ESHRE Task Force on Ethics and Law 11: Posthumous assisted reproduction

This article analyses the different ethical aspects of posthumous assisted reproduction. Two situations are distinguished: cases in which the gametes or embryos are used by the surviving partner and cases in which the gametes or embryos are made available for third persons. The moral evaluation of the procedure depends on whether the act is restricted to the existing parental project. A major difficulty for the moral evaluation is the inconclusiveness of the empirical data on the psychosocial development of children born after this procedure. The Task Force concluded that posthumous reproduction by a partner is acceptable if the following conditions are met: written consent has been given by the deceased person, the partner received extensive counselling and a minimum waiting period of 1 year is imposed before a treatment can be started. For use by third parties, the usual conditions for gamete and embryo donation apply.     

ESHRE Task Force on Ethics and Law 13: the welfare of the child in medically assisted reproduction

The analysis of the welfare of the child in the context of medically assisted reproduction is divided in two parts: the first part addresses the risks associated with the would-be parent(s), the second part focuses on possible risks inherent in the technologies and treatments themselves. The risk factors connected with the intended parents may be medical and psychosocial. Two important considerations are raised here: the necessity to avoid discrimination and respect for the privacy of the patients. The second part concerns the ethical questions involved in the rapid dissemination of new technologies in assisted conception. Technology and research must always be subordinate to the welfare of the future offspring. The different steps involved in the responsible application of medical technologies to treat infertility are analysed.     

ESHRE Task Force on Ethics and Law 12: oocyte donation for non-reproductive purposes

The present paper focuses on oocyte donation for non-reproductive purposes, i.e. research and future therapy. The general principles of research ethics apply to these interventions. The proportionality principle demands that any possible harms to the oocyte donors should be proportionate to the possible benefits for society. The non-maleficence principle states that every reasonable effort should be made to minimize risks for donors. The position is adopted that, mutatis mutandis, women who donate oocytes for research should be treated similarly to research participants in clinical trials. This implies, among other things, that oocyte donors for research should receive reimbursement for all costs of the procedure and should get compensation for the time lost and inconvenience suffered during the treatment. In order to avoid malpractice and exploitation of poor women, a number of measures are proposed such as a ban on the import of oocytes.     

ESHRE Task Force on Ethics and Law 14: equity of access to assisted reproductive technology

Justice and access are among the most urgent questions for medicallyassisted reproduction. This paper analyses this question notonly for people suffering from infertility, but also for peoplewho need assistance to prevent the birth of a child with a specificgenetic disorder. Based on the impact of not being able to havea child on the quality of life of a person, the position isdefended that infertility treatment should be at least partiallyreimbursed. Simultaneously, the medical professionals have anobligation towards their patients and the health care systemto bring down the costs as far as reasonably possible.     

Surrogacy: the experience of commissioning couples

BACKGROUND: Findings are presented of a study of families with a child created through a surrogacy arrangement. This paper focuses on the commissioning couples' reports of their experiences. METHODS: A total of 42 couples with a 1-year-old child born through surrogacy were assessed using a standardized semi-structured interview. Data were obtained on motivations for surrogacy, details about the surrogate mother, experience of surrogacy during pregnancy and after birth and disclosure of the surrogacy to friends and family. RESULTS: Couples had considered surrogacy only after a long period of infertility or when it was the only option available. Couples retrospectively recalled their levels of anxiety throughout the pregnancy as low, and relationships between the couple and the surrogate mother were found to be generally good. This was the case regardless of whether or not the couple had known the surrogate mother prior to the arrangement. After the birth of the child, positive relations continued with the large majority of couples maintaining some level of contact with the surrogate mother. All couples had told family and friends about the surrogacy and were planning to tell the child. CONCLUSIONS: Commissioning couples generally perceived the surrogacy arrangement as a positive experience.     

When genes determine motherhood: problems in gestational surrogacy.

Gestational surrogacy in which a commissioning couple's egg and spermatozoon are united in vitro and the resulting embryo is implanted in a woman's uterus is, of all the new methods for overcoming infertility, the most genetically appealing. This is because the genes are often perceived as determining all aspects of human health, disease and even behaviour. Having a child with the genes of both parents has become far more attractive to most infertile couples than having one who is only genetically related to the father. However, gestational surrogacy has created a situation where one child has two mothers, each one claiming to be the 'true' mother having exclusive parental rights. Surrogacy arrangements also raise the question of the meaning of motherhood.     

