Heidi Mertes

Social egg freezing: for better, not for worse

The possibility for healthy women to cryopreserve their oocytes in order to counter future infertility has gained momentum in recent years. However, women tend to cryopreserve oocytes at an age that is suboptimal from a clinical point of view--in their late thirties--when both oocyte quantity and quality have already considerably diminished and success rates for eventually establishing a pregnancy are thus limited. This also gives rise to ethical concerns, as the procedure is seen as giving false hope to (reproductively speaking) older women. This study evaluates which measures can be taken to turn social freezing into a procedure that is both clinically and ethically better than the current practice. The main objective of these measures is to convince those women who are most likely to (want to) reproduce at an above-average age to cryopreserve their oocytes at a time when this intervention is still likely to lead to a live birth and to discourage fertility clinics from specifically targeting women who have already surpassed the age at which good results can be expected. The possibility for healthy women to cryopreserve their oocytes in order to counter future infertility has gained momentum in recent years. However, women tend to cryopreserve oocytes at a time that is suboptimal from a clinical point of view - in their late thirties - when both oocyte quantity and quality have already considerably diminished and success rates for eventually establishing a pregnancy are thus limited. This also gives rise to ethical concerns, as the procedure is seen as giving false hope to (reproductively speaking) older women. We evaluate which measures can be taken to turn social freezing into a procedure that is both clinically and ethically better than the current practice and discern three different steps: creating public awareness; offering individualized, age-specific information and counselling; and offering predictive tests such as anti-Müllerian hormone measurements or antral follicle count. The main objective of these measures is to convince those women who are most likely to benefit from social freezing to present themselves before age 35 and to discourage fertility clinics from specifically targeting women who have already surpassed the age at which good results can be expected.

Does company-sponsored egg freezing promote or confine women’s reproductive autonomy?

PurposeA critical ethical analysis of the initiative of several companies to cover the costs of oocyte cryopreservation for their healthy employees. The main research question is whether such policies promote or confine women’s reproductive autonomy.ResultsA distinction needs to be made between the ethics of AGE banking in itself and the ethics of employers offering it to their employees. Although the utility of the former is expected to be low, there are few persuasive arguments to deny access to oocyte cryopreservation to women who are well informed about the procedure and the success rates. However, it does not automatically follow that it would be ethically unproblematic for employers to offer egg banking to their employees.ConclusionsFor these policies to be truly ‘liberating’, a substantial number of conditions need to be fulfilled, which can be reduced to three categories: (1) women should understand the benefits, risks and limitations, (2) women should feel no pressure to take up the offer; (3) the offer should have no negative effect on other family-friendly policies and should in fact be accompanied by such policies. Fulfilling these conditions may turn out to be impossible. Thus, regardless of companies’ possible good intentions, women’s reproductive autonomy is not well served by offering them company-sponsored AGE banking.

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.

Ethical Aspects of the Use of Stem Cell Derived Gametes for Reproduction

A lot of interest has been generated by the possibility of deriving gametes from embryonic stem cells and bone marrow stem cells. These stem cell derived gametes may become useful for research and for the treatment of infertility. In this article we consider prospectively the ethical issues that will arise if stem cell derived gametes are used in the clinic, making a distinction between concerns that only apply to embryonic stem cell derived gametes and concerns that are also relevant for gametes derived from adult stem cells. At present, it appears preferable to use non-embryonic stem cells for the derivation of gametes. Adult stem cell derived gametes do not present any problems with regard to the moral status of the human embryo, bypass the safety risks linked to SCNT and do not present any ambiguity or novel problems with regard to informed consent, psychological consequences for the child or genetic parenthood. A remaining ethical concern, however, regards the safety of the procedure in terms of the welfare of the resulting children. This should spark a thorough reflection on how far one must go to accommodate a person’s wish to have a genetically related child.

Cross-border Research on Human Embryonic Stem Cells: Legal and Ethical Considerations

Although stem cell research is a field that stands to benefit a lot from international cooperation, collaboration between scientists of different countries is hampered by the great divergence in national stem cell legislations. More specifically, researchers from countries with restrictive stem cell policies find themselves unable to participate in international research or attend meetings or workshops in more permissive environments as they fear being prosecuted in their home country for activities that are deemed acceptable abroad. Juridical clarity on this subject is long overdue. Legally, extraterritorial jurisdiction based on the nationality principle does not conflict with international law. However, invoking this principle to prosecute stem cell researchers would constitute a breach with the current custom to limit extraterritorial jurisdiction to exceptional crimes or circumstances. On the ethical front, legislators have an obligation towards their constituents to protect them from harm through the criminal justice system, but at the same time they should be wary of legal moralism and of jeopardising freedom of research. Researchers on their part cannot simply ignore the law whenever it deviates from their personal moral opinions, but they are not acting unethically if they perform research that they esteem to be ethically justified where it is also legally accepted. Allowing researchers to work freely abroad—within the jurisdiction of the host country—is a way for legislator and researcher to show respect for each other’s different moral values and to balance their rights and obligations towards each other.

