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4.3.2 Reproductive Health: Control and Use of Gametes and Embryos

Josephine Johnston, LLB, MBHL

Educational Objectives

  1. To understand ethical and legal issues that might arise when patients harvest gametes, receive gametes from donors and create embryos in the course of assisted reproduction.

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.

Question

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

Case Continuation

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.

Question

  1. 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?

Case Continuation

Dr. Garcia thaws three embryos, of which only one survives to the blastocyst stage and is transferred to Mara's uterus. Unfortunately, Mara does not become pregnant. Mara and Tony ask Dr. Garcia to thaw the remaining four embryos, of which two survive to blastocyst stage. Mara and Tony reveal to Dr. Garcia that they are cousins. Since their first transfer, they have learned that some of their family members have albinism. Mara and Tony ask Dr. Garcia to order PGD on the embryos and to transfer only those that do not carry the genes for autosomal recessive oculocutaneous albinism.

Question

  1. Should Dr. Garcia order PGD to test the embryos for the presence of albinism-causing genes?

Case Continuation

Both remaining embryos test positive for the genetic mutation, and Mara and Tony decide to repeat the IVF process using donor sperm. Mara and Tony tell Dr. Garcia that they plan to recruit a sperm donor by advertising in a local university newspaper and offering $1,000 for a sperm sample.

Question

  1. Should Dr. Garcia allow Mara and Tony to use a sperm donor to whom they are paying $1,000?

Case Continuation

Using donor sperm, Dr. Garcia is able to create 10 embryos, of which she transfers two and freezes eight. Mara becomes pregnant with twin girls, who are born healthy. (The case continues in case 4.3.3, "Storage and Disposal of Gametes and Embryos.")

Question

  1. Should Dr. Garcia maintain information about the circumstances of the twins' conception, including the identity of and health information about the sperm donor, in order to provide this information to the twins when they are older?

Discussion

Q1. Should Dr. Garcia order PGD to help Mara and Tony select the sex of their child?

Canadian law on the question of sex selection is clear. Canada's Assisted Human Reproduction Act of 2004 (hereafter "the Act")1 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 5[1][e]). 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.

There are interesting ethical arguments for and against allowing parents to select the sex of embryos, which is permitted in some other countries. Some arguments centre on the idea that parents should be allowed to exercise as much choice as possible when creating a family. Thus, it is argued that sex selection should be permitted because it allows parents to control the gender balance in their family and to create the family they desire. Some of the arguments against sex selection emphasize the link between exercising this kind of control and seeing future children as "products," rather than as individuals to be valued and loved for who they are. Opponents of sex selection also argue that permitting the procedure could result in more males than females in cultures with a son preference.

Q2. 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?

Transferring more than one embryo at a time increases the likelihood of the women becoming pregnant with more than one child (e.g. twins, triplets). Although pregnancy is certainly the goal of IVF, multiple pregnancies, particularly triplets and above, carry serious risks for both the mother and her babies.

The Act does not limit the number of embryos that may be transferred to a woman at one time, although this question could conceivably be addressed in future regulations issued under the Act.

In 2006, Committees of the Society of Obstetricians and Gynaecologists of Canada and the Board of the Canadian Fertility and Andrology Society approved guidelines addressing the number of embryos that should be transferred to a woman at one time. They recommended that for 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, and that physicians should consider transferring only one embryo if the woman has an excellent prognosis (Mara meets the criteria listed in the guidelines for "an excellent prognosis"). The guidelines go on to consider women of various ages with various prognoses, increasing the number of embryos that may be transferred as the chances of success are deemed to decrease. They also include the general recommendation that, when blastocyst-stage embryos are used, fewer embryos should be transferred than when cleavage-stage embryos are used.

Dr. Garcia should carefully consider these guidelines before she and her patients decide how many embryos to transfer at one time. Dr. Garcia and her patients will need to 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. A prudent approach would involve transferring up to the maximum number of embryos recommended by the guidelines (in Mara's case this would be two embryos), with the final decision about whether to transfer less than the maximum number of embryos resting with the patient (i.e., Mara may choose to transfer only one embryo). To facilitate the patient's decision, Dr. Garcia should clearly explain the serious medical risks associated with a multiple pregnancy.

Q3. Should Dr. Garcia order PGD to test the embryos for the presence of albinism-causing genes?