Gestational surrogacy: a feasible option for patients with Rokitansky syndrome

Rokitansky syndrome is a developmental defect characterized by agenesis of the uterus and vagina but normal gonads and secondary sexual characters. It is not commonly transmitted as a dominant genetic trait. Surrogacy, which is legally and ethically accepted in the UK and other countries, has made it possible for the patients with this syndrome to have their own genetic children. Six patients with Rokitansky syndrome underwent 11 ovarian stimulation cycles that resulted in 11 fresh and three frozen embryo transfer procedures into six prospective surrogate mothers. Both commissioning and surrogate couples were properly screened and counselled and their treatment was approved by the clinic internal review committee (ethics committee). The treatment cycles resulted in six clinical pregnancies (42.9% pregnancy rate per embryo transfer and 54.5% per oocyte retrieval) and three live births (21. 4% per embryo transfer, 27.3% per retrieval and 50% per patient). Gestational surrogacy is a viable treatment for patients with Rokitansky syndrome. Such patients should be well informed and supported to be able to have a family using their own genetic gametes.     

Non-genetic surrogacy: no cure but problems for infertility?

Non-genetic surrogacy characterizes a situation where the gestational mother is not the genetic mother. It further widens a circle that started with the introduction of in-vitro fertilization (IVF) and creates problems in defining motherhood and identifying at birth the mother who will have the rights and responsibilities of rearing the child.     

Organizational selection and assessment of women entering a surrogacy agreement in the UK.

In the UK, surrogacy procedures are unregulated and not monitored. Information concerning the selection and assessment of intended (the mother commissioning) and surrogate mothers (the mother carrying and delivering the baby) is therefore not generally available (BMA, 1996). It is important to determine what type of assessment is used, and how selection takes place within the organizations dealing with surrogate motherhood arrangements. The present survey enquired about the incidence, selection and assessment procedures of all registered surrogate and commissioning couples, and aimed to find out what advice and support is given. Eight organizations took part in the survey, six were clinics and two agencies dealing with surrogate arrangements. Two voluntary organizations/helplines were also surveyed, but their data are not relevant to the results presented here. An interview and questionnaire approach was used. Psychosocial assessment was minimally addressed by all organizations, and no fixed procedures for assessment and selection were employed. Despite this, few incidences of controversial cases were reported. Confidence in this practice could be increased in the future if both parties embarking on a surrogacy arrangement knew they were properly selected and assessed. A regulatory body could monitor consistent use of professional evidence-based criteria prior to arrangements.     

A relationship between traditionally motivated patterns and gamete donation and surrogacy in urban areas of Greece

BACKGROUND: Although gamete receipt or donation has become an integral part of infertility management, previous research in the field of social attitudes and intention to use medical technologies is limited. The aim of this paper was to investigate people's intentions to receive or donate sperm, oocyte or uterus (surrogacy) and to identify possible motivational patterns explaining this intention. METHODS: Personal interviews were conducted with 365 men and women of reproductive age (18-45 years). Stratified random sampling was performed to select the men and women for interview. The content of the instrument used was derived from in-depth qualitative interviews with physicians experienced in assisted reproductive technologies, as well as from people who had recourse to gamete donation and surrogacy. RESULTS: The results obtained highlighted the following major aspects: (i) approximately 50% of the survey's participants would be prepared to receive/donate sperm and oocyte; (ii) the results from multiple regression analysis suggest that the 'traditional gender roles' pattern is positively associated with 'intention to use gamete donation and surrogacy'. On the contrary, 'confidence in emotional relationship' is negatively associated with 'intention to use gamete donation and surrogacy, and (iii) men are more likely than women to report 'intention to use gamete donation and surrogacy'. CONCLUSION: These data suggest that specific motivational patterns of the population need to be thoroughly analysed and taken into consideration, in order that appropriate counselling be addressed to individuals and couples.     

