Reproductive Services: The Need for Ongoing Evaluation

The rapid expansion of assisted reproductive technologies and related research offers great hope for those experiencing the problem of infertility. Concern has been expressed, however, that practical, legal, and ethical evaluations of new technologies have not kept pace with the introduction of these services into clinical practice. Even common reproductive services, such as gamete donation, need to be examined on an ongoing basis as new research becomes available and as long term implications are revealed. Despite the increasing public familiarity with gamete donation, many issues related to this medical procedure require careful consideration. Canadian public attitudes toward gamete donation will be highligthted as the following areas are explored: the acquisition of donor gametes and embryos; the disclosure or non-disclosure of biological origins and the ’best interest’ of the child; and the potential long term implications for donors and recipients. The dilemmas raised by the relatively routine practice of gamete donation clearly illustrate the need for ongoing examination of the many complexities arising from assisted reproductive technologies, and the need for careful guidelines and accountability in the area of reproductive medicine.     

Welche Änderungen bringt das Samenspenderregistergesetz?

On 1 July 2018, the “Samenspenderregistergesetz” (Sperm Donation Registry Act) came into force. This regulates that from now on all sperm donors will be recorded in a central register when a child is conceived with the help of their semen. The personal data of the donor and the woman who received the sperm donation will be stored for 110 years. Persons who suspect that they have been born from a sperm donation can contact the registration office of the German Institute for Medical Documentation and Information (DIMDI) to clarify their genetic origin. The new sperm registry Act is a first step to improve the incomplete legislation in the field of reproductive medicine. In the future it will be easier for “donor children” to enforce their right to know their own descent. The law is also advantageous for sperm donors, since their legal paternity can no longer be established on the basis of the newly introduced § 1600d IV BGB (German Civil Code) and therefore no maintenance or inheritance obligations can arise. Despite these advantages, the law is also criticized because it will not help all “donor children”. For example, children who were conceived before the law came into force are not entitled to the right to information against the DIMDI.     

Reproduktionsmedizin in Deutschland

The legal basis of reproductive medicine is the Embryo Protection Act (EPA). According to this law, without exception, in vitro fertilization can only be performed to achieve pregnancy in the woman from whom the ovum was harvested. During the course of a single cycle only as many embryos may be developed as will be transferred to the woman up to a maximum of three (“rule of three”). Preimplantation genetic diagnosis and egg donation are prohibited. Safety standards for handling gametes and embryos are governed by the Transplantation Law. The EPA is incomplete. Enactment of a law on reproductive medicine is required which provides comprehensive regulation of the medical technology used for assisted fertilization and the subsequent problems involved. The EPA allows for advancements in scientific knowledge and techniques of reproductive medicine only to a limited extent. The so-called eSET/eDET as practiced in other countries is not permitted due to the“rule of three.” This rule, however, is in fact interpreted partly in opposition to the explicit wording and intended purpose of the regulation and from a legal standpoint is no longer considered definitive. The validity of the rule of three has to be elucidated by the legislature. Preservation of gametes, pronuclei, and embryos as well as the prerequisites for their destruction also need to be regulated, especially when eSET/eDET or comparable procedures of morphological evaluation and selection are applied before transfer since surplus embryos regularly accumulate. A law on reproductive medicine would have to define the modalities for documenting the source of the donated sperm, regulate the child’s right to access information on its biological heritage, and clarify the validity of the rule of three.     

The consequences of S.H. and Others v. Austria for legislation on gamete donation in Europe: an ethical analysis of the European Court of Human Rights judgments

There is a high degree of legal diversity within Europe concerning medically assisted reproduction. This is in direct opposition to the project of harmonization of the European institutions. This paper takes a closer look at the different national interpretations of the European Convention on Human Rights with regard to gamete donation. In the case of S.H. and Others v. Austria, the European Court of Human Rights originally condemned the prohibitions on egg donation and sperm donation for the purpose of IVF. The court judged the law to be incoherent and disproportionate. This decision was recently reversed on appeal based on the margin of appreciation doctrine. This paper critically reviews the judgments of the European Court of Human Rights and analyses what this case means for the future of legislation on medically assisted reproduction in Europe. It is concluded that legal diversity and cross-border reproductive care will persist and that the court failed to protect European patients from arbitrary interference with their right to procreation.     

