The Family Federation of Finland, Infertility Clinic, Helsinki, Finland
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Abstract |
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Key words: anonymity/attitudes/embryo donation/infertility/recipients
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Introduction |
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Embryo donation is a family-building option for a selected group of couples in which the woman has premature ovarian failure or is a poor responder to traditional ovarian stimulation, and the man suffers from severe disturbances in gamete production. Embryo donation may also be indicated for couples who are carriers of a hereditary disease which may cause significant morbidity in the child. However, many such couples will be able to use their own embryos in the future, thanks to advances in the field of preimplantation genetic diagnosis.
Cryopreservation of excess embryos is a widely practised part of assisted reproduction techniques in centres performing IVF cycles. Well-functioning cryopreservation systems have made it possible to replace only a small number of embryos at a time, and to freeze surplus embryos for future use. For some couples there will, with time, be no need to use their frozen embryos, for example because they have already had the number of children they desired. One choice will then be to donate the frozen embryos to another infertile couple. Embryo donation is an accepted method in assisted reproduction techniques in many parts of the world, for example in the USA, in Australia and in European countries such as Belgium, Greece, Russia, Spain and the UK (Schenker, 1997; Jones and Cohen, 1999
). In Finland, treatment with donated embryos has been carried out since the early 1990s. In the proposal of Finnish assisted reproduction technique law, which will be presented to the parliament in the near future, embryo donation is suggested to be approved. On the other hand, in many European countries embryo donation is prohibited by legislation.
The practice of embryo donation raises many ethical issues, since it involves several parties with separate interests: the donor couple; the recipient couple; and the offspring. How strict should the criteria for selection of embryo donors be? Which couples should be offered embryo donation treatment? How old should the couples be that are treated? A further issue is whether to tell the child and others about the gamete donation, as the question of secrecy or disclosure affects both the donor and the recipient family. Thus far, there are no follow-up studies concerning anonymity and secrecy issues in embryo donation families. Within the adoption and donor insemination literature, findings support openness with the child from the beginning as being the best way to build strong and secure family relationships (Karpel, 1980; Baran and Pannor, 1993
; Daniels and Taylor, 1993
; McWhinnie, 1995
, 1998
). Other authors have not been able to conclude that non-disclosure would be harmful to family relationships, or to the child's well-being (Golombok et al., 1996
; Nachtigall et al.,1997
; Shenfield and Steele, 1997
). Studies with donor offspring have shown there to be no significant differences in the psychological adjustment or socioemotional welfare of children conceived by oocyte donation or donor insemination, compared with that in adopted children, IVF children or children conceived normally (Golombok et al., 1996
, 1999
).
Few reports exist which describe pregnancy results from embryo donation programmes, and to our knowledge there are no studies of attitudes among donors and recipients. Previously, higher pregnancy rates were found in women who received donated embryos compared with those who were given embryos originating from donated oocytes or embryos from their own IVF cycle (Asch, 1992). Others (Sauer et al., 1995
) utilized donated oocytes and donated spermatozoa in creating fresh embryos, and reported a pregnancy rate of 33.3% per embryo transfer. In the UK, it was reported that the use of embryos created separately from donated oocytes and donated spermatozoa resulted in a higher success rate than the use of excess embryos donated by other infertile couples (Marcus and Marcus, 1999
). The high incidence of multiple gestations in assisted reproduction technique pregnancies carries a significant risk for a number of adverse outcomes (Bergh et al., 1999
; Hazecamp et al., 2000
). Recently, two couples were presented who terminated their twin/triplet pregnancies after transfer of embryos created from donor oocytes and donor spermatozoa (Marcus and Brinsden, 2000
). The primary reason for requesting termination after a protracted period of infertility was that these couples felt unable to cope with the stress of their multiple pregnancies. Various other aspects involved in establishing an embryo donation programme have also been described (Van Voorhis et al., 1999
). These authors found that 12% of couples having frozen embryos in storage for 2 years or more were willing to donate them to other couples.