Using attitudinal indicators to explain the public's intention to have recourse to gamete donation and surrogacy

BACKGROUND: Although the donation and receipt of gametes has become an integral part of infertility management, previous research in the field of social attitudes and intention to use medical technologies is limited. This study aimed to investigate attitudinal indicators and their potential relationship with the public's intention to have recourse to gamete donation and surrogacy. METHODS: A total of 365 individuals of reproductive age (49.3% men and 50.7% women) completed a questionnaire referring to their intention to receive or donate sperm/oocytes and their acceptance of becoming a commissioning couple or surrogate mother, and also to explore their attitudes towards gamete donation and surrogacy. Two attitudinal indicators emerged from the principal component analysis identifying (i). recipients' and donors' choice for anonymity, donors' renunciation of parental obligations and refusal of children's rights to know their biological parents and (ii). favourable attitudes towards legislative and financial measures to be adopted by the Government for the promotion of reproductive technologies. RESULTS: It was found that the indicator of 'Donors Anonymity and Refusal of Children's Rights' (DARCR) and the 'Legislative and Financial Support' (LFS) scale are positively associated with intention to have recourse to Gamete Donation and Surrogacy (GDS) (regression coefficients 0.31 and 1.08 respectively). Moreover, among the other variables used in the analysis only the 'church attendance' variable is negatively related with reported rates of intention to have recourse to GDS (P = 0.029), suggesting that the more religious respondents are less willing to use GDS. CONCLUSION: Social, legislative and financial implications provide a convenient rationale for adopting a favourable intention towards reproductive technologies. The findings of the present research should be given close consideration by policy makers and health education campaigns.     

Risks and complications in assisted reproduction techniques: Report of an ESHRE consensus meeting

Assisted reproduction technique (ART) is an efficacious treatment in subfertile couples. So far little attention has been paid to the safety of ART, i.e. to its adverse events and complications. The consensus meeting on Risks and Complications in ART held in Maastricht in May 2002 focused on four topics: multiple pregnancies, long-term effects of ART on women, effects of ART on offspring, and morbidity/mortality registries.     

The WHO Task Force on Vaccines for Fertility Regulation. Its formation, objectives and research activities

Over the past 18 years, the WHO Task Force on Vaccines for FertilityRegulation has been supporting basic and clinical research onthe development of birth control vaccines directed against thegametes or the preimplantation embryo. These studies have involvedthe use of advanced procedures in peptide chemistry, hybridomatechnology and molecular genetics as well as the evaluationof a number of novel approaches in general vaccinology. As aresult of this inter national, collaborative effort, a prototypeanti-HCG vaccine is now undergoing clinical testing, raisingthe prospect that a totally new family planning method may beavailable before the end of the current decade.     

Infertility: Clinical pregnancy and male subfertility; the ESHRE multicentre trial on the treatment of male subfertility

Ovulation induction alone, and ovulation induction in conjunctionwith one of four assisted procreation methods [intra-uterineinsemination (IUI), intra-peritoneal insemination (IPI), gameteintra-Fallopian transfer (GIFT) or in-vitro fertilization (TVF)]were tested as a treatment for male infertility in a prospectiverandomized trial. The trial when completed had generated dataon 499 cycles from 346 patients. There was overwhelming evidencethat some form of assisted procreation was beneficial, whencompared to the spontaneous natural conception rate, which isgenerally assumed to be between 0.01 and 0.02 for male infertility.There was also firm evidence that IUI, GIFT or FVF (mean percycle pregnancy rate 0.212) were superior to the remaining twotreatments of IPI and ovulation induction alone (mean per cyclepregnancy rate 0.068). Duration of infertility and a diagnosisof endometriosis were the most important (adverse) pre-treatmentfactors detected.     

Non-genetic and non-gestational parenthood: consequences for parent-child relationships and the psychological well-being of mothers, fathers and children at age 3

BACKGROUND: Findings are presented of the third phase of a longitudinal study of children conceived by assisted reproduction procedures involving surrogacy and/or donor conception. METHODS: At the time of the child's third birthday, 34 surrogacy families, 41 donor insemination families and 41 oocyte donation families were compared with 67 natural conception families on standardized interview and questionnaire measures of the psychological well-being of the parents, mother-child relationships and the psychological well-being of the child. RESULTS: The differences found between family types reflected higher levels of warmth and interaction between mothers and their 3-year-old children in assisted reproduction families than in families with a naturally conceived child. A higher proportion of surrogacy parents than donor conception parents had told their children about the nature of their birth. CONCLUSIONS: It appears that the absence of a genetic and/or gestational link between parents and their child does not have a negative impact on parent-child relationships or the psychological well-being of mothers, fathers or children at age 3.     

The ESHRE multicentre trial on the treatment of unexplained infertility: a preliminary report. European Society of Human Reproduction and Embryology.

