Support for selling embryos among infertility patients Tarun Jain, M.D.,a and Stacey A. Missmer, Sc.D.b,c,d a Department of Obstetrics and Gynecology, University of Illinois Medical Center, Chicago, Illinois; b Department of Obstetrics, Gynecology, and Reproductive Medicine, and c Channing Laboratory, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston; and d Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
Objective: To determine the opinions of infertility patients regarding selling extra embryos, and to investigate the relation between patient choice and demographic and socioeconomic characteristics. Design: Cross-sectional, self-administered survey. Setting: University hospital-based fertility center. Patient(s): 1350 consecutive women who presented for infertility care. Intervention(s): None. Main Outcome Measure(s): Patient opinion regarding selling extra embryos to other couples, and correlations with their demographic and socioeconomic background. Result(s): Of respondents with a definitive opinion, 56% felt that selling extra embryos to other couples should be allowed. After adjustment for observed predictors favoring selling extra embryos, we found statistically significantly lower support for selling embryos among patients who were Hispanic (relative to Caucasians) or had never been pregnant, whereas significantly greater support was observed among Hindu and secular women, patients being treated for male factor infertility, and those who in the past had or were currently undergoing intrauterine insemination. Age, education, marital status, and parity were not statistically significantly associated with the opinions about selling extra embryos to other couples. Conclusion(s): A large proportion of infertility patient participants approved of selling leftover embryos to other couples. However, some demographic and reproductive factors are significantly associated with patient opinion. (Fertil Steril 2008;90:564–8. 2008 by American Society for Reproductive Medicine.) Key Words: In vitro fertilization, IVF, assisted reproductive technology, ART, embryos, cryopreservation, infertility, ethics, embryo adoption
The use of assisted reproductive technology (ART) in the United States continues to steadily rise, resulting in over 120,000 in vitro fertilization (IVF) cycles being performed annually (1, 2). An unexpected consequence of this rise has been the creation and cryostorage of thousands of extra embryos in fertility centers. It has been estimated that in 2002 there were 396,526 embryos in storage with fertility clinics (3). The disposition of these extra cryopreserved embryos has been the subject of much debate by ethicists, policy makers, researchers, clinicians, and patients. Ultimately however, the embryos belong to the couples whose gametes were used to generate them. Potential disposition options commonly available to couples include use of the embryos for future pregnancy attempts, donation to other couples or embryo donation agencies, donation to researchers, or thawing and discarding (4). Recently, a controversial new option for embryo disposition has emerged—the selling of human embryos. This option has emerged in part due to demand from a large Received May 3, 2007; revised and accepted June 27, 2007. Reprint requests: Tarun Jain, M.D., Division of Reproductive Endocrinology and Infertility, University of Illinois at Chicago, 820 South Wood Street, M/C 808, Chicago, IL 60612 (FAX: 312-996-4238; E-mail:
[email protected]).
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segment of infertile women with diminished ovarian reserve who are unable to conceive using their own oocytes. They are subsequently left with the option of using oocyte donors, which can be very expensive. Furthermore, even among couples who need conventional IVF, the significant cost of this treatment (which is often not covered by insurance) (5) may push them toward considering purchasing preexisting embryos because this is a more cost-effective option. Use of preexisting embryos is also less physically intensive than conventional IVF, because undergoing controlled ovarian stimulation and oocyte retrieval could be avoided. The American Society for Reproductive Medicine (ASRM) and the Society for Assisted Reproductive Technology (SART), however, explicitly state that the selling of human embryos is ethically unacceptable (6). Not withstanding the controversy, a 1997 front-page story in the New York Times reported on a U.S. fertility center selling extra frozen embryos for $2750 (7). There are also several ‘‘embryo adoption’’ centers selling donated embryos to couples for between $4000 and $10,000 (8, 9). One of those centers has also received the endorsement and financial support of the federal government, with over $1 million in funding (10). More recently, a company has been formed that considers itself ‘‘the world’s first human embryo bank,’’ creating customized embryos (based on client preference) and selling them for $2500 per embryo (11, 12).
Fertility and Sterility Vol. 90, No. 3, September 2008 Copyright ª2008 American Society for Reproductive Medicine, Published by Elsevier Inc.
