Archive for the ‘cryopreservation’ Category

Are Disposal Ceremonies or Compassionate Transfers the Answer to the Frozen Embryo Dilemma?

By Dr. Craig R. Sweet
Medical & Practice Director
Founder, Embryo Donation International

In recent years, researchers led by Dr. Anne D. Lyerly of Duke University have conducted several studies about infertility patients’ attitudes toward disposition of excess frozen embryos. Their research has shed some light on the difficulties facing patients about this important decision and patient reaction to the different options clinics offer.

As a quick review, options for excess frozen embryos are:

• Personal reproductive use
• Donation to research
• Donation to patients in need
• Thaw and discard

Timing has a significant impact on patient decision-making. Clearly, the in vitro fertilization (IVF) process can overwhelm patients. First, they’re worried about whether they will create embryos and, then, about how many of them will be high quality. Then after the transfer, they endure the long wait while hoping and dreaming for a positive pregnancy test and an encouraging ultrasound weeks later. The last thought on their mind involves the eventual disposition of excess frozen embryos. It is probably unreasonable to expect patients to make this type of decision, but most fertility clinics ask them to select an option before they even start of the IVF process. Many patients stated that from the start the IVF clinics didn’t do a good job in explaining their choices (Lyerly AD, et al 2008). While this may be true in some instances, clinics may have explained the alternatives well, but patients simply couldn’t absorb all the information. When forced to decide what to do with the cryopreserved embryos before they have successfully delivered a child through IVF and/or have made the decision to stop treatment, many patients will inevitably change their minds.

It would appear that almost half of all the estimated hundreds of thousands of cryopreserved embryos are not used for reproduction. We found this to be true in our own 2006 internal review and others have published similar statistics. As I have written before, the decision regarding what to do with excess cryopreserved embryos is very difficult such that 15% of the patients choose to not decide and keep their embryos frozen indefinitely (Lyerly AD, et al. 2011).

Many patients don’t like any of the existing alternatives for frozen embryos. A disposal ceremony at the time of thaw and/or a compassionate transfer may be better options. A compassionate transfer occurs when the embryos are placed into a women’s uterus or vagina at a time when she can’t conceive. Some patients prefer this process, letting the embryos be absorbed naturally and allowing closure while honoring what has been described as the physical and emotional attachments between them and their embryos (Lyerly AD, et al. 2006 & 2011). One of the rare studies to examine if patients would choose compassionate transfer found that about 20% would consider this alternative (Lyerly AD, et al. 2010). In a separate but associated article written by the same author in 2011, she stated:

“Given the morally difficult nature of the disposition decision, informed consent is unlikely to be the full solution: ensuring options that patients find responsible and respectful, such as compassionate transfer or a disposal ceremony may benefit those who assign high moral status or value to the embryos but are disinclined to donate them to another couple.”

There are, unfortunately, three problems with these two options. The first is that very few facilities offer these disposal techniques (Gurmankin AD et al. 2004). Second, I can’t help but wonder who is receiving the compassion, the patients (probably) or the embryos? Third, no matter how you phrase it, the embryos are still being thawed and discarded.

Let me be clear that the parent organization of Embryo Donation International (EDI), Specialists In Reproductive Medicine & Surgery, P.A. (SRMS), removed the destruction option for excess frozen embryos years ago, believing that better alternatives existed. I feel the embryos deserve an intermediate level of respect and that donating them to research (human embryonic stem cell or other valuable studies) or donating them to patients in need serve a greater good for the embryos and society as a whole. We try to make this as clear as we can to the patients undergoing IVF at SRMS, emphasizing our non-destruct policy in our consent. Interestingly, over the years, not one patient or couple has disagreed with the policy. Our desire is that other facilities consider what we call our “non-destruct” policy.

EDI/SRMS’ views are currently in the minority, with the majority of IVF programs still allowing patients to thaw and discard their embryos (Gurmankin AD et al. 2004). While I would far prefer that patients consider donation to research or patients in need, as a clinician, I have to be aware that my personal and professional views may differ significantly from others.

Perhaps the facilities that continue to offer the thaw and discard option would consider offering alternatives that some patients really want. It would seem a disposal ceremony consistent with the patient’s religious or spiritual beliefs or a compassionate transfer are two options patients prefer but rarely seem to be able find.