Reproductive agency and projects: Germans searching for egg donation in Spain and the Czech Republic

German patients in search of IVF with egg donation (which is prohibited by German law) are increasingly deciding to travel to clinics in other countries (mostly to the Czech Republic and Spain) that are able to provide them with the eggs of other women. Through three case studies of German couples who crossed international borders for IVF with egg donation, this article provides insight into these transnational practices aiming to circumvent restrictions in reproduction, whatever they may be. The material for this article is based on ethnographic fieldwork and interviews conducted in Germany, Spain and the Czech Republic, as well as research undertaken on IVF internet bulletin boards. The concepts of 'reproductive agency' and 'reproductive projects' are used to analyse the ways in which people search for information about treatments and clinics in other countries, how they embed the practice into their daily lives and how they deal with and position themselves regarding the need for reproductive travel.     

Third-party reproductive assistance around the Mediterranean: comparing Sunni Egypt, Catholic Italy and multisectarian Lebanon

The article examines religious and legal restrictions on third-party reproductive assistance in three Mediterranean countries: Sunni Egypt, Catholic Italy and multisectarian Lebanon. In Egypt, assisted reproduction treatments are permitted, but third parties are banned, as in the rest of the Sunni Islamic world. Italy became similar to Egypt with a 2004 law ending third-party reproductive assistance. In multisectarian Lebanon, however, the Sunni/Catholic ban on third-party reproductive assistance has been lifted, because of Shia rulings emanating from Iran. Today, third-party reproductive assistance is provided in Lebanon to both Muslims and Christians, unlike in neighbouring Egypt and Italy. Such comparisons point to the need for understanding the complex interactions between law, religion, local moralities and reproductive practices for global bioethics.     

Assisted reproduction on treacherous terrain: the legal hazards of cross-border reproductive travel

The growing phenomenon of cross-border reproductive travel has four significant legal dimensions. First, laws that ban or inhibit access to assisted reproductive procedures in one country lead patients and physicians to travel to other countries to acquire, to contribute to or to provide assisted reproductive services. Such laws may include provisions that criminalize those who assist or advise patients to undertake such travel. Second, the law may expressly criminalize crossing borders to obtain, to be a donor for or to perform certain procedures. Third, the law may interfere with the ultimate goal of reproductive travellers by refusing to recognize them as the parents of the child they have crossed borders to conceive. Finally, facilitating cross-border reproductive travel may expose physicians, attorneys and brokers to malpractice or other civil liability. This article explores these legal dimensions of cross-border reproductive care and uses the legal doctrines of proportionality, extraterritoriality and comity to assess the legality and normative validity of governmental efforts to curb or limit assisted reproductive practices.     

Presidential address at the 20th Journees sur la Fertilite et l'Orthogenie

Recollections of the author's early experiences in French family planning and reflections on the ethical issues and legal status of new fertility technologies are the major topics of this address. The group that was to become le Mouvement francais pour le Planning Familial (MFPF) was founded in 1956 by the author and others and opened its first family planning center in 1961, before contraception became legal. Despite opposition from physicians and Catholic clergy, the MFPF operated 100 centers serving over 100,000 clients by 1965. In 1969 the MFPF began a study of abortion. Despite legalization, the controversy concerning the legitimacy of abortion has not subsided. More recently, the practices of artificial insemination with donor sperm, in vitro fertilization, surrogate mothers, and other medically assisted fertility technologies have raised moral, ethical, and legal questions for all societies. The questions range from the legitimacy of gamete donation to the status of unused embryos. The dissociation of different stages of the reproductive process affects concepts of filiation, paternity and maternity. In the absence of appropriate legislation, it has been left largely to the courts to create a new body of law at this frontier. The review of legislation in France, elsewhere in Europe, and in the U.S. concerning contested filiation in cases of artificial insemination, the legitimacy of insemination of a woman after the death of her spouse, the preservation and donation of embryos, surrogate motherhood, the child's rights to information about his biological parents, and other questions indicate that no consensus has yet emerged concerning the admissibility and legitimacy of specific practices. It would be highly desirable for the European countries to adopt a common legislation in these areas.     

