Profession

Ethics for extra embryos: Doctors face a dilemma

Adoption? Disposal? There are no legal rules on what to do, so the number of embryos keeps growing

By Andis Robeznieks — Posted Feb. 14, 2005

Print  |   Email  |   Respond  |   Reprints  |   Like Facebook  |   Share Twitter  |   Tweet Linkedin

News reports concerning the nation's inventory of 400,000 cryopreserved embryos can conjure up images of overflowing fertility clinic freezers surrounded by clinicians scratching their heads over what to do with all of the embryos that have been abandoned by the couples who created them.

The number, much higher than previous estimates that ranged from 30,000 to 200,000, comes from a 2003 embryo census conducted by the Society for Assisted Reproductive Technology. But reproductive specialists note that the vast majority of stored embryos -- almost 350,000 -- are still earmarked for future fertility treatments. And of those, 35% likely would not survive the thawing process.

Arlene J. Morales, MD, medical director of the Sharp Fertility Center in San Diego, thinks the perception that fertility clinics are overstuffed with extra embryos is the result of press sensationalism. "The media seems to highlight couples who don't know what they want to do," she said. "But in my experience, most couples intend to save them for future use."

The American Society for Reproductive Medicine recommends using one to five embryos per treatment, depending on the woman's age and other risk factors.

Better technology and more sensitivity is leading fertility clinics to use and create fewer embryos in the first place, said both Dr. Morales and Jeffrey Keenan, MD, medical director of the Southeastern Fertility Center in Knoxville, Tenn.

"I think the biggest hot topic is single-embryo transfer," Dr. Morales said. "We are certainly working toward decreasing multiple births with the goal of a delivering a single, healthy baby."

When this goal is reached, Dr. Keenan said it would be good news.

"First, I think we should be limiting the number of eggs we are fertilizing," he said. "I don't think we should inseminate 15 or 20 just because a patient is young and has a lot of eggs. We're almost asking for them to be put in an uncomfortable position."

Dr. Keenan's facility has a strict policy on not destroying any leftover embryos when a couple is finished creating a family.

"If they want to work with me, couples need to sign a release saying that if they don't use them, the embryos would be made available for donation to other couples," he said. "If they don't agree, they go elsewhere."

In taking this stand, Dr. Keenan said even poor-quality embryos are used. "Not everyone agrees, but even if an embryo has only a 1% or 2% chance, that's a higher chance than this couple would have if we didn't transfer it," he said.

Dr. Keenan, director of the National Embryo Donation Center, also in Knoxville, thinks that having couples "adopt" and use other couples' embryos is a viable method of getting a handle on the issue of what to do with extra embryos.

The U.S. government has distributed $2 million in grants in the last two years to promote embryo adoption.

Last fall, the National Embryo Donation Center received a $304,000 federal grant to pay for efforts to educated the public about embryo adoption. Just over a year old, NEDC has 200 couples on its waiting list, plus 86 embryos "here or on their way," Dr. Keenan said.

The NEDC has performed eight embryo transfers, and, although it hasn't produced a baby yet, there are two pregnancies.

The Snowflake Embryo Adoption Program in Fullerton, Calif., also has received federal funds to promote embryo adoption. Snowflake Director Lori Maze said its grant of more than $325,000 had been used to produce a series of general videos for clinics and the public about embryo adoption.

The Snowflake program is responsible for 70 babies being born since 1997. At least 15 more are due in 2005, Maze said.

Maze said Snowflake receives its share of "e-mail rantings" that accuse it of encouraging the creation of embryos to populate its program.

"Whether some people like it or not, the embryos are there," she said. "All we're doing is trying to create a solution to a problem that already exists and doesn't look like it's going away in the near future."

New FDA rules

Although one part of the federal government is spending money on promoting embryo adoption, the Food & Drug Administration -- in an effort to provide more protection against the spread of disease -- is set to establish new rules May 25 that could make embryo donation more difficult.

Donors are required to be screened for infectious disease upon donation and again six months later. Dr. Keenan said the new regulations also would require a physical exam along with a complete medical history.

"It's going to stifle the whole embryo-donation movement," he said.

