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Planned Oocyte Cryopreservation for Women Seeking to Preserve Future Reproductive Potential: an Ethics Committee Opinion

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Planned Oocyte Cryopreservation for Women Seeking to Preserve Future Reproductive Potential: an Ethics Committee Opinion Planned oocyte cryopreservation for women seeking to preserve future reproductive potential: an Ethics Committee opinion Ethics Committee of the American Society for Reproductive Medicine American Society for Reproductive Medicine, Birmingham, Alabama Planned oocyte cryopreservation (‘‘planned OC’’) is an emerging but ethically permissible procedure that may help women avoid future infertility. Because planned OC is new and evolving, it is essential that women who are considering using it be informed about the un- certainties regarding its efficacy and long-term effects. (Fertil SterilÒ 2018;110:1022–8. Ó2018 by American Society for Reproductive Medicine.) Discuss: You can discuss this article with its authors and other readers at https://www.fertstertdialog.com/users/16110-fertility- and-sterility/posts/37565-26808 KEY POINTS informed decision-making. Pro- dotoxic medical treatment, the chance viders should disclose their own to have biologically related children in For women who want to try to pro- clinic-specific statistics, or lack the future. The history of cryopreserva- tect against future infertility due to thereof, for successful freeze-thaw tion of sperm, embryos, and oocytes is reproductive aging or other causes, and for live birth. Patients should set forth in the ASRM Practice Commit- advance oocyte cryopreservation be informed that medical benefits tee document, ‘‘Mature oocyte preser- ‘‘ ’’ ( OC ) is ethically permissible. The are uncertain and harms that are vation: a guideline’’ (1). While the first Ethics Committee will refer to this not fully understood may emerge human birth from a previously frozen ‘‘ procedure as planned oocyte cryo- from planned OC. oocyte occurred in 1986, the more ’’ ‘‘ ’’ preservation or planned OC. To improve scientific understanding recent use of vitrification, an ultrarapid Planned OC serves women's legiti- of planned OC, including efficacy, cooling technique, has led to a marked mate interests in reproductive advisability, and long-term effects, improvement in the efficacy of oocyte autonomy. medical professionals offering this cryopreservation (1). Planned OC is relatively new, and procedure are encouraged to collect OC initially was classified by ASRM fi uncertainties exist regarding its ef - outcome data, conduct research, as experimental. In 2012, the ASRM cacy, appropriate use, and long-term and report planned OC cycles to the Practice Committee removed the exper- effects. Society for Assisted Reproductive imental label after a thorough review of Providers should ensure that women Technology (SART). the scientific literature. The report who request planned OC are concluded that in vitro fertilization fi informed about its ef cacy, safety, (IVF) and pregnancy rates with cryo- fi bene ts, and risks, including the un- BACKGROUND preserved oocytes compared favorably known long-term health effects for Cryopreservation of reproductive tis- to those with fresh oocytes. In addition, offspring. Because of the uncer- sues has created important reproduc- short-term studies of health of tainties that accompany this devel- tive options. It has given individuals offspring from OC revealed no in- oping procedure, there are distinct facing potential loss of reproductive creases in congenital anomalies when obligations regarding disclosure and capacity, such as those receiving gona- compared with other IVF offspring (1). While the ASRM Practice Committee Received August 8, 2018; accepted August 8, 2018. and Ethics Committee approved the Correspondence: Ethics Committee, American Society for Reproductive Medicine, 1209 Montgomery Highway, Birmingham, Alabama 35216 (E-mail: [email protected]). use of OC for patients facing therapies likely to be gonadotoxic (1–3), the Fertility and Sterility® Vol. 110, No. 6, November 2018 0015-0282/$36.00 Practice Committee declined at that Copyright ©2018 American Society for Reproductive Medicine, Published by Elsevier Inc. https://doi.org/10.1016/j.fertnstert.2018.08.027 time to recommend OC ‘‘for the sole 1022 VOL. 110 NO. 6 / NOVEMBER 2018 Fertility and Sterility® purpose of circumventing reproductive aging in healthy than maternal age. The critical difference between the women,’’ on the grounds that there were insufficient data oocyte cryopreservation examined in this Opinion and that on the ‘‘safety, efficacy, ethics, emotional risks, and cost- which is done when gonadotoxic therapy is imminent is its effectiveness’’ for that indication (1). non-emergency nature. It is being undertaken as a matter of Since that time, further research on efficacy has been re- planning before a medical indication has materialized