In practice, the maximum storage period of frozen embryos in Finland is 10 years. Cryopreservation consent covers 35 years at a time. If the couples choose not to use their own embryos, they can donate them to other infertile couples or to research, or they can decide to discontinue cryopreservation whereupon the embryos will be destroyed. At the Family Federation of Finland, Infertility Clinic, Helsinki, Finland, about 700 IVF cycles are carried out each year. Of those couples who have had embryos cryopreserved for more than 5 years, 18% donate some or all of them to other infertile couples (Sundgren and Siegberg, 1999).
At the Family Federation of Finland, Infertility Clinic, Helsinki, Finland, the first donation of frozen embryos to be used by another couple was in November 1993, and the first transfer with cryopreserved donated embryos was carried out in February 1994. The aim of the present study was to report the current experience and outcome of embryo donation during a 6-year period up to February 2000. During the counselling with the patients, many complicated ethical questions arose however. To obtain some insight into the experiences of donors and recipients, and to obtain information about their attitudes regarding ethical issues involved in this treatment option, a questionnaire was sent to all participants in the embryo donation programme.
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Materials and methods |
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Embryo recipients
A total of 27 couples underwent treatment cycles with donated frozenthawed embryos between 1994 and 2000. The indication for treatment was the same as for oocyte donation, in combination with severe male infertility. The recipient woman underwent medical evaluation to ensure good general health, and to exclude any contraindication for pregnancy. The couples were informed about the extent of genetic and infectious screening of the donors. If donated intracytoplasmic sperm injection (ICSI) embryos were used, the recipients were made aware of the limitations of genetic screening, and also of the risk that there may be a genetic reason behind the infertility in the male donor. Information was given to the recipient couple about the age, height, weight, eye and hair colour of the donor woman and man. If possible, matching of phenotypic characteristics was carried out to a limited extent, predominantly looking at height and eye colour. Counselling as regards issues of anonymity, and secrecy was an important part of preparing the couples before embryo donation. The recipients had the opportunity to decide upon (an) embryo(s) from a donor couple who had registered identifying information about themselves.
The donated embryos were cryopreserved by using 1,2 propanediol (Lassale et al., 1985). The endometrium of the recipient woman was prepared using oestradiol valerate, 46 mg daily, and vaginally administered micronized progesterone (Lugesteron®; Leiras, Turku, Finland), 600 mg daily. Recipients with functioning ovaries had the same replacement therapy as above but they also underwent pituitary down-regulation with a gonadotrophin-releasing hormone agonist, buserelin (Suprecur®; Hoechst, Frankfurt, Germany), given as a nasal spray from the midluteal phase in the previous menstrual cycle. Transvaginal ultrasonography was used to monitor the endometrial response. A favourable endometrium was defined as being at least 7 mm thick with a triple-line pattern. Two-day-old embryos were transferred to the recipient on the third progesterone day, and 3-day-old embryos were transferred on the fourth progesterone day. If pregnancy was confirmed, oestradiol therapy was continued until 1011 weeks gestation and progesterone therapy was continued until 12 weeks gestation.
Questionnaire
A questionnaire was sent to all donors and recipients who had participated in the embryo donation programme up to May 2000. In constructing the questionnaire, the attention centred on the most complicated ethical issues which had arisen during discussions with donor and recipient candidates. The questionnaire consisted of 12 questions, with both structured and open answer options. The form was filled in separately by the female and male partners. The participants were asked which characteristics or details concerning the donor/recipient couple they would like to know. Should there be any upper age limits for donors/recipients? Is it important to inform the recipients whether or not the donor couple have children of their own (genetically siblings to the child-to-be)? Should the recipients be informed if ICSI embryos are used? Should the child be told about the manner of his/her conception? Does a child born from a donated embryo have the right to receive identifying information about the donors? The donors were asked whether they planned to inform their own children about the embryo donation. They were also asked whether they would like to be informed if a child with a hereditary or severe disease resulted from their embryos. In the questionnaire there was space for the respondents to note freely their comments, thoughts and wishes regarding the treatment.
The study was approved by the ethics committee of the Family Federation of Finland.
