Disposition of cryopreserved embryos
Disposition of cryopreserved embryos
Disposition of cryopreserved embryos
Embryo cryopreservation has long been established as an effective means to utilize surplus embryos and to decrease the risks of multiple pregnancies during fresh IVF cycles. Another goal of these techniques is also to offer the couples an opportunity for further treatment cycles without the need for repeat ovarian hyperstimulation. It is usually both medically safer and less expensive to undergo a frozen cycle. Couples typically choose to utilize their frozen embryos if their fresh cycle was unsuccessful, or, if they are able to achieve a live birth, for further pregnancies.
On the surface, having cryopreserved embryos in storage sounds like a win-win situation, from both the risk-benefit and cost-benefit perspectives. On further probing, however, the multiple personal, religious, and ethical challenges involved become obvious. Some estimate that one fourth of couples do not utilize their cryopreserved embryos. The fact that there are 400,000 surplus unused embryos currently in storage in the United States alone, is a testament to the complexities involved in the disposition decisions.
The inability or unwillingness on the part of the couples to decide the fate of the unused embryos has even led to legislative limits of storage from 2-5 years in various European countries, like Denmark. However, a survey of Danish patients showed that 60% believed that the legislative limit of 2 years was just too short to decide.
The disposition options currently available to patients are limited. The embryos may be thawed and transferred in an attempt to achieve another pregnancy. Embryos may be donated to another infertile couple for a future attempt, although this option is illegal in some countries. Embryos may be donated for research and/or stem cell research, or may be thawed and discarded. The fifth, and perhaps too frequently utilized option, is that of inaction, which is simply maintaining embryos in their cryopreserved state.
It may be eye-opening for practitioners to explore the reasons for their patients' indecision. In the professional world, where day to day conversations are filled with technical jargon and revolve around embryos and pregnancies, it may be easy to lose sight of what these "embryos" mean to the patients namely a potential "baby". It is not surprising, then, that so many couples do not want to assume responsibility for the final disposition of their embryos.
Abandoning surplus cryopreserved embryos most frequently occurs after a successful delivery from a prior IVF cycle, with only a minority of patients deciding not to pursue further treatment in the absence of a successful cycle. The patients who had a successful delivery describe different reasons for their indecision patients consider their family completed, some do not wish further treatment because of complications with the pregnancy or morbidity with child and/or themselves. Other patients are unaware of treatment options with thawed embryo, or have had marital issues (separation, divorce, etc).
When one considers the complexities of such decision-making, it becomes clear why such a large number of patients choose "indecision" as their decision. Usually, family and personal issues are the most prevalent, with the most important decision being whether the couple wants to have more children. Some couples feel that by having cryopreserved embryos they are pressured to continue thinking about child-bearing beyond what they considered to be "normal" reproductive years. For some, other personal or financial aspects are important. A theme that sometimes comes up is that of trust patients are sometimes afraid that physicians and/or researchers will mix up their embryos, or mistakenly allow development of an embryo donated to research into an individual. Many couples are at cross-roads because of the way they view the embryo (a living entity) or because of protective responsibility to the embryo (in case of embryo adoption). Others view their decision- making in terms of a global responsibility to society, and thus look to research as a way to benefit the humankind.
Surprisingly, many patients report either a lack of adequate information or too much information at the time of having to make the decision or in follow up storage period. Some patients even express a desire to have embryos placed into their body at the time when they are not likely to get pregnant, or to have a private ceremony in a hospital facility (i.e. chapel) which would allow time to reflect and impart a sense of closure, while also ensuring that their wishes were carried out.
When faced with the options, couples struggle with the decision. Some couples who choose to dispose their frozen embryos do not want to donate to another couple because a resulting child would be a full sibling to their own child, and are in general against research on embryos. Out of those who wish to donate to research, some want to help advance science, and others simply do not want to waste the embryos. If a couple makes a decision to donate their embryo to a different couple, it's because they want to help them conceive, and to give the embryos a chance at life. The majority of couples, however, find it quite difficult or even very distressing to make a decision about the fate of their embryos, and are frequently discordant between the male and the female partner.
Overall, about one quarter of surplus embryos are not utilized, mainly due to successful outcome in a prior treatment. Recognizing that disposition decisions are frequently very difficult for patients for a variety of personal, religious, ethical, and financial reasons, is very important. It is essential to provide adequate counseling at the time of freezing and in follow up, to educate couples about their options, and to assist in this difficult process. Disposition options which include discarding, donating for research or donating to other infertile couples may be insufficient for patients, and programs might consider offering additional options. Finally, if legislative limits to cryopreservation duration are to be set, they should allow ample time for the couple to come to this complex decision.
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