and assuring (4, 5). Increasing numbers of women are seeking will be referred to as ‘‘planned oocyte cryopreservation’’ or planned OC and increasing numbers of physicians are ‘‘planned OC.’’ providing it (6–8). In 2014, ASRM published a fact sheet on its patient education website, describing how women may use OC even if they are not facing a fertility-threatening dis- Rationales for Planned OC ease (9). All these factors point to planned OC as a medical It is not only the aforementioned medical advances that make innovation that is moving into practice. As such, it raises planned OC attractive to women at this time. For decades, ‘‘ethical issues involving evaluation of evidence, balancing women in the United States have been having children at benefits and harms, supporting patient autonomy, avoiding older ages. Nationwide, the rate of first births to women conflict of interest, and promoting advances in health care’’ ages 35–39 has been rising since the 1970s, though now pla- (10). The Committee here addresses the ethical issues that arise teaued; the rate of first births to women 40–44 has been rising when OC is used by women whose goal is to protect their abil- since the early 1980s (14, 15). Many factors contribute to this ity to have children in the future apart from an immediate trend, but it is well recognized that women's increased access threat from gonadotoxic therapy. to education and participation in the workplace are central. For all stakeholders who provide and use planned OC, The critical periods of advancement in these pursuits caution is warranted. There is a risk of misplaced confidence usually take place when women are in their 20s and 30s, in the effectiveness of this procedure, as well as scientific un- which is also the time when female fertility has reached its knowns concerning long-term or transgenerational offspring peak and is beginning to decline (16). health. Mindful of these cautions, however, this Committee Sometimes this trend is described as women ‘‘delaying’’ or finds the use of OC for women attempting to safeguard their ‘‘postponing’’ childbearing, a statement that suggests affirma- reproductive potential for the future to be ethically permis- tive choice or even blame that women have brought the diffi- sible. It bears emphasis that most of the medical procedures culty upon themselves (17). Rather, the data show that many involved in planned OC are well established; ovarian stimula- women who want to have children face conflicts about their tion, oocyte retrieval, embryo culture, and embryo transfer preferred life path in a culture where the optimal time for are all regular components of IVF that are well tested, used educational and career advancement coincides directly with worldwide, and regarded as safe. the period that the body is best suited for reproduction. More- The Ethics Committee previously supported OC for over, many women report that their life circumstances (part- women facing immediate, medically induced loss of fertility nership, marriage, finances) are not as they want them, or as (3). But there are many less-immediate developments that society supports or regards as acceptable, and these circum- could also threaten women's ability to have children in the stances are what prevent them from starting a family at an future. These developments include diseases, primary ovarian earlier time (18–21). Finally, what may appear to be insufficiency, traumatic injury, planned female-to-male affirmative delay may actually be the unwitting product of gender transition, and the fertility loss that occurs as a woman a ‘‘knowledge gap’’: the widespread and persistent ages. Planned OC may also benefit women seeking children in overestimation of both female reproductive potential with response to unanticipated future events such as remarriage or age and the ability of reproductive medicine to restore that the death of an existing child (11). potential (22). Given these societal and personal reasons for procreation later in life, a biological truth comes into play: older female Terminology age increases the risk of inability to conceive due to reduced The appropriate language to describe the process of preser- oocyte quantity and quality, with increased chromosomal ab- ving oocytes for future fertility is unsettled. ‘‘Oocyte cryopres- normalities leading to more fetal abnormalities and preg- ervation’’ or ‘‘OC’’ is the most generic terminology and does nancy losses. Fertility and offspring health are affected by not distinguish the rationale for oocyte preservation. When men's age, too, although not until men are older, generally OC is used in contexts other than to avoid immediate gonado- past age 40 or 50. For both sexes, the more time that passes toxic effects, observers have criticized terms like ‘‘social egg before they reproduce, the greater the chance some illness, freezing,’’ ‘‘freezing for nonmedical reasons,’’ and ‘‘elective’’
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