Guido Pennings

Reproductive wish in transsexual men

BACKGROUND Hormonal therapy and sex reassignment surgery (SRS) in transsexual persons lead to an irreversible loss of their reproductive potential. The current and future technologies could create the possibility for female-to-male transsexual persons (transsexual men) to have genetically related children. However, little is known about this topic. The aim of this study is to provide information on the reproductive wishes of transsexual men after SRS. METHODS A self-constructed questionnaire was presented to 50 transsexual men in a single-center study. RESULTS The majority (64%) of transsexual men were currently involved in a relationship. Eleven participants (22.0%) reported having children. For eight participants, their female partner was inseminated with donor sperm, whereas three participants gave birth before hormonal therapy and SRS. At the time of interview, more than half of the participants desired to have children (54%). There were 18 participants (37.5%) who reported that they had considered freezing their germ cells, if this technique would have been available previously. Participants without children at the time of investigation expressed this desire more often than participants with children (χ²; test: P= 0.006). CONCLUSIONS Our data reveal that the majority of transsexual men desire to have children. Therefore, more attention should be paid to this topic during the diagnostic phase of transition and to the consequences for genetic parenthood after starting sex reassignment therapy.

A European perspective on testicular tissue cryopreservation for fertility preservation in prepubertal and adolescent boys

STUDY QUESTION What clinical practices, patient management strategies and experimental methods are currently being used to preserve and restore the fertility of prepubertal boys and adolescent males? SUMMARY ANSWER Based on a review of the clinical literature and research evidence for sperm freezing and testicular tissue cryopreservation, and after consideration of the relevant ethical and legal challenges, an algorithm for the cryopreservation of sperm and testicular tissue is proposed for prepubertal boys and adolescent males at high risk of fertility loss. WHAT IS KNOWN ALREADY A known late effect of the chemotherapy agents and radiation exposure regimes used to treat childhood cancers and other non-malignant conditions in males is the damage and/or loss of the proliferating spermatogonial stem cells in the testis. Cryopreservation of spermatozoa is the first line treatment for fertility preservation in adolescent males. Where sperm retrieval is impossible, such as in prepubertal boys, or it is unfeasible in adolescents prior to the onset of ablative therapies, alternative experimental treatments such as testicular tissue cryopreservation and the harvesting and banking of isolated spermatogonial stem cells can now be proposed as viable means of preserving fertility. STUDY DESIGN, SIZE, DURATION Advances in clinical treatments, patient management strategies and the research methods used to preserve sperm and testicular tissue for prepubertal boys and adolescents were reviewed. A snapshot of the up-take of testis cryopreservation as a means to preserve the fertility of young males prior to December 2012 was provided using a questionnaire. PARTICIPANTS/MATERIALS, SETTING, METHODS A comprehensive literature review was conducted. In addition, survey results of testis freezing practices in young patients were collated from 24 European centres and Israeli University Hospitals. MAIN RESULTS AND THE ROLE OF CHANCE There is increasing evidence of the use of testicular tissue cryopreservation as a means to preserve the fertility of pre- and peri-pubertal boys of up to 16 year-old. The survey results indicate that of the 14 respondents, half of the centres were actively offering testis tissue cryobanking as a means of safeguarding the future fertility of boys and adolescents as more than 260 young patients (age range less than 1 year old to 16 years of age), had already undergone testicular tissue retrieval and storage for fertility preservation. The remaining centres were considering the implementation of a tissue-based fertility preservation programme for boys undergoing oncological treatments. LIMITATIONS, REASONS FOR CAUTION The data collected were limited by the scope of the questionnaire, the geographical range of the survey area, and the small number of respondents. WIDER IMPLICATIONS OF THE FINDINGS The clinical and research questions identified and the ethical and legal issues raised are highly relevant to the multi-disciplinary teams developing treatment strategies to preserve the fertility of prepubertal and adolescent boys who have a high risk of fertility loss due to ablative interventions, trauma or genetic pre-disposition.

Preimplantation genetic diagnosis for mitochondrial DNA disorders: ethical guidance for clinical practice.