Balancing Ethical Pros and Cons of Stem Cell Derived Gametes

In this review we aim to provide an overview of the most important ethical pros and cons of stem cell derived gametes (SCD-gametes), as a contribution to the debate about reproductive tissue engineering. Derivation of gametes from stem cells holds promising applications both for research and for clinical use in assisted reproduction. We explore the ethical issues connected to gametes derived from embryonic stem cells (both patient specific and non-patient specific) as well as those related to gametes derived from induced pluripotent stem cells. The technology of SCD-gametes raises moral concerns of how reproductive autonomy relates to issues of embryo destruction, safety, access, and applications beyond clinical infertility.

Ethical Concerns Eliminated: Safer Stimulation Protocols and Egg Banking

The health risk for research donors—in this case women donating oocytes for somatic cell nuclear transfer (SCNT)—has indeed been one of the major indirect arguments against embryonic stem cell research via SCNT. In accordance with Ellison and Meliker (2011), we already argued some years ago that ovarian hyperstimulation syndrome (OHSS) incidence rates in an IVF population cannot be transferred to oocyte donors (Mertes and Pennings 2007). Moreover, the field of assisted reproduction is constantly evolving and new developments may well defuse this argument completely. There are two elements that we would like to contribute to the discussion. First, new stimulation protocols can reduce the risk of OHSS to an even greater extent than Ellison and Meliker suggest. Second, just as “spare” in vitro fertilization (IVF) embryos are now being donated for human embryonic stem cell research, it is only a matter of time until “spare” human oocytes will also become available so that there will no longer be a need to stimulate women solely for research purposes. The first development consists of banning human chorionic gonadotrophin (hCG) from the ovarian stimulation protocol. OHSS is directly related to hCG, which is administered to trigger final egg maturation and ovulation. How-

Gamete derivation from stem cells: revisiting the concept of genetic parenthood

Genetic parenthood is usually portrayed as a value-neutral concept that can be confirmed or rejected based on objective, scientific tests. However, on inspection, it is exposed as a very complex idea that we might need to consider as something that comes in different shapes and forms and that is open to interpretation rather than being clearly defined and fixed. Different people may therefore also desire different aspects of the general concept of genetic parenthood, which implies that some may not even be satisfied with gametes that have all the properties that their own natural gametes would have, whereas others may be satisfied with a much simpler solution. Encouraging infertility patients to gain insight into what it is exactly that they hope to gain by pursuing genetic parenthood (rather than choosing for donor conception or adoption) may lead them to recognise that the added advantage may be limited and may be acquired in other ways as well. Nevertheless, many people will find it difficult to let go of the desire for genetic parenthood as it is deeply rooted in our genes. Infertility is experienced as a grave medical condition and entails an intense grieving process for many. For that reason alone it is important that the medical and research community develop and apply methods to help people in their quest for genetic parenthood. On the other hand, it is important not to reinforce the dogma that genetic parenthood is ‘the best kind of parenthood’.

The force of dissimilar analogies in bioethics

Although analogical reasoning has long been a popular method of reasoning in bioethics, current literature does not sufficiently grasp its variety. We assert that the main shortcoming is the fact that an analogy’s value is often judged on the extent of similarity between the source situation and the target situation, while in (bio)ethics, analogies are often used because of certain dissimilarities rather than in spite of them. We make a clear distinction between dissimilarities that aim to reinforce a similar approach in the source situation and the target situation and dissimilarities that aim to undermine or denounce a similar approach. The former kind of dissimilarity offers the analogy more normative force than if there were no dissimilarities present; this is often overlooked by authors who regard all relevant dissimilarities as detrimental to the analogy’s strength. Another observation is that an evaluation of the normative force of an analogy cannot be made independently of moral principles or theories. Without these, one cannot select which elements in an analogy are morally relevant nor determine how they should be interpreted.

Stem cell research policies: who's afraid of complicity?

Countries that oppose embryo destruction for research purposes can forbid the production of human embryonic stem cell lines on their territory, but these cell lines are nevertheless produced abroad. Therefore, these countries also need to determine if their position on embryo destruction allows them to import and use existing stem cell lines. It is claimed that those who genuinely believe that stem cell derivation is wrong should avoid contributing to it, benefiting from it or even tolerating it when it takes place elsewhere. If not, they become complicit to an act they claim to oppose, which is hypocritical. Rather than arguing that compromise positions are flawed because they do not avoid complicity, we argue that the bar is set too high. When considering all the values that a country adheres to, a country cannot go to extremes in its opposition to human embryonic stem cell research. The illusion that it should (supported by both opponents and supporters of the research) leads to policies that impose disproportionate limitations on stem cell research in light of the other values that these restrictive countries stand for.