Decisional conflict and the disposition of frozen embryos: implications for informed consent

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A.D. Lyerly1,2,*, S. Nakagawa3 and M. Kuppermann3

1Department of Social Medicine, University of North Carolina, Chapel Hill, NC, USA

2Center for Bioethics, University of North Carolina, Chapel Hill, NC, USA

3Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA, USA *Correspondence address. University of North Carolina at Chapel Hill, School of Medicine, CB#7240, 333 South Columbia Street, MacNider Hall, Chapel Hill, NC 27599-7240, USA. Tel: +1-919-962-6735; Fax: +1-919-962-2154; E-mail: alyerly{at}email.unc.eduReceived September 17, 2010. Revision received November 1, 2010. Accepted November 29, 2010. BACKGROUND Fertility patients often struggle with decisions about disposition of embryos remaining after fertility treatment. We aimed to identify predictors and correlates of decisional conflict among patients facing these decisions.

METHODS We analyzed results from a survey of 2210 patients from nine geographically diverse US fertility clinics. The main outcome measure was decisional conflict about embryo disposition, as measured by the decisional conflict scale (DCS).

RESULTS Of 1244 respondents who returned the survey, 1005 with cryopreserved embryos and DCS scores were included in the analysis. Of the respondents, 39% reported high decisional conflict (DCS = 37.5). Thoughts about future childbearing were associated with high decisional conflict: respondents who were either uncertain about whether to have a baby in the future or sure they did not want to have a baby were at higher odds of high decisional conflict than participants who desired a baby [adjusted odds ratio (aOR) = 3.93, P < 0.001 and aOR = 1.69, P = 0.04, respectively]. Also associated with high decisional conflict were being likely to have embryos thawed and discarded (aOR = 2.08, P < 0.001), donated for research (aOR = 1.66, P = 0.01) or frozen ‘forever’ (aOR = 1.90, P = 0.01); being likely to choose compassionate transfer if it were available (aOR = 1.65, P = 0.03); attributing high, but not full, moral status to human embryos; not having enough information; and not being satisfied with the informed consent process.

CONCLUSIONS Decisional conflict about frozen embryo disposition differs according to reproductive preferences that may vary according to stage of treatment. Informed consent for embryo disposition should be revisited periodically, with serious discussions about disposition after childbearing is complete.

© The Author 2011. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com This ArticleHum. Reprod. (2011) 26 (3): 646-654. doi: 10.1093/humrep/deq368 First published online: January 7, 2011

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Cellular and genetic analysis of oocytes and embryos in a human case of spontaneous oocyte activation

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Catherine M.H. Combelles1,*, William G. Kearns2, Janis H. Fox3 and Catherine Racowsky3

1Biology Department, Middlebury College, Middlebury, VT 05753, USA

2Shady Grove Center for Preimplantation Genetics, Department of Gynecology and Obstetrics, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA

3Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA *Correspondence address. E-mail: ccombell{at}middlebury.eduReceived October 4, 2010. Revision received November 18, 2010. Accepted November 25, 2010. Unusual and consistent defects in infertility patients merit attention as these may indicate an underlying genetic abnormality, in turn necessitating tailored management strategies. We describe a case of repeated early pregnancy loss from in vivo conceptions, followed by cancelled embryo transfers after one IVF and one ICSI/PGD cycle. Following the unexpected presence of cleaved embryos at the fertilization check in the first IVF attempt, oocytes and embryos were subsequently analyzed in an ICSI/PGD case. Part of the oocyte cohort was fixed at retrieval for a cellular evaluation of microtubules, microfilaments and chromatin. The remaining oocytes were injected with sperm, and resultant embryos were biopsied for genetic analysis by fluorescence in situ hybridization (FISH), single-nucleotide polymorphism (SNP) microarray for 23 chromosome pairs, as well as with PCR for sex chromosomes. The presence of interphase microtubule networks and pronuclear structures indicated that oocytes were spontaneously activated by the time of retrieval. FISH revealed aneuploidy in all seven blastomeres analyzed, with all but two lacking Y chromosomes. Microarray SNP analysis showed an exclusively maternal origin of all blastomeres analyzed, which was further confirmed by PCR. From our multi-faceted analyses, we conclude that spontaneous activation, or parthenogenesis, was probably the pathology underlying our patient's recurrent inability to maintain a normal pregnancy. Such analyses may prove beneficial not only in diagnosing case-specific aberrations for other patients with similar or related failures, but also for furthering our general understanding of oocyte activation.