Statistical analysis
Student's t-test was used to compare age limits, and the 2 test was employed to compare attitudes between different groups.
Definitions
Transient hypertension was defined as blood pressure levels 140/90 mmHg on two or more occasions at least 6 h apart without proteinuria after 20 weeks gestation. Mild pre-eclampsia was defined as repeated blood pressure levels
140/90 mmHg with proteinuria
0.5 g/day after 20 weeks gestation.
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Results |
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Data on recipients
The mean age of the recipient women (n = 27) was 36 years (range 2644 years), and that of their male partners (n = 27) was 35 years (range 2558 years) at the time of the first donor embryo treatment. The mean duration of infertility was 8 years (range 219 years). Twenty-three of the 27 recipient women had not given birth earlier. Four women had had offspring with a previous partner. Table I shows the indications for embryo donation among the female and male recipients. In 23 of the 27 cases the indication for treatment was a combination of some degree of ovarian insufficiency and various types of spermatogenesis failure. The decision to choose donated embryos was most often a consequence of several unsuccessful assisted reproduction technique attempts. Seventeen couples had undergone several IVF/ICSI treatments (range 27), eight women had earlier been treated with donated oocytes, with or without ICSI, in two cases IVF with donated spermatozoa had been carried out, and six women had tried several unsuccessful donor inseminations. Two couples had never gone through any other infertility treatment, because of genetically based male and female infertility.
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Recipient mother: `You have to admit that you think of this matterwill you feel as happy as mothers with their biologically own children? But when the child is born this matter is obvious; this child is ours and the love I feel for him is unlimited. It really does not matter whether the eyes are green or blue, although information about these things was important when the treatment was planned'.
Female donor: `I could well think of meeting a child born from my cells. Still, I would never feel her/him to be my own, because he/she was born by another mother and brought up by other parents. This child would be a stranger to me. I am really happy if I have been able to make another couple happy by helping them in such a significant way as by having a child'.
Female donor: `I am still wondering whether I should register identifying information about myself. If I do, will I then have to meet a young girl or boy who says: Mother, why did you give me away? Will this child make comparisons with our own twins and think whether it was good or bad luck that he was born to another mother? On the other hand I understand that a child may be very interested in his/her origin and that this knowledge may be comforting'.
Female donor: `My attitude about embryo donation is the same as if I would have donated blood or some organ to another human being. The wish to help was the primary reason. The relationship between the mother and the child-to-be-born grows and becomes deeper during life experienced together. I hope that this thing should not be considered taboo, but [be] part of life'.
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Discussion |
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From a medical point of view, embryo donation includes screening and selection of donors, screening and evaluation of recipients, and matching of donors and recipients. During the first few years, no age limit was set for embryo donors. The recommended upper age limit for oocyte donors is 36 years (Barratt et al., 1998), which has been followed very strictly in our oocyte donation programme (Söderström-Anttila, 1998
). However, if a couple wanted to donate their frozen embryos which mostly originated from a successful treatment cycle, it was regarded as inappropriate not to accept them merely because of the age of the female donor. Embryos originating from women aged >36 years have been transferred to recipient women older than the donor, and the recipient couple has been thoroughly informed about the genetic risks involved. Some donors consider their embryos to be potential children, and they cannot accept that they will be destroyed or used for research purposes. In this respect, embryo donors differ from oocyte donors, who mostly consider that they are only giving away a cell, not a child (Söderström-Anttila, 1995
). Our study showed that 50% of both donors and recipients thought that there should be an upper age limit for a female donor, and they suggested an average age of about 40 years. The poor outcome of IVF in women aged
40 years is mostly due to poor oocyte quality (Navot et al., 1991
). It is important to ensure a good quality of donated embryos in order to avoid unnecessary treatment failures, which most of the recipients have repeatedly experienced in their earlier treatment attempts. In the future it might be wise to set an age limit of 36 years for the female donor.