Albinism is not usually life-threatening, although different kinds of albinism are associated with various health issues. This scenario, therefore, raises the question of which conditions are serious enough to warrant genetic screening of embryos before implantation. There is no clear law on this question in Canada, and there are ethical arguments both for and against screening.

Like screening for sex, screening for genetic disorders (and other genetic traits) can be seen as an appropriate exercise of what is sometimes called "procreative liberty." But it can also be considered an inappropriate extension of a patent's interest in controlling her body and the medical treatment she receives. Proponents of such screening see it as a way to prevent suffering, while some critics are concerned that it is based on negative stereotypes of the lives of people with disabilities and will have the effect of devaluing individuals with disabilities.

Before Dr. Garcia orders PGD for this or any other genetic trait, she should consider referring her patients to a genetic counsellor. A genetic counsellor should be able to explain to the patients which genetic conditions can and cannot be detected using PGD. He/she should also be able to help Dr. Garcia's patients learn more about what life with albinism is like, so that they may base their PGD test choices on facts rather than assumptions.

Q4. Should Dr. Garcia allow Mara and Tony to use a sperm donor to whom they are paying $1,000?

The Act prohibits purchasing sperm or eggs from a donor (section 7[1]). It does, however, allow licensed clinics to reimburse donors for their expenses in accordance with regulations that will be issued under the Act (section 12[1][a]). Mara and Tony are not a "licensed clinic" under the Act, and so they may not pay any money to their sperm donor, either for compensation or expenses. As soon as the applicable regulations come into effect, Dr. Garcia's clinic (provided it is licensed under the Act) will be able to reimburse its volunteer sperm and egg donors for their donation-related expenses (for which the donors must supply receipts), but it will not be able to pay any additional costs.

Again, it is legal to pay donors in some other countries and there are interesting ethical arguments on both sides of this issue. Some commentators are concerned about the inherent morality of offering money in exchange for donated eggs or sperm, while others are concerned about the consequences that might flow from paying for the provision of gametes (e.g., individuals who are not emotionally or physically suitable may be encouraged to donate). Others have argued that it is unfair to expect egg and sperm donors to give their time and effort, and in some cases endure discomfort or even pain, for no compensation. Still others are concerned that without compensation (above and beyond expenses) there will be too few egg or sperm donors to meet demand.

As regards the moral appropriateness of paying for gametes, the worry is that doing so "commodifies" the human body and/or human reproduction. That is, offering money in exchange for eggs or sperm treats these substances, the bodies they come from and any children that might result as commodities that may be bought and sold rather than as sacred gifts or as inherently valuable.

Q5. Should Dr. Garcia maintain information about the circumstances of the twins' conception, including the identity of and health information about the sperm donor, in order to provide this information to the twins when they are older?

The Act requires Dr. Garcia to collect "the identity, personal characteristics, genetic information and medical history" of all donors (section 14[1] and section 3). However, she should not share this information with the twins. Instead, the Act requires that she share this information with the Assisted Human Reproduction Agency of Canada (the Agency), which will maintain it in a registry (section 17).

The Agency will disclose all of this information except identifying information to the twins upon their request. Identifying information about the sperm donor will only be disclosed with his written consent (section 18[2]). In addition, either of the twins 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 18[4]). Therefore, provided the twins know that they were conceived using donor sperm (there is no law requiring that children are told), they will be able to access health information about their sperm donor and they will be able to determine whether they are related to another person who was also conceived using donor sperm (e.g., a future husband). They may have access to the identity of their sperm donor if he agrees to disclosure of his identity.

Although there is no law requiring that children be told they were conceived using donor gametes and no guarantee that they will be able to know the identity of their donor, there are ethical arguments favouring openness and honesty. We know from studies of adoption and from the testimony of children (and now adults) conceived using donor gametes that it is very important to some individuals that their patents tell them the truth about their conception, and that they have an opportunity to one day meet those to whom they are genetically related. Other individuals do not attach much significance to genetic relatedness. Given these divergent opinions, it would be prudent for Dr. Garcia to err on the side of caution and encourage her patients to be honest with their children about the use of donated gametes. She may also want to consider establishing open donation programs within her clinic and requiring that patients discuss this issue with a counsellor, psychologist or social worker before using a donor.

References

  1. Department of Justice Canada. Assisted human reproduction act, 2004 (c. 2). Available from: http://laws.justice.gc.ca/en/A-13.4/index.html.

Further Reading and Resources