Nineteen European fertility centres participated in a controlled randomized trial aimed at comparing the effectiveness of five methods for the treatment of unexplained infertility. Each centre was invited to employ two of the five treatments being investigated, and the treatment allocated to individual patients was then decided by randomization. The treatments were superovulation alone, and superovulation together with one of the following procedures: intra-uterine insemination (IUI), intra-peritoneal insemination (IPI), gamete intra-Fallopian transfer (GIFT), in-vitro fertilization (IVF). All the patients admitted to the study had experienced greater than 36 months infertility prior to the start of the trial, and only patients less than 38 years of age were included in the investigation. Further, the study was confined to patients with normal Fallopian tubes, and where there was evidence of spontaneous ovulation. Yet another prerequisite for inclusion in the study was that the male partner was 'normal' as regards fertility. Due to unavoidable practical difficulties, the experimental design eventually obtained was severely unbalanced. Nevertheless, objective statistical comparisons were possible among the five treatments, using non-orthogonal analyses of variance. By the completion of the trial 444 patients had been treated in a total of 649 cycles. There was some statistical evidence that the pregnancy rate obtained from superovulation alone was inferior to that obtained by using superovulation together with one of the methods of assisted conception.(ABSTRACT TRUNCATED AT 250 WORDS)     

Community/Research Collaborations: Ethics and Funding

Ethical challenges discussed in this innovative Special Issue on community-based participatory research projects suggest that the funders of such projects may misunderstand the unique challenges imposed when a researcher and a community agency collaborate. This commentary conveys information about ways in which a funding agency can more clearly envision these specific challenges and facilitate collaborations through ethical grant mechanisms. Although other articles in the series have discussed the ethical challenges of the researcher, this article discusses the importance of the ethical stance of the funder in protecting both the academic and community stakeholders, so that sustainable, effective, community-based interventions succeed.     

心理咨询师/治疗师与来访者对职业伦理的态度比较

目的:考察我国当前心理咨询或治疗师与来访者在心理咨询与治疗领域职业伦理上的态度和意识,以帮助专业人员更好地理解和解决职业伦理困境,并为制定我国在该领域的职业伦理规范提供参考。方法:采用自编心理咨询与治疗职业伦理意识和态度问卷对48名专业人员(咨询师/治疗师)和48名来访者进行调查,比较两组人群在职业伦理意识和态度上的差异,以及一些重要人口学变量的可能影响。结果:两组人群在自编问卷的12个条目评判上有显著差异,其中涉及咨询关系原则4条(如47.9%的来访者认为专业人员可以和来访者发展私人关系,专业人员持同样看法的为4.2%,P<0.01);保密性原则1条;职业责任原则2条;评估、测量和解释原则2条;督导、培训和教学原则2条,另有一条为询问被调查者是否听闻过有违伦理的行为,发现来访者知晓的违反伦理行为(35.4%)显著少于专业人员(97.9%)(P<0.001);专业人员群体在17个条目上评判一致,仅在涉及咨询关系原则的1条目有争议,即48.3%的专业人员认为在来访者和咨询师价值观冲突时应转介来访者,51.7%的专业人员认为不应转介;来访者群体则在11个条目上评判一致,有4个争议条目,其中涉及咨询关系原则的条目3条(即在咨询师可否和来访者发生私人关系,咨询可否给来访者带来伤害,咨询师可否接受来访者的礼物问题上持肯定或否定意见的来访者都在40%以上);职业责任原则的条目1条,即56.3%的来访者认为咨询师可以按照自己的喜好选择病人,46.7%的来访者则持反对意见。结论:专业人员总体上表现出较强的伦理意识和较为一致的伦理态度,而来访者的伦理态度更不一致,两组人群在保密原则和咨询关系方面的态度差异尤其明显。     

Families working it out: adolescents' views on communicating about donor-assisted conception

BACKGROUND: Prompted by legislation in Victoria, Australia, permitting gamete donors to seek identifying details of people conceived from their gametes, this research investigated the views of adolescents from the general population on how parents can best talk to their donor-conceived adolescent children about their conception. METHODS: Qualitative interviews (six group discussions, n = two to six per group, and one individual interview) lasting c. 50 min with 25 secondary school students. RESULTS: Na?ve adolescents had views largely consistent with those of donor-conceived adults, for example, urging parental honesty, adaptation to individual children, and family cohesion. They identified the social father as the parent while acknowledging the significance of genetic connection to the donor. A minority asserted a preference for non-disclosure; all said that, if disclosed, it should be by parents. CONCLUSIONS: This small study contributes to increasing understanding of communication within families about donor-assisted conception.