0015-0282/08/$34.00 doi:10.1016/j.fertnstert.2007.06.101
Given the emergence of embryo selling, there is currently no published information on the opinion of infertility patients regarding this controversial issue. Ultimately, infertility patients will be the potential gatekeepers of their embryos. We conducted a survey study of women presenting to a fertility center in Illinois. Our objectives were to determine the support among infertility patients for selling extra embryos and to investigate the relation between a patient’s choice and her demographic and socioeconomic characteristics. MATERIAL AND METHODS Collection of Data Institutional review board approval was obtained from the University of Illinois at Chicago before conducting the study. We mailed a brief questionnaire (consisting of 24 questions) to 1350 consecutive women who had presented to the University of Illinois at Chicago Fertility Center for infertility care, determined by their primary ICD-9 diagnosis code for infertility (628.x or 606.x), between March 2004 and April 2005. The survey instrument collected information on patient demographics, obstetric and infertility history, and opinion regarding selling extra embryos to other couples. The question regarding the opinion on selling embryos was written as follows: ‘‘Should selling extra embryos to other couples be allowed?’’ The answer choices for this question were Yes, No, or Unsure. To ensure face validity, the questionnaire was pilot tested with the assistance of three infertility physicians, three noninfertility physicians, four infertility patients, and a sociologist. Based on their feedback, the questionnaire was amended to ensure future subjects’ understanding of the questions. The questionnaire (along with a cover letter and postage-paid return envelope) was mailed in June 2005, and responses were collected during the next 3 months. One month after the initial mailing, a second mailing was sent to nonrespondents to improve the response rate. The survey results were entered into a database (Microsoft Access 2000; Microsoft Corp., Redmond, WA), and reverified for accuracy. Statistical Analysis We compared the distribution of demographic characteristics and reproductive history between women who did and did not approve of selling their extra embryos to other couples. Logistic regression analysis was used to calculate the multivariable (adjusted) odds ratio (OR) and 95% confidence interval (CI) that are presented as estimates of the relative risk (13). A multivariate OR for each main effect was calculated after adjustment for variables that were considered a priori or confounded crude relations. We considered all variables as potential confounders of the association of the exposure of interest with opinion on selling embryos if addition of that variable to the model changed the OR by 10% or more (14). For annual household income, which was reported in ordinal categories, we conducted tests for trend by creating an ordinal variable in which the median value or midpoint of each cateFertility and Sterility
gory was assigned to all participants in that group and then calculated a Wald statistic (15). All P values are based on two-sided tests. We used SAS statistical software (version 9.12; SAS Institute Inc., Cary, NC) for all analyses.
RESULTS Out of 1350 questionnaires that were mailed, 129 were returned by the postal service for lack of a correct mailing or forwarding address. From the remaining 1221 mailings, we received a total of 743 completed questionnaires (61% response rate). Of the 743 respondents, 588 (79%) stated definitely if they did or did not approve of selling extra embryos to other couples. None of the 743 responders declined to answer the question. The 155 who were ‘‘unsure’’ of their opinion had a nearly similar age (mean 33.6 years), race (Caucasian 47%, African-American 23%), reproductive history (nulligravid 22%, nulliparous 46%), education (high school degree 35%, undergraduate degree 35%), religion (Catholic 44%, Protestant 30%), and income (2–3 years >3–4 years >4 years Primary infertility diagnosis Age/poor ovarian reserve Ovulation Blocked tubes Uterine factor Endometriosis Male factor infertility Unexplained Current or past form(s) of assisted reproduction None Intrauterine insemination (IUI) In vitro fertilization Both IUI and IVF
38.5 24.6c
44.7 27.9c
103 (31.1) 61 (18.4) 56 (16.9) 111 (33.5)
65 (25.3) 42 (16.3) 42 (16.3) 108 (42.0)
Test for trend: P¼ .13 1.00 (referent) 1.04 (0.62–1.75) 0.98 (0.57–1.69) 0.87 (0.54–1.39)
29 (8.8) 61 (18.5) 67 (20.3) 10 (3.0) 25 (7.6) 69 (20.9) 69 (20.9)
16 (6.2) 40 (15.6) 65 (25.3) 19 (7.4) 19 (7.4) 30 (11.7) 68 (26.5)
2.10 (0.98–4.48) 1.60 (0.93–2.75) 1.30 (0.78–2.18) 0.55 (0.23–1.32) 1.45 (0.70–3.00) 2.49 (1.40–4.42) 1.00 (referent)
86 (26.0) 115 (34.7) 63 (19.0) 67 (20.2)
108 (42.0) 35 (13.6) 79 (30.7) 35 (13.6)
1.00 (referent) 3.52 (2.15–5.76) 0.96 (0.61–1.52) 2.00 (1.19–3.36)
1.00 (0.99–1.00)
a
Table values in parentheses are percentages. Adjusted for age (continuous in years), nulliparity, and religion (Christianity, Judaism, agnosticism, other). c Mean standard deviation. b
Jain. Selling embryos. Fertil Steril 2008.
To our knowledge, this is the first study to examine the opinions of a general infertility population about selling spare embryos to other couples, and to analyze those opinions based on the patients’ sociodemographic and reproductive backgrounds. It is important to note that, although a large percentage of our respondents favored selling embryos, this may not necessarily reflect the views of the general population. Fertility and Sterility
We examined the opinions of a general infertility population (rather than only IVF patients) because their opinion would be the rate-limiting step toward the potential selling of embryos to other couples. Such a study would also allow us to capture and study a more diverse and heterogeneous population of patients, as patients with access to IVF in the United States tend to be predominantly Caucasian, highly educated, and wealthy (16, 17). 567
It is not surprising that women who have never been pregnant would be less approving of selling extra embryos. They may be more apt to hold on to extra embryos to have more children of their own in the future. It is interesting that Hispanic patients in our study were statistically significantly less likely to favor selling embryos compared with Caucasians. The Chinese and other Asian patients were also less likely to favor selling embryos, but the difference did not reach statistical significance. There may, perhaps, be some cultural and religious differences accounting for these differences in opinion.
market for selling embryos, our study shows that a large percentage of infertility patients are not opposed to selling extra embryos to other couples. Given the potential for a significant increase in the commoditizing of spare embryos, medical societies and policy makers may need to pay close attention to this controversial area.