Harvard School of Public Health Professor Andrea Gurmankin, PhD, said creating fewer embryos or donating them to other couples would not do enough to get the number of embryos down to a more manageable level. She is calling for standardization of policies -- not only on embryo storage and disposition -- but for screening practices, informed consent and financial compensation for eggs.

The absence of standardization "can lead to inequities and the potential downward spiral of discrimination," she said. "There's a whole host of issues where there has been a call for debate and standardization."

Dr. Gurmankin's study on embryo disposal practices at 217 IVF clinics published in the journal Politics and the Life Sciences last fall found that what may happen to embryos depends a lot on who is storing them.

For example, of the 175 clinics surveyed that dispose of extra embryos, 166 (95%) said they attempted to contact a couple before disposal, with 110 saying they would not proceed without that contact -- even with prior consent. Also, 136 clinics required permission of both potential parents before disposal.

Dr. Gurmankin's study also turned up some differences among clinics' disposal practices: Four clinics said they required the couple to be present at disposal, 23 gave the option of being present, four gave the embryos to couples to dispose of themselves and seven performed a ceremony that included a prayer.

Dr. Morales said the standardization of policies imposed by outside regulators is unnecessary, as medical groups have been successful in self-regulating fertility treatments.

"Anything that's cutting edge will be politicized to some degree," she said. "I can't imagine a positive outcome from government regulations. [Medical] groups have shown an ability to self-regulate."

ASRM policy states that it is "ethically acceptable" for a clinic to dispose of stored embryos that appear to have been abandoned if there has been no communication with the couple after five years and after "diligent efforts" have been made to contact them. The policy also states that abandoned embryos should not be donated to other couples or for research without prior consent.

Last year, the American College of Obstetricians and Gynecologists' committee on ethics released a report regarding research done on pre-embryos -- cells less than 14 days old. In the report, ACOG called on each IVF program to develop its own policies for transfer, storage, donation, research and disposal of embryos.

The American Medical Association opinion allows for donating extra pre-embryos to other couples or for research but prohibits their sale.

The opinion also calls for deciding in advance what should happen in case of divorce or other "changes in circumstance."

"Predetermination is the best course," said Michael Goldrich, MD, chair of the AMA Council on Ethical and Judicial Affairs. "That predetermination [agreement] should not only address all potential uses for the pre-embryos, it should also address what the policies are for maintaining storage of the pre-embryos."

Back to top


ADDITIONAL INFORMATION

Reproduction through the ages

1677 Human sperm is first viewed under a microscope.

1827 Ovum is discovered.

1873 U.S. Comstock Law designates all contraception devices and information about them as "obscene material."

1914 The term "birth control" is coined.

1934 Progesterone is isolated by Adolf Butenandt, who goes on to win Nobel Prize in chemistry in 1939.

1937 A New England Journal of Medicine editorial proposes the concept of in-vitro fertilization.

1945 British Medical Journal reports on cases of artificial insemination with donor sperm.

1948 Archbishop of Canterbury recommends outlawing artificial insemination.

1960 U.S. FDA approves sale of Enovid, a drug used to treat menstrual disorders, for use as birth control.

1973 First attempts at in-vitro fertilization in the United States. First IVF pregnancy is reported in Australia but does not result in birth of a baby.

1978 First "test tube baby," Louise Brown, is born in Cambridge, England.

1978 Illinois passes law giving doctors legal custody of embryos they create.

1981 The first baby produced by IVF in the United States is born in Virginia.

1982 Sperm Bank of California is founded to make donations available to unmarried women.

1983 First baby is conceived with a donated egg born in Australia.

1984 The first baby developed from a frozen embryo is born in Australia.

1987 Embryo transfer procedure is patented.

1988 New Jersey Supreme Court awards custody of "Baby M" to the child's genetic father and his wife. The woman who served as the surrogate mother and originally refused to surrender the baby is given visitation rights.

1990 AMA Board of Trustees report on frozen pre-embryos is published in JAMA.

1991 A 42-year-old woman serves as the surrogate mother of her own grandchild after becoming pregnant with egg donated by her daughter and sperm donated by her daughter's husband.

