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ASRM issues guidance on gamete donation
Providers should consider potential consequences
A woman seeking help conceiving through assisted reproduction inquires about the possibility of using her sister as an egg donor because previous attempts using her own have failed. Would your program allow it?
Another patient wants to use donor eggs from her adult daughter to conceive a child with her second husband, the potential donor’s stepfather. Would your program allow this? Why or why not?
Assisted reproduction technologies (ART) present the possibility of family relationships that would never before have been possible. A woman could gestate the genetic child of her daughter or her sister.
It also may allow the formation of genetic relationships that are socially or physiological unacceptable, such as a man providing donor sperm for an in vitro procedure for his sister and her husband, or a father for his daughter.
It may be surprising to some, but such requests are not unheard of in ART circles, says Lori A. Marshall, MD, fertility specialist with the Center for Fertility and Reproductive Endocrinology at Virginia Mason Medical Center in Seattle, and author of a recent ethics committee report from the American Society of Reproductive Medicine (ASRM).1
"Sometimes, it comes up as a serious request — certainly sister-to-sister egg donation is a pretty common request — but some of the other requests are uncommon, but do happen," she says. "My feeling is that much of the time, it is exploratory — My brother said he would give me sperm for my egg donor procedure’ — but they haven’t thought it through."
The ethics committee developed its report to help providers decide what requests are appropriate and inappropriate, she says.
The document evaluates the different ethical and physiological issues raised by different types of intergenerational and intragenerational gamete donation and surrogacy arrangements.
For example, it examines potential brother-to-sister sperm donation (never considered acceptable), a traditional surrogacy arrangement for a mother by her daughter (acceptable only if issues of potential coercion and undue pressure are addressed); and sister-to-sister ovum donation (generally accepted).
Not all of the situations addressed are known to have occurred — or even to have been proposed — Marshall notes, but they are important to address in a methodical and reasoned way, she says.
Marshall first became interested in the issue after a woman seeking treatment at her facility asked to use donor eggs from her daughter, who lived with the patient and her new husband.
"Without giving it too much thought, the team said, No way,’" she relates.
However, several months later, other team members decided to accept the request of another woman to use donor eggs from her niece.
"I said, Wait a minute, why did we say yes to one and no to the other?’" Marshall says. "In all fairness, it really was the specific circumstances of the case — the mother was an extremely manipulative individual and the daughter lived in the same home at the time. Those things raised so many red flags that no one would even consider involving themselves. With the other situation, the woman had the respect of the team, the niece did not live nearby, and it was a situation where the niece was a medical student and volunteered to donate rather than being asked."
However, their reasons were not well articulated prior to both decisions, so Marshall felt it was important to independently evaluate the different ethical issues involved in order to ensure that such decisions are made fairly and not based on a transient feeling or emotion.
"The whole point of the paper is to encourage providers to step back a minute, spend some time on this, and think about the issues," she says.
First, the committee recommends that clinics not allow any procedure that would involve the combination of consanguinous gametes (those from first-degree relatives), such as brother to sister, woman to sister-in-law, father to daughter, daughter to father, etc.
Such procedures obviously would produce a child that would be genetically the same as a child conceived through an incestuous relationship.
For clarification, Marshall notes that "incest" is defined as a sexual relationship between two closely related persons, but consanguinity refers to marriage and/or reproduction between close relatives.
Providers also should be cautious, however, about procedures that would not actually involve mixing of consanguinous genes but still might give the appearance of incest.
As an example, Marshall cites the well-publicized case of a French woman and her brother who traveled to the United States to undergo ART. "The woman was about 50 or so, and they posed as husband and wife, and she had egg donation and used his sperm," she recalls. "There ended up being a huge outcry when they returned home that this was awful, that it was incestuous, etc. In truth, it wasn’t, because there was no sexual relationship and no combination of consanguinous gametes."
The team at her facility probably would have had the biggest problem with the couple’s deception, but might have been willing to agree to the procedure provided they were comfortable that the couple were prepared for the consequences of their decision, Marshall notes. "In a sense, gestational surrogacy (in which the woman carrying the pregnancy is not genetically related to the child) presents the least problems, but they may give the appearance of incest. Certainly, when a woman is pregnant, that appearance is very public and not something that is confined to family and friends."
Donors or surrogates who are related to the prospective parents also are vulnerable to coercion, and these issues should be investigated before any procedures are initiated, she adds.
A woman agreeing to donate eggs to her mother, with whom she lives and is financially dependent upon, may not feel able to refuse a request and may have difficulty weighing the risks and benefits involved in the process.
The life partners of potential donors or surrogates also should be questioned to determine whether they understand the consequences of the procedure and whether they are supportive of the process, she adds.
In one survey of sperm donors that included family donors, 25% of the respondents said the donation process led to a deterioration of the relationship between the infertile couple and the donor; and, the deterioration was always related to the attitude of the donor’s partner, who had not been involved in the decision to donate sperm.
"We cite that study to highlight the need to counsel and involve as many people as possible in these relationships, so they can assess how they feel about the donation or the surrogacy relationships and make absolutely sure they buy into it, and you don’t just look at the donor or surrogate as an isolated individual," Marshall says.
It’s important that ART providers have policies in place that ensure that decisions about familial donation and surrogacy are handled fairly and consistently and are not made in an arbitrary fashion, she continues.
The ethics committee report is designed to give them a framework for evaluating all of the issues involved in different situations. Specific policies should reflect the mores and ethics of the providers at that program.
"You should be able to look through the cases that have come through your facility and feel that you have been fair to all the individuals who presented to you for care," she said.
The committee also wants to emphasize to providers that they have a responsibility to their patients beyond just providing a safe, effective ART procedure.
Patients who ask to use family members as surrogates and donors, as well as the potential surrogates and donors and any other family members, should undergo counseling and education to explore the possible ramifications the proposed procedure would have.
"The other point we tried to make in the paper is that if you don’t have the ability to investigate these relationships further, then you should not involve yourself in these relationships," Marshall says. "If you are saying, You know, I really cannot tell whether this daughter is being coerced or not and I don’t have the ability or resources to investigate this further,’ then you should not do the procedure."
1. American Society of Reproductive Medicine. Ethics committee report: Family members as gamete donors and surrogates. Fertil Steril 2003; 80:1,124-1,130.