With regard to religion, this study found that Hindu and secular women were statistically significantly more approving of selling extra embryos relative to Protestant women; however, the number of Hindu respondents was low (n ¼ 23), which makes it difficult for us to further generalize. It does make sense that secular women would be more approving because belief in a particular religious edict may not be influencing their opinion. It is unclear as to why patients being treated for male factor infertility would be more approving of selling extra embryos. There may perhaps be a financial motive because those patients would incur greater expenses from use of intracytoplasmic sperm injection (ICSI) or a need for donor sperm. Also, patients using donor sperm may be more open to helping other couples conceive, as they also benefited from purchasing someone’s sperm.
REFERENCES
It is interesting that there was a trend toward wealthier households being more likely to agree with the selling of extra embryos. This opinion may reflect the possibility that these wealthier households would like the option of purchasing unused embryos from other couples. Also, because IVF is an expensive procedure that is often not covered by health insurance (5), less wealthy patients may wish to save extra embryos for future use rather than consider selling them. Given the varying opinions regarding selling extra embryos based on a patient’s background, conducting qualitative research may be an important next step in better understanding the reasons behind these opinions. It may also be useful to replicate this study in other regions of the country and in different clinical settings because there may also be geographic differences in opinion. It is important to note that, among the patients who felt that selling extra embryos should be allowed, this may not necessarily mean that they would be willing to sell their own embryos. With an increasing number of embryos being created and cryopreserved in the United States along with an emerging
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Selling embryos
Acknowledgments: We thank Neelima Sharma, MD for her assistance with data collection.
1. Jain T, Missmer SA, Hornstein MD. Trends in embryo-transfer practice and in outcomes of the use of assisted reproductive technology in the United States. N Engl J Med 2004;350:1639–45. 2. Centers for Disease Control and Prevention (CDC). 2004 Assisted reproductive technology success rates. Atlanta: CDC, 2006. 3. Hoffman DI, Zellman GL, Fair CC, Mayer JF, Zeitz JG, Gibbons WE, et al. Cryopreserved embryos in the United States and their availability for research. Fertil Stertil 2003;73:1063–9. 4. Bankowski BJ, Lyerly AD, Faden RR, Wallach EE. The social implications of embryo cryopreservation. Fertil Steril 2005;84:823–32. 5. Jain T, Harlow BL, Hornstein MD. Insurance coverage and outcomes of in vitro fertilization. N Engl J Med 2002;347:661–6. 6. Practice Committee of the American Society for Reproductive Medicine and the Practice Committee of the Society for Assisted Reproductive Technology. 2006 Guidelines for gamete and embryo donation. Fertil Steril 2006;86(Suppl):S38–50. 7. Kolata G. Clinics selling embryos made for ‘‘adoption.’’ New York Times, November 23, 1997. 8. National Embryo Donation Center (Web site). Accessed March 8, 2007. Available at: http://www.embryodonation.org/index.php. 9. Nightlight Christian Adoptions (Web site). Accessed March 8, 2007. Available at: http://www.nightlight.org/snowflakeadoption.htm. 10. Caplan A. The problem with ‘‘embryo adoption.’’ Why is the government giving money to ‘‘Snowflakes’’? MSNBC, June 24, 2003. Available at: http://www.msnbc.msn.com/id/3076556. 11. Stein R. Embryos for sale—a new angle in bioethical debate. Washington Post, January 7, 2007. 12. Obasogie OK. ‘‘Wal-Martization’’ of embryos. Boston Globe, February 1, 2007. 13. Rothman KJ, Greenland S. Modern epidemiology. 2nd ed. Philadelphia: Lippincott-Raven, 1998. 14. Greenland S. Modeling and variable selection in epidemiologic analysis. Am J Public Health 1989;79:340–9. 15. Hosmer DW, Lemeshow S. Applied logistic regression. New York: Wiley, 1989. 16. Jain T. Socioeconomic and racial disparities among infertility patients seeking care. Fertil Steril 2006;85:876–81. 17. Grainger DA, Siefer DB, Frazier LF, Rall MJ, Tjaden BL, Merrill JC. Racial disparity in clinical outcomes from women using advanced reproductive technologies (ART): Analysis of 80,196 ART cycles from the SART database 1999 and 2000. Fertil Steril 2004;82(Suppl): S37–8.
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