Building Irish families through surrogacy: medical and judicial issues for the advanced reproductive technologies

Surrogacy involves one woman (surrogate mother) carrying a child for another person/s (commissioning person/couple), based on a mutual agreement requiring the child to be handed over to the commissioning person/couple following birth. Reasons for seeking surrogacy include situations where a woman has non-functional or absent reproductive organs, or as a remedy for recurrent pregnancy loss. Additionally, surrogacy may find application in any medical context where pregnancy is contraindicated, or where a couple consisting of two males seek to become parents through oocyte donation. Gestational surrogacy is one of the main issues at the forefront of bioethics and the advanced reproductive technologies, representing an important challenge to medical law. This analysis reviews the history of surrogacy and clinical and legal issues pertaining to this branch of reproductive medicine. Interestingly, the Medical Council of Ireland does not acknowledge surrogacy in its current practice guidelines, nor is there specific legislation addressing surrogacy in Ireland at present. We therefore have developed a contract-based model for surrogacy in which, courts in Ireland may consider when confronted with a surrogacy dispute, and formulated a system to resolve any potential dispute arising from a surrogacy arrangement. While the 2005 report by the Commission on Assisted Human Reproduction (CAHR) is an expert opinion guiding the Oireachtas' development of specific legislation governing assisted human reproduction and surrogacy, our report represents independent scholarship on the contractual elements of surrogacy with particular focus on how Irish courts might decide on surrogacy matters in a modern day Ireland. This joint medico-legal collaborative also reviews the contract for services arrangement between the commissioning person/s and the surrogate, and the extent to which the contract may be enforced.     

Attitudes about donor information differ greatly between IVF couples using their own gametes and those receiving or donating oocytes or sperm

Objective

The objective of the study is to examine attitudes towards aspects of donation treatment based on a national Swedish sample of gamete donors and couples undergoing assisted reproductive techniques (ART).

Methods

The present study was part of the Swedish study on gamete donation, a prospective longitudinal cohort study including all fertility clinics performing gamete donation in Sweden. The sample comprised 164 oocyte donors, 89 sperm donors, 251 people treated with their own gametes (in vitro fertilisation (IVF)), 213 oocyte recipients and 487 sperm recipients. A study-specific questionnaire was used.

Results

Attitudes vary widely between couples using their own gametes for IVF and those receiving or donating oocyte or sperm. The groups differed in their responses to most questions. Oocyte and sperm donors were more likely to agree with the statements “The donor should be informed if the donation results in a child” and “Offspring should receive some information about the donor during mature adolescence” than recipients of donated gametes and couples treated with their own gametes.

Conclusion

Donor recipients, IVF couples and donors expressed different attitudes towards openness and information when it came to gamete donation, and those differences seemed to depend on their current reproductive situation.

     

Embryo donation: a review

BACKGROUND: Embryo donation is currently an uncommon procedure associated with many ethical, legal and psychosocial implications. It is, however, the only answer to infertility in some patients. This article summarizes the indications for embryo donation as well as the procedure and considerations in the preparation of both the donors and the recipients. METHODS: A MEDLINE search was conducted for all English articles using the keywords embryo donation, in vitro fertilization and gamete donation. CONCLUSION: Embryo donation might indeed be the answer to many infertile couples who would otherwise have to resort to childlessness or adoption. The advent of in vitro fertilization and cryopreservation of the spare embryos make these embryos a ready source for potential donors. The success rates of both fresh and freeze-thawed embryo transfers have been encouraging and there do not seem to be any long-term clinical implications for the offspring. However, there remain many legal and psychosocial issues associated with embryo donation.     