1996 American Society for Reproductive Medicine adopts policy on disposition of abandoned embryos.

1997 Snowflakes embryo adoption program started.

1997 First birth from frozen egg in the United States.

1998 First embryonic stem cells isolated.

1998 First instance of pregnancy in which sperm is collected after a man's death.

1999 Natalie Brown, sister of Louise and an IVF baby herself, becomes the first "test tube baby" to give birth to a baby conceived by natural means.

2000 Preimplantation genetic diagnosis is used to select an embryo to create a child who will serve as a bone marrow donor to save a sibling.

2001 President Bush announces policy allowing embryonic stem cell research but limits federal funding to existing stem cell colonies.

2001 New Jersey Supreme Court upholds woman's right to prevent her ex-husband from using their embryos to create a pregnancy with another woman.

2002 Congress allocates $900,000 to promote embryo adoption.

2003 Society for Assisted Reproductive Technology study calculates that there are 400,000 frozen embryos being stored at IVF facilities in the United States.

2005 A 66-year-old Romanian woman gives birth to twin girls. One dies shortly after birth.

Sources: AFP, American Society for Reproductive Medicine, BBC, Bloodlines/PBS, Canadian Broadcast Co., Christian Medical Assn., Fertility & Sterility, Monash IVF

Back to top


External links

AMA Council on Ethical and Judicial Affairs opinion on frozen pre-embryos (E-2.141) (link)

American Society for Reproductive Medicine's policy on the disposition of abandoned embryos (link)

American College of Obstetricians and Gynecologists committee report on preembryo research, 2004, in pdf (link)

"Embryo disposal practices in IVF clinics in the United States," Politics and the Life Sciences, September 2004, in pdf (link)

"Eligibility Determination for Donors of Human Cells, Tissues and Cellular and Tissue-based Products," Food and Drug Administration final rule, March 10, 2004, in pdf (link)

American Society of Reproductive Medicine reaction to Food and Drug Administration's final rule "Eligibility Determination For Donors of Human Cells, Tissues, and Cellular and Tissue-Based Products" (link)

"Cryopreserved embryos in the United States and their availability for research," Fertility and Sterility, May 2003, in pdf (link)

"Preembryo Research," American College of Obstetricians and Gynecologists committee on ethics report, 2004, in pdf (link)

"Trends in Embryo-Transfer Practice and in Outcomes of the Use of Assisted Reproductive Technology in the United States" abstract, New England Journal of Medicine, April 15, 2004 (link)

"The Legend of the 400,000 Embryos," Do No Harm, The Coalition of Americans for Research Ethics press release, June 11, 2004 (link)

Back to top


ADVERTISEMENT

ADVERTISE HERE


Featured
Read story

Confronting bias against obese patients

Medical educators are starting to raise awareness about how weight-related stigma can impair patient-physician communication and the treatment of obesity. Read story


Read story

Goodbye

American Medical News is ceasing publication after 55 years of serving physicians by keeping them informed of their rapidly changing profession. Read story


Read story

Policing medical practice employees after work

Doctors can try to regulate staff actions outside the office, but they must watch what they try to stamp out and how they do it. Read story


Read story

Diabetes prevention: Set on a course for lifestyle change

The YMCA's evidence-based program is helping prediabetic patients eat right, get active and lose weight. Read story


Read story

Medicaid's muddled preventive care picture

The health system reform law promises no-cost coverage of a lengthy list of screenings and other prevention services, but some beneficiaries still might miss out. Read story


Read story

How to get tax breaks for your medical practice

Federal, state and local governments offer doctors incentives because practices are recognized as economic engines. But physicians must know how and where to find them. Read story


Read story

Advance pay ACOs: A down payment on Medicare's future

Accountable care organizations that pay doctors up-front bring practice improvements, but it's unclear yet if program actuaries will see a return on investment. Read story


Read story

Physician liability: Your team, your legal risk

When health care team members drop the ball, it's often doctors who end up in court. How can physicians improve such care and avoid risks? Read story

  • Stay informed
  • Twitter
  • Facebook
  • RSS
  • LinkedIn