Disposition of cryopreserved embryos
Inna Berin, MD
Embryo cryopreservation has 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. 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 led to legislative limits of storage from 2-5 years in various European countries. A Danish study concluded that the majority of patients (59%) believed that the legislative limit of 2 years was 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, and simply maintaining embryos in their cryopreserved state. In one Italian study, it was demonstrated that a quarter of the couples choose this route.
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.
The reasons for abandoning surplus cryopreserved embryos have been investigated in numerous studies, and primarily involve those patients who had a successful delivery after a prior cycle. One Danish study showed that only a minority of patients who did not conceive chose to abandon their cryopreserved embryos (7%), citing the reason as not wishing to pursue further treatment. 2 Among those who conceived, some of the reasons given for their indecision included the following: patients considered their family completed; patients did not wish further treatment because of complications with the pregnancy or morbidity with child and/or themselves; patients believed legislative limit for cryopreservation too short to make a decision; patients were unaware of treatment options with thawed embryos; and other miscellaneous reasons (divorce, etc).
Lyerly et al explored factors that affect patients’ decision about disposition of their frozen embryos. 4 When one considers the complexities of some of these issues, it becomes clear why such a large number of patients choose “indecision” as their decision. Seven general themes were identified. Family and personal issues were the most prevalent, with the most important decision being whether the couple wanted to have more children. Some felt that by having cryopreserved embryos they were pressured to continue thinking about child-bearing beyond what they considered to be “normal” reproductive years. For some, other personal or financial aspects were important. Another theme was that of trust – patients remarked that it was important for them to trust the physicians and/or researches not to mix up embryos, or mistakenly allow development of an embryo donated to research into an individual. Many couples were at cross-roads because of the way they viewed the embryo (a living entity) or because of protective responsibility to the embryo (in case of embryo adoption). Others viewed their decision- making in terms of a global responsibility to society, and thus looked to research as a way to benefit the humankind. Surprisingly, many patients reported either a lack of adequate information ortoo much information at the time of having to make the decision or in follow up storage period. Finally, some patients avoided making a decision because of lack of acceptable options. Some patients expressed 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.
Reasons behind decisions of couples regarding utilization of their embryos were looked at by Hammarberg et al in a survey to 123 couples.5 Out of those who chose to dispose, fifty percent reported not wanting to donate because a resulting child would be a full sibling to their own child, and 43% as being against research on embryos. Out of those who donated to research, half wanted to help advance science, and others did not want to waste the embryos. Finally, all of those who chose to donate to another couple wanted to help them conceive, and most wanted to give the embryos a chance at life. One other notable finding of this study was that almost half of the sample found it quite difficult or even very distressing to make a decision about the fate of their embryos, and were frequently discordant between the male and the female partner.
An additional layer of complexity exists when the embryos in question are conceived with the help of donor gametes. Looking specifically at couples with embryos derived from donor oocytes, Nachtigall et al noted that 72% of couples had not come to a disposition decision at the time of the interview. 6 The disposition decision process allowed for four temporal stages – reassurance of being able to conceive in the future if the fresh cycle was unsuccessful , avoidance of thinking about the frozen embryos once their childbearing was completed, confrontation with disposition decision causing discomfort and uncertainty, and resolution with profound sense of completeness once the couple came to an agreement. The difficulty with the disposition decision was partly due to couples’ conceptualization of their embryos, which ranged from viewing them as biological material to living entities with capacity to experience discomfort.
Researchers at our institution also looked at the issue of disposition decisions in couples faced with this situation in more than 1 IVF cycle (unpublished data). Preliminary results from our center indicate that approximately 55% of couples changed their disposition wishes, mostly addressing the disposition in case of demise of one of the partners. When research option became available, more than half of couples changed their decision in favor of donating to research.
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. Adequate counseling at the time of freezing, as well as in follow up, is essential 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.
REFERENCES: Hoffman DI, Zellman GL, Fair CC, Mayer JF, Zeitz JG, Gibbons WE, Turner TG Jr. Cryopreserved embryos in the United States and their availability for research. Fertil Steril. 2003 May;79(5):1063-9 Bangsbøll S, Pinborg A, Yding Andersen C, Nyboe Andersen A. Patients' attitudes towards donation of surplus cryopreserved embryos for treatment or research. Hum Reprod. 2004 Oct;19(10):2415-9. Cattoli M, Borini A, Bonu MA. Fate of stored embryos: our 10 years experience. Eur J Obstet Gynecol Reprod Biol. 2004 Jul 1;115 Suppl 1:S16-8 Lyerly AD, Steinhauser K, Namey E, Tulsky JA, Cook-Deegan R, Sugarman J, Walmer D, Faden R, Wallach E. Factors that affect infertility patients' decisions about disposition of frozen embryos. Fertil Steril. 2006 Jun;85(6):1623-30. Hammarberg K, Tinney L. Deciding the fate of supernumerary frozen embryos: a survey of couples' decisions and the factors influencing their choice. Fertil Steril. 2006 Jul;86(1):86-91. Nachtigall RD, Becker G, Friese C, Butler A, MacDougall K. Parents' conceptualization of their frozen embryos complicates the disposition decision. Fertil Steril. 2005 Aug;84(2):431-4.