Using family members as gamete donors or gestational carriers Ethics Committee of the American Society for Reproductive Medicine American Society for Reproductive Medicine, Birmingham, Alabama The use of adult intrafamilial gamete donors and gestational surrogates is generally ethically acceptable when all participants are fully informed and counseled, but consanguineous arrangements or ones that simulate incestuous unions should be prohibited. Adult child- to-parent arrangements require caution in order to avoid coercion, and parent-to-adult child arrangements are acceptable in limited situations. Programs that choose to participate in intrafamilial arrangements should be prepared to spend additional time counseling participants and ensuring that they have made free, informed decisions. This document replaces the document of the same name, last published in 2012 (Fertil Steril 2012;98:797–803). (Fertil SterilÒ 2017;107:1136–42. Ó2017 by American Society for Reproductive Med- icine.) Discuss: You can discuss this article with its authors and with other ASRM members at https://www.fertstertdialog.com/users/ 16110-fertility-and-sterility/posts/14833-23775 KEY POINTS Research on the long-term impact on prefer to involve a family member in parents, offspring, and relatives the arrangement. This may occur intra- The use of adult intrafamilial gamete involved in intrafamilial reproduc- generationally between siblings or donors and gestational surrogates is tion should be encouraged. cousins of similar ages, such as a sister generally ethically acceptable except providing eggs for a sister or a brother Collaborative or third-party repro- when such arrangements are donating sperm to a brother. It may duction is sometimes considered by consanguineous or simulate inces- also occur intergenerationally, as couples or individuals who either lack tuous unions. when a mother gestates her daughter's eggs, sperm, or a uterus, or whose gam- Providers should be prepared to embryos or a father provides sperm to etes or uterus cannot be used due to spend more time screening and his infertile son. medical reasons. Gamete donation is a counseling participants in familial Some possible collaborative repro- recognized method to enable infertile gamete donor and surrogacy ar- ductive arrangements that involve couples without viable eggs or sperm rangements as compared with those family members are listed in Table 1. to conceive. Gestational surrogacy is involving anonymous or unrelated This table and the following discussion indicated when the uterus is absent or gamete donors and surrogates. Re- involve primarily first-degree relatives. abnormal, when the female partner quests for intergenerational gamete The use of second-degree relatives such for medical reasons cannot gestate a donation or surrogacy are especially as cousins, nephews, or aunts and un- pregnancy, or in cases where a single challenging. cles raises similar issues, but for male or same-sex male couple utilize Care should be taken to avoid coer- simplicity these arrangements are ART to have a child. The practice of cion and ensure fully informed con- omitted from the table and most of traditional surrogacy, in which the sur- sent when using intrafamilial gamete the subsequent discussion. rogate provides the egg as well as her donors and gestational surrogates. While familial collaboration may uterus, is discouraged by this Commit- All Assisted Reproductive Technol- offer advantages over the use of unre- tee (1) and will not be discussed in ogy (ART) programs should develop lated donors and surrogates, it also pre- this opinion. policies and procedures for dealing sents unique challenges. These include While collaborative reproduction with requests for the use of family issues of apparent though not actual usually involves anonymous or unre- members as donors or surrogates. incest (i.e., sexual relations between lated known individuals, some couples two closely related individuals) or con- sanguinity (i.e., reproduction between Received January 30, 2017; accepted February 3, 2017; published online March 24, 2017. individuals who are closely related Reprint requests: Ethics Committee, American Society for Reproductive Medicine, 1209 Montgomery fl Hwy, Birmingham, Alabama 35216 (E-mail: [email protected]). genetically), undue in uence to partici- pate, and possible confused parentage Fertility and Sterility® Vol. 107, No. 5, May 2017 0015-0282/$36.00 for resulting children (2–7).Limited Copyright ©2017 American Society for Reproductive Medicine, Published by Elsevier Inc. http://dx.doi.org/10.1016/j.fertnstert.2017.02.118 data have been collected regarding the 1136 VOL. 107 NO. 5 / MAY 2017 Fertility and Sterility® TABLE 1 Potential intrafamilial collaborative reproductive