Our embryo recipients were couples in which both partners suffered from severe disturbances in gamete production, or had repeated failures in earlier infertility treatments. Our strategy has been to use a couple's own gametes as long as is medically reasonable. There is a limited supply of donated embryos, and by keeping to strict medical criteria it has been possible to offer this type of treatment to those really needing it, without any unnecessary waiting time. In our embryo donation programme each partner had separately met the criteria for donor gametes. The upper age limit for female recipients has been 42 years. Significantly more of the donors than the recipients thought there should be an upper age limit for the recipients: the donors suggested an average of 43 years as an upper age limit for the female recipient and 4647 years for the male. Thus, the donors wanted their embryos to be given to couples at a natural family-building age. The donors were also very anxious to emphasize that the persons receiving their embryos should emotionally and socially have good qualifications for parenthood. Some of them expressed wishes concerning whether or not the embryos should be given to persons from abroad, or to single women or lesbian couples. In our practice we have followed such wishes carefully.
The success rate of embryo donation depends primarily on the viability of the donated embryos. One group (Sauer et al., 1995) reported a clinical pregnancy rate of 33.3% per embryo transfer using fresh embryos produced from separate oocyte and sperm donations, when they transferred up to five embryos at a time. Others (Marcus and Marcus, 1999
) found higher pregnancy rates after replacement with embryos created separately from donated oocytes and donated spermatozoa than with excess embryos donated by infertile couples. Pregnancy rates of 19.1% after frozenthawed donor embryo transfer, and 32.3% after fresh donor embryo transfer have also been reported (Marcus and Marcus, 1999
). We achieved a clinical pregnancy rate of 27.8% with frozenthawed donated embryos, which is better than that reported earlier in the literature. During the same time period, the clinical pregnancy rate with frozenthawed embryos created from donated oocytes from healthy, fertile donors was 22% (53/242) at our clinic (Söderström-Anttila et al., 2001
). Thus, the success rate for donations of excess embryosthose not previously chosen for transferis at least as good as for embryos originating from healthy oocyte donors.
An important challenge in assisted reproduction techniques is to avoid multiple pregnancies by reducing the number of embryos transferred at a time. Multiple pregnancy is associated with significantly increased health risks for both mother and offspring. At our clinic we always discuss with our patients the choice of transferring only one frozenthawed embryo at a time. Of 54 embryo transfers, eight were single-embryo transfers, of which two were successful, and the remainder were two-embryo transfers. A new expression has been suggested (Hazecamp et al., 2000) for success rate in IVF as `birth per embryos transferred'. Applied to our embryo donation study, the success rate can be expressed as 12 births per 100 donated frozenthawed embryos transferred.
Pregnancies after oocyte donation are at an increased risk of obstetric complications such as pre-eclampsia which may, at least partly, be due to immunological mechanisms (Serhal and Craft, 1987; Pados et al., 1994
; Söderström-Anttila et al., 1998
; Salha et al., 1999
). The same complications might be expected to occur when we use donated embryos. In our embryo donation recipients the incidence of pregnancy-induced hypertension (PIH) (30%) was similar to that (31%) observed in our oocyte donation programme, and higher than that (14%) noted in our IVF patients (Söderström-Anttila et al., 1998
). Thus far, our experience of obstetric outcome in embryo donation recipients is limited. As the risks associated with pregnancy (e.g. PIH) increase considerably with increasing maternal age (Berkowitz et al., 1990
; Prysak et al., 1995
), we have been very cautious in suggesting embryo donation to older women, until more experience is gained.