I still implore patients with excess cryopreserved embryos to consider embryo donation and to pay it forward to other infertile patients traveling the difficult infertility road without success. From my perspective, the best option is to take a deep breath and make the difficult decisions that will not result in the discarding of their cryopreserved embryos. If, however, a disposal ceremony or compassionate transfer will result in embryos not being abandoned or frozen forever, then perhaps this is a marginally better option to consider. Marginally better, but still in my mind, not the best of the options readily available.

Craig R. Sweet, M.D.
Founder, Embryo Donation International
Reproductive Endocrinologist
Medical & Practice Director

Excellent References:

–  Gurmankin AD, Sisti D. Embryo disposal practices in IVF clinics in the United States. Politics and the Life Sciences. 2004;22(2):4-8.
–  Lyerly AD, et al. Decisional conflict and the disposition of frozen embryos: implications for informed consent. Hum Reprod. 2011 Mar;26(3):646-54.
–  Lyerly AD, et. al. Factors that affect infertility patients’ decisions about disposition of frozen embryos. Fertil Steril 2006;85:1623-30.
–  Lyerly AD, et al. Fertility patients’ views about frozen embryo disposition: results of a multi-institutional US survey. Fertil Steril 2010;93:499-509.

To be discussed in the next blog, please share your opinion.

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By Dr. Craig R. Sweet, Medical Director & Founder

During in vitro fertilization (IVF), numerous eggs are removed from the woman, and fertilized with sperm to create embryos that are grown in the laboratory for several days. Almost always the final number of embryos available for transfer is less than the number of eggs (oocytes) originally retrieved from the woman.

For example:

• 12-14 oocytes retrieved
• 10-12 mature ooctyes (available for fertilization)
• 8-10 oocytes successfully fertilize with sperm
• 3-6 embryos survive and are available for transfer or storage in liquid nitrogen for future use

From the few embryos left on day five of fertilization, we try to transfer the smallest number needed to achieve a pregnancy. Approximately, one-third of the patients will have enough extra embryos to freeze for future use.

These embryos may last for decades frozen in liquid nitrogen (Mazur P, 1980). For many, deciding what to do with the embryos is a very difficult decision. In general, the following options exist:

• Thaw and transfer for personal use
• Donate to science
• — Human embryonic stem cell research
• — Other valuable studies
• Discard
• — Thaw and dispose
• — “Compassionate Transfer” into a uterus at a time when implantation cannot occur
• Donate to patients in need (i.e., embryo donation)

Many, but not all facilities, offer the “discard” option. We believe that better choices exist than destruction and no longer include it in our patient consents. The actual options available to a given patient may be more limited than the list above.

There are many reasons patients do not use the embryos for personal use (Kirkman M, 2003):

• They have completed their family
• Past pregnancy complications
• Age
• Emotional exhaustion
• Cannot afford further treatment
• Divorced

Many find deciding the next steps for their cryopreserved embryos to be exquisitely difficult. I feel that all reproductive facilities could perform far better at counseling patients and assisting them in making these decisions. Patients have complained that we haven’t done an adequate job (Nachtigall RD, et al., 2005). I suspect they are right. I believe it is the responsibility of the cryopreservation or reproductive endocrine facility to educate patients adequately and offer assistance and information when requested. EDI designed a brief brochure to address these very issues.

If one is really uncertain and the personal use of the embryos is still a possibility, then I agree that the embryos should be stored longer, but not indefinitely. If, however, additional family building has been ruled out, then I advise the patient to take a deep breath and make the difficult decision that ultimately must be made.

My patients put so much, emotionally and financially, into the creation of their embryos. Our goal is to support them through the difficult decision, no matter what they decide. I can only hope they will consider either human embryonic stem cell research or embryo donation. I personally believe embryos deserve a heightened level of respect. These two possible destinations serve a common and greater good for everyone involved. While human embryonic stem cell research holds some future promise, the immediacy of growing a family though embryo donation seems to be the best choice for those wonderful and precious gifts, a donors’ embryos.

Craig R. Sweet, M.D.
Founder, Embryo Donation International
Reproductive Endocrinologist
Medical & Laboratory Director

References:

• Kirkman M. Egg and Embryo Donation and the Meaning of Motherhood. Women & Health 2003;38(2):1-18.
• Mazur P. Limits to life at low temperatures and at reduce water contents and water activities. Orig Life 1980:10(2):137-59.
• Nachtigall RD,et al. Parents’ conceptualization of their frozen embryos complicates the disposition decision. Fertil Steril 2005;84:431-4.