© The Author 2011. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com This ArticleHum. Reprod. (2011) 26 (3): 545-552. doi: 10.1093/humrep/deq363 First published online: January 11, 2011

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To continue or discontinue storage of cryopreserved embryos? Patients' decisions in view of their child wish

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V. Provoost1,*, G. Pennings1, P. De Sutter2, J. Gerris2, A. Van de Velde2 and M. Dhont2

1Bioethics Institute Ghent, Ghent University, Blandijnberg 2, B-9000 Ghent, Belgium

2Department of Reproductive Medicine, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium *Correspondence address. E-mail: veerle.provoost{at}ugent.beReceived August 19, 2010. Revision received November 23, 2010. Accepted December 3, 2010. OBJECTIVE Cryopreservation of supernumerary embryos resulting from IVF treatment offers extra chances to conceive. The objective of this study is to describe patients’ decisions to continue or discontinue storage of their embryos after a minimum storage period of 2 years.

METHODS Female patients who had embryos stored at the Infertility Centre of the Ghent University Hospital (Belgium) were sent a mail questionnaire to be completed anonymously.

RESULTS The questionnaire had a response rate of 79% (326/412). After an embryo storage period of at least 2 years, 40% of the couples who were still together wished to continue storage of their embryos. Half of these had no concrete plans for a transfer and wanted to postpone the decision or keep all options open. For those who decided to discontinue storage (60%), the main reason was the completion of their families. Despite the fact that the patients’ child wish was the main factor in their storage decision, two groups of patients with distinct profiles made decisions that were inconsistent with their child wish: those who wanted to continue storage while not wanting a(nother) child (7% of those with no child wish), and those who wanted a(nother) child but decided to discontinue storage (25% of those with a child wish). Overall, these patients more often expressed emotional difficulties regarding this decision.

CONCLUSIONS This study demonstrates the importance of gaining more insight into patients’ embryo storage decisions (along with their embryo disposition decisions) and into the emotional factors playing a role in patients’ decision-making.

© The Author 2011. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com This ArticleHum. Reprod. (2011) 26 (4): 861-872. doi: 10.1093/humrep/deq392 First published online: January 18, 2011

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Treating women under 36 years old without top-quality embryos on day 2: a prospective study comparing double embryo transfer with single blastocyst transfer

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F. Guerif1,2,3,4,*, C. Frapsauce1,2,3,4, C. Chavez1, V. Cadoret1,2,3,4 and D. Royere1,2,3,4

1Service de Médecine et Biologie de la Reproduction, CHRU de Tours, F-37044 Tours, France

2Université François Rabelais de Tours, F-37041 Tours, France

3INRA, UMR85 PRC, F-37380 Nouzilly, France

4CNRS, UMR6175 PRC, F-37380 Nouzilly, France *Correspondence address. Service de Medecine et Biologie de la Reproduction, 2 boulevard Tonnelle, 37000 Tours, France. E-mail: guerif{at}med.univ-tours.frReceived November 17, 2010. Revision received January 4, 2011. Accepted January 11, 2011. BACKGROUND Embryologists currently face a challenge when counselling patients regarding the stage and the number of embryos to transfer when no top-quality embryos (TQE) are available.

METHODS The aim of this study was to evaluate the efficacy of single blastocyst transfer (SBT) in comparison with the transfer of two cleavage-stage embryos in women under 36 years old. A total of 450 women under 36 years undergoing their first or second IVF treatment who had no TQE on Day 2 were included in this prospective study. Couples were assigned to either a SBT or a double cleavage-stage embryo transfer (DET). The clinical end-points monitored were rates of implantation, delivery and multiple deliveries.

RESULTS The rate of transfer was significantly lower for couples assigned to the SBT group compared with the DET group (88 versus 100%, respectively, P < 0.001) while the delivery rate per oocyte retrieval was similar in both groups (26.7%). By contrast, the rate of multiple deliveries was significantly lower in the SBT group compared with the DET group (3.3 versus 23.3%, respectively, P < 0.01). Blastocyst cryopreservation was twice as high in the SBT group compared with the DET group (39 versus 18%, respectively, P < 0.001).

CONCLUSIONS These findings show the value of extended embryo culture for couples without TQE. In such situations, delaying embryo transfer in order to select a single blastocyst with the highest potential for implantation can reduce the number of multiple pregnancies. Furthermore, our results demonstrate that extended culture allows blastocyst cryopreservation from embryos not available for Day 2 cryopreservation.

© The Author 2011. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com This ArticleHum. Reprod. (2011) 26 (4): 775-781. doi: 10.1093/humrep/der020 First published online: February 9, 2011

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