The question of disclosure versus secrecy of origins is an unsettled issue within the field of assisted reproduction with donated gametes. Most psychologists and therapists familiar with these questions recommend openness with the child as the solution most likely to assure a harmonious relationship between the parents and their child, and to prevent conflicts because of family secrets (Mahlstedt and Greenfeld, 1989). When information is not disclosed, children might pick up hidden clues and feel that `things are not quite right' (Karpel, 1980
; McWhinnie, 1995
; Turner and Coyle, 2000
). This experience may be associated with feelings of discontinuity, mistrust within the family, and a lowering of self-esteem (Turner and Coyle, 2000
). In counselling, we inform the couples about the advantages of disclosure and encourage them to be open and honest with their child. The decision of whether or not to inform the child is, of course, to be made by the parents. Lately, a trend towards increasing openness about biological roots has been noted. In Sweden, the law gives the donor insemination child the right to receive identifying information about the sperm donor when he/she grows up. In a recent study, 52% of parents studied had told or intended to inform their child about the donor insemination (Gottlieb et al., 2000
). In our study, two-thirds of the embryo recipients thought that the child should be informed of the nature of his/her conception. On the other hand, only 29% thought the child should have the right to receive identifying information about the donor. This may reflect a fear among recipients that contact between the donor couple and the child may, perhaps, make them feel too closely connected to each other. Half of the donor women were willing to give identifying information about themselves, but because of reluctance on the part of their male partners, only one-third of the couples had registered this information. The difficulty of knowing whether or not to register identifying information was evident among many donors. What will be the situation in 20 years? How will your other family members react? Will knowledge of origin be enlightening or confusing for the donor child? Until further national guidelines have been established we intend to carry out the practice by careful counselling and by respecting the interests and wishes of both donors and recipients. A recipient couple who have decided to inform their child about the manner of conception will have the possibility of receiving embryos donated by a couple who have agreed to register identifying information. On the other hand, the donor couple may stay anonymous if they wish.
Embryo donation treatments using infertile couples' spare embryos differ from oocyte and sperm donation in that the child born may have genetically full-blood sisters and brothers living in another family. Anonymous donation gives no possibility to get to know these siblings. Some donors emphasized the fact that contact with a sister or brother may be of even more importance than contact with genetic parents, especially if the child does not have any siblings in his/her own family. Such arguments speak in favour of registration of identifying information about all embryo donors. This kind of approach cannot, however, guarantee a child knowledge of his/her genetic background, as shown recently (Gottlieb et al., 2000), but it makes access to this information possible for at least some of these children.
A point raised by several donors was the wish to know if the recipient had become pregnant. One male donor stated that this knowledge is an essential prerequisite as regards deciding whether or not to tell his own children about the embryo donation. If the donation was unsuccessful there would be no need to tell them. A strong desire to know the outcome has also been noted by oocyte donors (Schover et al., 1991; Söderström-Anttila, 1995
). Several recipients also felt that the donors should be given information about the outcome. One recipient mother wrote, `I would allow the donor couple this knowledge, accompanied by thanks'. Our policy at present is that if it is important for the donor couple, we tell them if their embryo donation resulted in pregnancy.
Many donors stated that the reason for donating was a desire to help other infertile couples because they had themselves received help. Our donors have not received any financial compensation for the donation of their embryos. Expenses covering the screening procedures and storage of embryos after donation have been passed to the recipients. The cost of embryo donation treatment to a recipient couple is still considerably less than the cost of oocyte donation and conventional IVF. The lower price, in combination with shorter waiting lists compared with oocyte donation, might increase the demand for embryo donation by couples for whom full or partial genetic parentage is not a primary concern.
In conclusion, embryo donation represents a useful option for couples with otherwise untreatable infertility of both partners to fulfil their family-building goals. We noted favourable pregnancy outcome by using excess frozenthawed embryos donated by infertile couples, transferring only one or two embryos at a time. Embryo donation treatment is unique among assisted reproduction techniques, as the child born will have no genetic connection to his/her parents. However, unlike adoption, this child will be gestated by his/her future mother and the future father has the possibility to commit himself to the child at an early stage. Careful attention and respect must be paid to the individual interests of all three parties involved, the donors, the recipients, and especially the offspring. The fact that children born from infertile couples' excess embryos may have full-blood genetic siblings living in another family makes this treatment ethically even more complex than oocyte or sperm donation. These children may be interested in getting to know each other, which speaks in favour of registration of identifying information about the embryo donors. An open and honest approach about the child's conception is essential in building healthy and trustful relationships in gamete donation families.
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Acknowledgements |
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Notes |
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References |
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Submitted on October 16, 2000; accepted on March 1, 2001.