arrangements among first degree relatives. Resulting genetic and social relationships of Arrangement offspring Comments I. Sperm donation Brother-to-brother Social paternal uncle is genetic father; other Most acceptable intrafamilial sperm donation relationships unchanged Brother-to-sister Rearing mother is also genetic and gestational Gives strong impression of incest, but not strictly mother; social uncle is genetic father illegal because neither sex nor marriage are involved; should be prohibited because gametes from a consanguineous relationship are combined (sister is genetic mother and brother is genetic father) Brother-to-sister (sister Rearing mother is gestational mother, but has no Gametes are not from consanguineous uses donated eggs) genetic relationship to offspring; social uncle is relationship; not prohibited, but may create genetic father; some cousins are half-siblings; impression of incest or consanguinity most other relationships unchanged Brother-to-sister's wife Gestational mother and her female partner are Generally acceptable. Brother will be genetic father rearing mothers; non-gestational mother has a and social uncle to child; brother's partner (if he genetic relationship to the child has one) should be involved in decision making Father-to-son Social paternal grandfather is genetic father; Acceptability may depend upon attitude of female rearing father is genetic half-brother partner Father-to-daughter Social maternal grandfather is genetic father A proposal for this arrangement involving a (daughter uses divorced daughter who lived with her father donated eggs) has been discussed (2); Gives strong impression of incest Son-to-father Rearing father is genetic grandfather; offspring's Usually second marriage for father; significant social half-brother is genetic father; genetic concerns for undue pressures on son; should be paternal grandmother is usually rearing father's discouraged ex-wife II. Ovum donation Sister-to-sister Social aunt is genetic mother; some cousins are Probably most common and most accepted half-siblings; most other relationships arrangement unchanged Sister-to-sister-in-law Social aunt is genetic mother Should be prohibited because gametes from (brother's wife) consanguineous relationship are combined; gives strong impressions of incest, never reported Sister-to-brother's Sister is genetic mother and social aunt Generally acceptable. Sister's partner (if she has husband one) should be involved in decision making Daughter-to-mother Rearing mother is genetic grandmother; Usually second marriage for mother; concerns for offspring's social half-sister is genetic mother; coercion of daughter are significant; utmost rearing mother's ex-husband is usually genetic care should be taken to ensure informed maternal grandfather consent Mother-to-daughter Social maternal grandmother is genetic mother; Not reported; age of mother would make success offspring is half-sister of rearing mother unlikely III. Gestational surrogacy Sister-for-sister Genetic relationships unchanged; social maternal One of first reported cases of gestational surrogacy aunt is gestational mother Sister-for-brother Genetic relationships unchanged; social aunt is Gives impression of incest, but gametes are not gestational mother from consanguineous relationship Sister-for-brother's Genetic relationship is unchanged; social aunt is Generally acceptable. Sister's partner (if she has husband gestational mother one) should be involved in decision making Mother-for-daughter Genetic relationships unchanged; social maternal Health of older mother should be considered; grandmother is gestational mother should ensure daughter is not obligated to mother Daughter-for-mother Genetic relationships unchanged; social half-sister Not reported; age of mother would make success is gestational mother unlikely (unless using donor eggs) Daughter-for-father Genetic relationships unchanged; social half-sister Not reported; gives impression of incest is gestational mother ASRM. Family members as donors or gestational carriers. Fertil Steril 2017. attitudes, motivations, and experiences of donors and who are family members is in many cases ethically accept- recipients in such arrangements (8–10).Alsolimitedis able, but requires special care to avoid coercion and to information on the impact on children born as a result of assure informed consent. Providers of ART involving family such arrangements (11–13). members should pay special attention to the aforementioned The Ethics Committee in this document concludes that issues of consanguinity, risks of undue influence on deci- the use of adult gamete donors and gestational surrogates sions to participate, and the chance that the arrangement VOL. 107 NO. 5 / MAY 2017 1137 ASRM PAGES in question