Ethics of Reproductive Health: Control and Use of Gametes and Embryos Megha Poddar PGY4 Endocrinology May 28th, 2014

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

Should Dr. Garcia order PGD to help Mara and Tony select the sex of their child? YES? NO? WHY?

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 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.

Mara does not become pregnant following the first embryo transfer 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?

Should Dr. Garcia transfer more than one embryo at one time? YES? NO? IS THERE A LIMIT?

What’s 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.

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 Mara’s daughter obtain information about the sperm donor? Mara’s daughter is getting married and her fiance was also conceived with a donor gamete – What ethical implications arise in this case?

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 Mara’s daughter Can Mara’s 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 18[2]). Mara’s 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 18[4]). They may have access to the identity of their sperm donor if he agrees to disclosure of his identity.

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

What happens if the couple divorce/separate? Who owns the embryos? Does Mara need Tony’s permission to re-implant the remaining embryos?

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.

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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