Reproduction, genetics and the law

Both reproductive medicine and genetics are seeing rapid, and in some instances revolutionary, medical and scientific advances. Courts have been called upon to resolve a variety of novel disputes arising from these areas, and more can be anticipated as these technologies continue to develop and their use becomes more widespread. This article discusses some of the most relevant areas of the law and litigation that currently bear on reproduction and genetics or that may be anticipated to do so in the future. Specific developments and judicial decisions addressing them include: legal theories of wrongful birth and wrongful life and their application to children born with genetic impairments; a physician's duty to warn family members about a relative's genetic disease; disputes over reproductive materials and non-reproductive cells and tissues; unauthorized genetic testing in the workplace; and genetic discrimination. It is hoped that this discussion will be of value to medical and legal professionals and policy makers who work with these concepts in the increasingly inter-related fields of law and medicine.     

Crossing the line: the legal and ethical problems of foreign surrogacy

UK law has for many years taken a careful approach to surrogacy, neither banning it nor allowing it to develop unrestrictedly. This careful middle approach seeks to balance permitting what may be a last hope for infertile couples against a wider public policy that bars commercialized reproduction: surrogacy is allowed in the UK, provided it is consensual and involves the payment of no more than reasonable expenses. But in an increasingly globalized world, patients are crossing borders for treatment, often to places where such restrictions on the commerciality or enforceability of surrogacy arrangements do not apply. The resulting conflicts of law can be a minefield, and this makes the maintenance of the UK's careful legal balance increasingly untenable.     

Alternative solutions to the current situation of oocyte donation in Singapore

The rising incidence of age-related female infertility in Singapore, coupled with the prohibition on commercialized oocyte donation and egg sharing, has resulted in a severe shortage of donor oocytes. Infertile women are routinely encouraged by fertility doctors here to seek their close relatives and friends as prospective oocyte donors, which does not alleviate the shortage. A number of alternative solutions are discussed. The use of substantial financial remuneration to encourage oocyte donation is rejected as being legally, ethically and morally incompatible with present day Singaporean society. Egg sharing in return for subsidized fertility may have a strong case for ethical justification, but implementation would need amendment of the current legislation in Singapore. Cross- and mirror-exchange oocyte donations face less of a legal challenge in Singapore and also have a strong case for ethical justification. However, special consideration must be given to the unique socio-cultural values of Singaporean society, i.e. traditional Chinese culture. Finally, if no changes are made to restrictive regulations governing oocyte donation in Singapore, and shortage of donor oocytes still persists, then reproductive tourism abroad may be the solution for some patients; referrals by local fertility doctors are unlikely to be allowed in Singapore.     

Human reproductive cloning and related techniques: an overview of the legal environment and practitioner attitudes

Purpose: This study provides an overview of the legal environment and assisted reproductive technology (ART) practitioner attitudes toward human reproductive cloning. Methods: A review of the law and a survey of ART practitioners and a comparison group of attorneys were undertaken. Results: Human reproductive cloning has been prohibited in many countries, and may soon be prohibited in others. However, many ART practitioners support its use for limited indications. Conclusions: ART practitioners were surveyed concerning their views on human reproductive cloning and related techniques. A few had considered using or had used embryo splitting or germ cell nuclear transfer. Although they expressed some concerns about the present risk of reproductive cloning, most indicated that it did not violate their religious beliefs. More than three-quarters of ART practitioners responding indicated that they would be willing to provide human reproductive cloning in indicated cases if it were legally permissible to do so. A significant percentage of the group also indicated that they currently have the ability to provide this service.     

Women on waves: where next for the abortion boat?