Although morally acceptable in theory, preimplantation genetic diagnosis (PGD) for mitochondrial DNA (mtDNA) disorders raises several ethical questions in clinical practice. This paper discusses the major conditions for good clinical practice. Our starting point is that PGD for mtDNA mutations should as far as possible be embedded in a scientific research protocol. For every clinical application of PGD for mtDNA disorders, it is not only important to avoid a ‘high risk of serious harm’ to the future child, but also to consider to what extent it would be possible, desirable and proportional to try to reduce the health risks and minimize harm. The first issue we discuss is oocyte sampling, which may point out whether PGD is feasible for a specific couple. The second issue is whether one blastomere represents the genetic composition of the embryo as a whole – and how this could (or should) be investigated. The third issue regards the cutoff points below which embryos are considered to be eligible for transfer. We scrutinize how to determine these cutoff points and how to use these cutoff points in clinical practice – for example, when parents ask to take more or less risks. The fourth issue regards the number of cycles that can (or should) justifiably be carried out to find the best possible embryo. Fifth, we discuss whether follow-up studies should be conducted, particularly the genetic testing of children born after IVF/PGD. Finally, we offer the main information that is required to obtain a truly informed consent.

Socio-demographic and fertility-related characteristics and motivations of oocyte donors in eleven European countries

STUDY QUESTION Do the socio-demographic and fertility-related characteristics and motivations of oocyte donors differ in European countries? SUMMARY ANSWER The socio-demographic and fertility-related characteristics and motivations of oocyte donors differ considerably across countries. WHAT IS KNOWN ALREADY There have been no other international studies comparing the characteristics of oocyte donors. Regarding their motivations, most studies indicate mixed motives. STUDY DESIGN, SIZE, DURATION The proposed study was a transversal epidemiological study. Data were collected from 63 voluntarily participating assisted reproduction technology centres practising oocyte donation in 11 European countries (Belgium, Czech Republic, Finland, France, Greece, Poland, Portugal, Russia, Spain, UK and Ukraine). The survey was conducted between September 2011 and June 2012 and ran for 1-6 calendar months depending on the number of cycles of oocyte donation performed at the centre. The sample size was computed in order to allow an estimate of the percentage of a relatively rare characteristic (∼2%) with a precision (95% confidence interval) of 1%. The calculation gave 1118 donors. PARTICIPANTS/MATERIALS, SETTING, METHODS In total, 1423 forms were obtained from oocyte donors. All consecutive donors in these centres filled out an anonymous questionnaire when they started their hormonal stimulation, asking for their socio-demographic and fertility-related characteristics, their motivations and compensation. Population characteristics were described and compared by country of donation. Motives for donation and mean amount of money were compared between countries and according to the donors characteristics. MAIN RESULTS AND THE ROLE OF CHANCE The socio-demographic and fertility-related characteristics and motivations of oocyte donors varied enormously across European countries. The number of received forms corresponded with a participation rate of 61.9% of the cycles performed by the participating centres. Mean age was 27.4 years. About 49% of donors were fully employed, 16% unemployed and 15% student. The motivation in the total group of donors was 47.8% pure altruism, 33.9% altruism and financial, 10.8% pure financial, 5.9% altruism and own treatment and finally 2% own treatment only. About 15% of the donors were egg sharers (patient donors), mainly from the UK and Poland. Women were donating for the first time in 55.4% of cases, for the second time in 20.3% and for the third time in 12.8%. The motivation to donate was significantly related to being of foreign origin (P < 0.01), age (P < 0.001), living in couple or not (P < 0.01), level of education (P < 0.001) and number of donations (P < 0.001). The amount of compensation differed considerably between centres and/or countries. The general donor profile in this study was a well-educated, 27-year-old woman living with her partner and child who mainly donated to help others. LIMITATIONS, REASONS FOR CAUTION The selection of clinics in some countries and the limited participation rate may have led to a bias in donor characteristics. A possible effect of social desirability in the answers by the donors should be taken into account. WIDER IMPLICATIONS OF THE FINDINGS The diversity of the donor population reflects the differences in European legislation (for example, on anonymity and payment) and economic circumstances. The differences in systems of reimbursement/payment demonstrate the need to have a thorough discussion on the specific meaning of these terms. STUDY FUNDING/COMPETING INTEREST(S) The study was funded by the European Society for Human Reproduction and Embryology. The authors declare no conflicting interests.

Subsidized in-vitro fertilization treatment and the effect on the number of egg sharers

Egg sharing remains a controversial practice, mainly because of the presumed element of payment. In order to find out to what extent financial considerations motivated the women to share their oocytes, the data on egg sharing in Belgium are analysed. Belgium began providing full reimbursement for six in-vitro fertilization (IVF) cycles on 1 July 2003. Since this date, the numbers of egg sharers dropped approximately 70%. Although these data show that a large number of the donors were mainly motivated by the reduced cost of IVF, it cannot be concluded that money was the only motive to share. Nevertheless, to increase voluntary consent by egg sharers, public funding for infertility treatment should be provided.

