Elective oocyte cryopreservation/ fertility ethics Flashcards
Indications for oocyte cryopreservation
Electively
Medical indications:
Prior to oophorotoxic cancer treatment
significant gynaecological pathology threatening fertility (endometrioma, severe endometriosis)
POI
Unexpected failure to find sperm on the day of IVF oocyte retrieval
Coordination with microtese sperm extraction
prior to gender affirming therapy
At the time of IVF due to ethical objections to creating and freezing supernumerary embryos.
Vienna consensus benchmark and competency level for vitrified-warmed oocyte survival
Benchmark: 95-100%
Competency: 85-95%
Pros and cons of elective egg freezing
Pros;
Reproductive autonomy
May reduce involuntary childlessness
Rates of success from vitrified warmed oocytes reported as the same as fresh
Lower aneuploidy risk of oocytes cryopreserved at younger female age particularly <35
~90% will survive warming
Obstetric and neonatal outcomes of children born from vitrified oocytes appears comparable to those born via conventional IVF.
Cons:
Financial cost/burden
Inequitable access
Treatment risk/complications
Only small number return to use oocytes ~9%
Success rates higher from younger eggs but less likely to use eggs if younger
May need multiple cycles to get a reasonable number of eggs
Definition
Strategy to improve a woman’s longitudinal fertility potential with her own oocytes in the absence of a medical diagnosis of infertility or contraindication to pregnancy.
Treatment regimen
Antagonist cycle with planned GnRH agonist trigger.
Ovarian reserve testing should be offered prior to oocyte cryopreservation and counselling provided regarding expected oocyte yield per stim cycle
Fertilisation of warmed oocytes requires ICSI (loss of cumulus cells for freezing means ICSI only option for fertilisation)
Should be counselled that more than one cycle may by needed to obtain their target number of mature oocytes.
Best age to freeze
ANZSREI - <35 years as over 35 achieve poorer pregnancy outcomes from vitrified oocytes related to oocyte quality deterioration with advancing age.
However oocyte utilisation lower at younger ages. Women must be informed that there is a chance that they may not use their oocytes and that cryopreservation does not guarantee future live birth.
Women should be counselled that if they achieve a pregnancy at an advanced maternal age they will be at increased risk of perinatal and obstetric complications:
1. GHTN and PET
2. GDM
3. LSCS
4. SGA/IUGR
4. Breast feeding difficulties
Ethical aspects of oocyte cryopreservation (how to make more ethical)
Safer protocol - PPOS or antag with agonist
Lower cost - PPOS
Non stigmatising terminology
Informed consent
Awareness of low utility rate
Realistic idea about LBR per age and number collected
Continue to collect and publish data
shared decision making
Data from Australia
3 fold increase in use
Low utility rate
LBR per egg thawed quite low
Ethical principles.
Beneficence - obligation of a doctor to act for the benefit of the patient
Non-maleficence - obligation to do no harm
Automony - respect for the patient’s right to self-determination
Justice - fair, equitable, appropriate treatment of persons.
NHMRC ethical principles as they relate above
Beneficence:
Treatment done with interest of child born at forfront
Evidence based treatment
Non-maleficence:
Minimising harm
Transparency and openess
Autonomy:
Reproductive autonomy
Informed consent
Justice:
Equitable and just access
Respect to all involved
Non medical sex selection
Beneficence:
Treatment done with interest of child born at forfront - (FOR) Benefit to child of being wanted.
(AGAINST) Creation of a child should not be done to meet the standards/expectations of the parents
Evidence based treatment
Non-maleficence:
Minimising harm - CBRC reduced (FOR), Unnecessary treatments (risk and cost) (AGAINST)
Transparency and openess
Autonomy:
Reproductive autonomy - allows families self-determination over family size
Informed consent
Justice:
Equitable and just access
Respect to all involved (Sex selection increases gender stereotyping) Open the way to selection of other features (eye colour, hair colour etc)
Not legal in NZ/Aus
Permissible reasons for sex selection:
Not ethical:
1 child families
Maybe ethical:
2 same gender families
Donor egg bank ethical principles to consider
Beneficence:
Interests of person born - donor registry
Collect long term data with audit and review
Non-maleficence:
Minimise harm
Reproductive autonomy - informed consent
Justice:
Equitable access
NHMRC ethical principles
1.ART conducted in a way that shows respect to all involved.
2. Interests and wellbeing of the person born as a result of ART activity must be an important consideration in all decisions about the activity.
3. ART must be undertaken in a way that minimises harm and maximises benefit to the individual or couple undertaking it as well as to the unborn and any other children within the family unit
4. Decision making must recognise the biological connections and social relatiohsips that may be formed as a result of the ART activity.
5. Decision making must respect the autonomy of all relevant parties - supporting the notion of valid consent as fundamental to the use of ART.
6. Recognise that social relationships and social context may affect decision making and be sensitive to cultural and spiritual differences.
7. Processes and policies for determining an individuals or couples eligibility to access services must be just, equitable, transparent and respectful of human dignity and the natural human rights of all persons, including the right to not be unlawfully or unreasonably discriminated against.
8. Underpinned by policies that support effective and efficient practices that minimise interventions not supported by evidence of successful clinical outcomes.
9. Provision of ART must be transparent and open to scrutiny, while ensuring the protection of the privacy of all individuals involved