Women on Waves was founded to contribute to the prevention of unwanted pregnancy and unsafe abortions throughout the world by direct action. Because national penal laws, including those governing abortion, generally extend only as far as territorial waters (12 miles), Women on Waves made plans to provide reproductive health services on a ship with a mobile clinic, including abortions, outside the territorial waters of countries where abortion is illegal. We went to Ireland first because it was nearby and there was a dedicated pro-choice community with immediate interest in and commitment to the project. Although we encountered problems that meant we could not do abortions, we were contacted by more than 300 women in five days and provided reproductive health information, contraception, workshops and information on where to obtain legal abortions in Europe. In many parts of the world an anti-abortion backlash is taking place. To safeguard our reproductive rights in the face of anti-abortion activities, it is crucial to recapture a pro-active, pro-choice role. Women on Waves helped to make visible the need for legal abortion services in Ireland, and the extensive class and other differences between women able to access abortions abroad and those who could not. We are currently attempting to resolve our status under Dutch law, but until women everywhere have the right to reproductive freedom, we will continue to make waves.     

Judicial review of restrictions on gamete donation in Europe

The decision of S.H. and Others v. Austria vindicates the right of governments to enact restrictions on gamete donation against claims that these restrictions violate the guarantees of the European Convention on Human Rights. Van Hoof and Pennings in this issue predict that legal diversity on the question of gamete donation will persist in the wake of this decision and discuss how the decision itself is insufficiently protective of the private and family interests of individuals who seek reproduction-assisting medical treatment. This commentary discusses the difficult balancing work of the European Court of Human Rights, its questionable expansion of the margin appreciation doctrine in S.H. and Others v. Austria and how the decision might influence national courts in the future.     

Abortion law reform in Nepal

Across four decades of political and social action, Nepal changed from a country strongly enforcing oppressive abortion restrictions, causing many poor women’s long imprisonment and high rates of abortion-related maternal mortality, into a modern democracy with a liberal abortion law. The medical and public health communities supported women’s rights activists in invoking legal principles of equality and non-discrimination as a basis for change. Legislative reform of the criminal ban in 2002 and the adoption of an Interim Constitution recognizing women’s reproductive rights as fundamental rights in 2007 inspired the Supreme Court in 2009 to rule that denial of women’s access to abortion services because of poverty violated their constitutional rights. The government must now provide services under criteria for access without charge, and services must be decentralized to promote equitable access. A strong legal foundation now exists for progress in social justice to broaden abortion access and reduce abortion stigma.     

Can a restrictive law serve a protective purpose? The impact of age-restrictive laws on young people’s access to sexual and reproductive health services

This article explores the purpose, function and impact of legal restrictions imposed on children’s and young people’s involvement in sexual activity and their access to sexual and reproductive health services. Whilst there is no consensus on the age at which it is appropriate or acceptable for children and young people to start having sex, the existence of a minimum legal age for sexual consent is almost universal across national jurisdictions, and many states have imposed legal rules that place restrictions on children’s and young people’s independent access to health services, including sexual health services. The article draws on evidence and analysis from a recent study conducted by the International Planned Parenthood Federation in collaboration with the Coram Children’s Legal Centre, UK, which involved a global mapping of laws in relation to sexual and reproductive rights, and exploratory qualitative research in the UK, El Salvador and Senegal amongst young people and health care providers. The article critically examines the social and cultural basis for these rules, arguing that the legal concept of child protection is often founded on gendered ideas about the appropriate boundaries of childhood knowledge and behaviour. It concludes that laws which restrict children’s access to services may function to place children and young people at risk: denying them the ability to access essential information, advice and treatment.     

Ovum donation: Ethical and legal aspects

The newer technologies of assisted reproduction offer the infertile couple a wide spectrum of choices according to their specific problem. A relatively newer technique is that of ovum donation, whose technology is now well established. However, as with other newer technologies, it has given rise to new dimensions of ethical and legal issues which have to date not been fully appraised. It is very difficult to find a legal consensus under international umbrella to the specific issues involved in ovum donation. This is due to the different cultural, religious, and time influence atmosphere prevailing in the various parts of the world. Each society should develop its own statutes on ovum donation. A frame of ethical guidelines should be established by international organizations that may help each society issue its own regulations.