.

Regulating the new reproductive technologies: a cross-channel comparison

In Britain and in France medical developments in the new reproductive technologies (NRTS) have proceeded at a similar pace. Both countries have been at the forefront of progress. Statutes seeking to answer the dilemmas posed by that progress were passed in 1990 in Britain and in 1994 in France. These have in some respects been markedly different. The process of legislating to regulate assisted conception has proved to be much more problematic in France than in Britain due to the ambitions of the French and the existence of Constitutional rights which impinged on the substance of any new laws. The outcome in three key areas of the debate, namely controlling access to assisted conception, defining parenthood and defining the status of the embryo, reveals fundamental divisions between understandings of law and culture in these two major European states. Taken as a whole the three laws of 1994 in France, for example, afford protection much more substantially to the child and the embryo than the Human Fertilisation and Embryology Act 1990. What this paper seeks to do then is to explore the response in France and Britain to these three issues, to evaluate the reasons for each jurisdiction's response to them and finally, perhaps intrepidly, to conclude whether France or Britain has offered the better solution to the problems of modern reproductive medicine.

Gametes, embryos and the life in being: the impact of reproductive technology on the rule against perpetuities

As the twenty-first century begins, changing technology is testing old rules of property law. In this Article, the author discusses the effect of modern technology on the Role Against Perpetuities. This discussion includes the arguments for and against recognition of the embryo as a life in being, as well as suggestions for legislative solutions to this issue.

Social and ethical aspects of in vitro fertilization

In vitro fertilization (IVF) stands out as one of the contemporary period's most extraordinary technologies, and its social and ethical consequences among the most far reaching. Despite its uncertain effectiveness and medical consequences, IVF has contributed significantly to the medicalization of infertility and the increasingly imperative character of reproductive technology. New developments in IVF, particularly oocyte donation, have created new definitions of treatable infertility and new social needs for IVF; when the technology does not result in pregnancy or healthy babies, these developments have created profound new disappointments. IVF and the commodification of the extracorporeal embryo have also confused the social meaning and legal definition of parenthood. Ultimately the relationship between prospective parents, infertility specialists, and the embryos that they create is a highly ambiguous one. This ambiguity is likely to be a long-term characteristic of efforts to develop, use, and assess assisted reproductive technologies.

Commentary: legal and ethical aspects of sperm retrieval

Author argues that the adequacy of "reasonably inferred consent" as a justification for the retrieval of sperm posthumously or after persistent vegetative state suffers from definitional ambiguity, faulty comparisons, and ultimately may justify practices that are not in the interest of survivors or children yet to be conceived.

Ethical and legal aspects of sperm retrieval after death or persistent vegetative state

Author notes that sperm retrieval after brain death or persistent vegetative state can sometimes be ethical, provided there is explicit prior or reasonably inferred consent. Reasonably inferred consent typically has not been possible in reported cases.

Commentary: posthumous harvesting of gametes--a physician's perspective

Author offers a clinical perspective on problems arising from requests for postmortem sperm and oocyte retrieval.