Trends in embryo disposition decisions: patients’ responses to a 15-year mailing program

BACKGROUND This study examined the responses of patients of a Belgian fertility center to mailed requests to make or renew an embryo disposition decision (EDD), over a period of 15 years, to investigate trends in the decisions. METHODS A retrospective analysis was performed on a mailing program from 1992 to 2006, for patients, of the Department of Reproductive Medicine, Ghent University Hospital (Belgium), from whom embryos had been cryopreserved at least 2 years. RESULTS In 15 years, 3840 EDD forms were prepared for 2334 couples or female patients. The number of forms increased from 21 in 1992 to 558 in 2006. Each year, around a third of the forms were not returned. In general, a quarter of patients who received more than one form never answered. Donation to others for reproduction was overall the least popular option and decreased over the years. The rising trend in decisions to discard reversed into a negative trend from the introduction of donation for science (1997). Since then, donation for science has been the most popular option and its popularity increased with time. In 15 years, 2504 embryos were donated for science. More than a quarter of the patients who chose more than one final EDD in different years did not select the same EDD the second time. CONCLUSIONS This study showed a positive trend in donation for science and a negative trend in donation to others and discarding. A substantial number of individual patients chose different types of EDDs in consecutive mailings, which shows that advance EDD directives should be used with caution.

Spermatogonial stem cell preservation in boys with Klinefelter syndrome: to bank or not to bank, that's the question

Although early development of testis appears normal in boys with Klinefelter syndrome (KS), spermatogonial stem cell (SSC) depletion occurs in midpuberty, leading to infertility. Therefore, freezing of semen samples or testicular tissue sampling could be offered to boys with KS at onset of puberty. However, only in about half of patients with KS, adult or prepubertal, spermatozoa or SSCs can be observed, and to date, no clinical parameters are available to detect patients who might benefit from these techniques. Furthermore, strategies for the further use of the cryopreserved material are still under investigation. Retrieval of spermatogonial cells in prepubertal boys with KS should therefore still be viewed as experimental and patients and their parents must be counseled accordingly.

Extraterritoriality for cross-border reproductive care: should states act against citizens travelling abroad for illegal infertility treatment?

Since the development of assisted reproduction technologies, there has been discussion on which people should have access to these technologies and which treatments and techniques are morally acceptable. However, national legislation can no longer determine what citizens do. Some countries react to their citizens going abroad to evade restrictions by implementing even more restrictive laws. Turkey has recently become the first state to ban reproductive travel in pursuit of donor gametes. Several states in Australia have enacted or are considering laws that prohibit international commercial surrogacy. This article investigates the consistency and morality of several state reactions to cross-border reproductive care (CBRC), including extraterritorial regulation. The only widespread existing extraterritorial regulation of private life concerns female genital cutting (FGC), sex with children and (largely in the past) abortion. This discussion develops an analogy with these cross-border crimes to evaluate the morality of similar legislation in cases of CBRC. The dissimilarity in these analogies shows that extraterritoriality is a radical position that is generally inappropriate in the case of CBRC. Subsequently, several potential state reactions to CBRC for law evasion are considered. It is concluded that legislation of CBRC should be modest, tolerant and nuanced.

Embryonic Stem Cell–Derived Gametes and Genetic Parenthood: A Problematic Relationship

The recent success in generating live offspring from embryonic stem cell (ESC) –derived gametes in mice sparked visions of growing tailor-made sperm for men faced with infertility. However, although this development will almost certainly lead to new insights into the processes underlying spermatogenesis and thus in the possible causes of male infertility, it is less certain if deriving sperm from ES cells, which are in turn derived from a sterile man, can make someone a genetic parent. As the gap between newly envisioned reproductive technologies and natural reproduction widens, the question thus needs to be asked if these possible therapies still lead to genetic parenthood.

Decision-making authority of patients and fertility specialists in Belgian law

Belgium has finally introduced a law covering medically assisted reproduction and the disposition of supernumerary embryos and gametes, one of the last countries in Europe to do so. It is a liberal law, which gives extended decision-making authority to both patients and physicians. Importantly, access to treatment is given to all types of patients, with the exception of women over 47 years. All standard types of treatment are allowed. Simultaneously, fertility specialists and clinics have the right to refuse treatment to patients when they have a conscientious objection. Apart from the disposition of gametes and embryos, the law also permits the use of gametes and embryos post-mortem if there is written consent by the partners. Finally, the application of preimplantation genetic diagnosis for human leukocyte antigen typing is regulated.