Ethics of Reproductive Health: Control and Use of Gametes and Embryos

1
Ethics of Reproductive Health Control and Use of
Gametes and Embryos

• Megha Poddar
• PGY4 Endocrinology
• May 28th, 2014

2
Case

• Having tried unsuccessfully for 18 months to
  become pregnant, Mara (32) and Tony (37) have
  come to Dr. Garcia for in vitro fertilization
  (IVF) using Mara's eggs and Tony's sperm.
  Following the first egg retrieval, eight embryos
  are created. Dr. Garcia decides to transfer one
  and freeze the remaining seven. Before agreeing
  to the transfer, Mara and Tony ask Dr. Garcia
  whether they can have pre-implantation genetic
  diagnosis (PGD) performed on the embryo to
  determine whether it is male or female, since
  they would prefer for their first child to be a
  boy.

http//www.royalcollege.ca/portal/page/portal/rc/
resources/bioethics/cases/section4
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Should Dr. Garcia order PGD to help Mara and Tony
select the sex of their child?

• YES?
• NO?
• WHY?

4
Should Dr. Garcia order PGD to help Mara and Tony
select the sex of their child?

• Canada's Assisted Human Reproduction Act of 2004
  prohibits performing any procedure "that would
  identify the sex of an in vitro embryo, except to
  prevent, diagnose or treat a sex-linked disorder
  or disease" (section 51e).
• Under Canadian law, Dr. Garcia may not,
  therefore, order PGD to help Mara and Tony select
  the sex of their child simply because they would
  prefer to have a boy.

5

• Mara does not become pregnant following the first
  embryo transfer. The couple wants to try again,
  but this time they ask Dr. Garcia to transfer
  three embryos instead of only one to increase the
  chances of a pregnancy.
• Should Dr. Garcia transfer more than one embryo
  at one time? If so, is there a limit to how many
  embryos Dr. Garcia should transfer at one time?

6
Should Dr. Garcia transfer more than one embryo
at one time?

• YES?
• NO?
• IS THERE A LIMIT?

7
Whats the Harm?

• Multiple pregnancies can lead to serious
  peripartum and intrapartum risks to both mother
  and fetus
• The Act does not limit the number of embryos that
  may be transferred to a woman at one time
• Committees of the Society of Obstetricians and
  Gynaecologists of Canada Guidelines (2006)
• women under 35 years of age, no more than two
  cleavage-stage embryos (embryos at two or three
  days development) should be transferred at one
  time
• physicians should consider transferring only one
  embryo if the woman has an excellent prognosis
• increasing the number of embryos that may be
  transferred as the chances of success are deemed
  to decrease (various prognostic factors outlined
  in guidelines)
• balance the desire to maximize the chances of a
  pregnancy with the desire not to subject the
  mother or any eventual babies to additional risk
  of harm.

8

• Using donor sperm, Dr. Garcia is able to create
  10 embryos, of which she transfers two and
  freezes eight. Mara becomes pregnant with a baby
  girl, who is born healthy.
• Long term dilemmas
• Does Mara have to tell her daughter that she was
  conceived with a donor sperm?
• Can Maras daughter obtain information about the
  sperm donor?
• Maras daughter is getting married and her fiance
  was also conceived with a donor gamete What
  ethical implications arise in this case?

9

• Does Mara have to tell her daughter that she was
  conceived with a donor sperm?
• There is no law requiring that children are told
  they were conceived using donor gametes
• The Act requires Dr. Garcia she share information
  with the Assisted Human Reproduction Agency of
  Canada, which will maintain it in a registry but
  not directly with Maras daughter
• Can Maras daughter obtain information about the
  sperm donor?
• The Agency will disclose all information except
  identifying information to her upon her request.
  Identifying information about the sperm donor
  will only be disclosed with his written consent
  (section 182).
• Maras daughter is getting married and her fiance
  was also conceived with a donor gamete What
  ethical implications arise in this case?
• She can ask the Agency whether she is genetically
  related to another specific person who was
  conceived through sperm donation, and the Agency
  will disclose any information it has as to their
  genetic relatedness (section 184).
• They may have access to the identity of their
  sperm donor if he agrees to disclosure of his
  identity.

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Disposal of Embryos

• Options
• Local stem cell research effort
• Embryo donation program
• Unwanted embryos can be used for education and
  training
• Thaw embryos and return back to the patients
• Incineration in a laboratory
• The Canadian Institutes of Health Research
  guidelines state that "embryos no longer wanted
  for reproductive purposes may be donated to
  another couple, used for research (including
  research to derive and study human embryonic
  stem cells), or discarded" (CIHR Guidelines,
  guideline 8.3.1).
• The guidelines do not, however, require that
  patients are offered all three options

11
What happens if the couple divorce/separate?

• Who owns the embryos?
• Does Mara need Tonys permission to re-implant
  the remaining embryos?

12

• The Assisted Human Reproduction Act states if the
  embryos were created using only the genetic
  material of one member of the former couple, the
  member whose genetic material was used has sole
  control over the use made of these embryos
• Mara does not need Tony's consent to use the
  remaining frozen embryos (Section 8 Consent)
  Regulations, section 3(h))
• However, if Tony had provided the sperm for the
  embryos, his consent would have been required
  even if he and Mara subsequently divorced, and he
  would have the legal right to withdraw his
  consent, thus preventing her from using the
  embryos.

13
Case UK woman had created embryos with her
partner using his sperm and her eggs before she
underwent chemotherapy that left her sterile.
Following their separation, the woman argued that
her ex-partner's withdrawal of consent to her use
of their frozen embryos deprived her of the
ability to have a genetically related child and
amounted to a breach of her human rights.
However, courts in the UK and in Europe found
that her ex-partner's withdrawal of consent
overrode her interest in having a child to whom
she is genetically related.
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• END