Compassionate transfer: patient requests for embryo transfer for nonreproductive purposes

KEY POINTS:

• Patient requests to transfer potentially viable embryos into their bodies in a location or at a time when pregnancy is not expected to occur, and when pregnancy is not the intended outcome, is deemed a request for ‘‘compassionate transfer.’’ This is distinct from embryo transfer with reproductive intent.
• Valid and reasoned arguments exist to support physician decisions to perform the compassionate transfer of embryos for non-reproductive purposes and to decline to assist in such transfers. Principles of reproductive liberty, patient autonomy, and physician beneficence are potentially invoked in decision-making in this area.
• Clinics should develop policies and procedures for handling requests for compassionate transfer of embryos, including requirements for written informed consent, and make these written policies available to all patients.

Patient requests to transfer embryos when pregnancy is not expected to occur and when pregnancy is not the intended outcome may raise clinical and ethical dilemmas for physicians and their patients. During in vitro fertilization (IVF), embryo transfer ordinarily is performed with the intent to produce a viable, ongoing pregnancy. In rare but clinically and ethically significant instances, patients may request the transfer of supernumerary cryopreserved embryos into their bodies without the intention of establishing a pregnancy. This represents a method of disposition other than laboratory discard, donation for research or training, third-party reproduction, or continued cryopreservation. Such patients seek to transfer embryos into their bodies at a time in the menstrual cycle or in a location where pregnancy is not expected to occur. An embryo transfer for nonreproductive purposes is often called a ‘‘compassionate transfer’’ to reflect a physician’s benevolent empathy in facilitating a patient’s desired method of embryo disposition. This opinion discusses the practice of compassionate transfer from the perspective of patients and physicians. It further examines the clinical and ethical considerations for fertility clinics in providing or declining to provide these services in response to patient requests.

TRANSFER OF EMBRYOS WHEN PREGNANCY IS UNDESIRED

The ability to cryopreserve embryos for potential later use has necessitated decisions regarding their ultimate disposition. To facilitate this decision-making process, clinics and physicians solicit written instructions from patients and, where applicable, their partners, regarding their preferences for the disposition of frozen embryos under a range of potential future circumstances. Supernumerary cryopreserved embryos exist because the intended parents have completed their family plan or have opted to discontinue attempts to conceive (1). Clinics that offer cryopreservation typically request that patients provide a written expression as to their desires regarding the ultimate disposition of embryos not used for reproductive purposes. Dispositional options for supernumerary embryos may include: donation for research or training; donation to another individual or couple for the purpose of reproduction; laboratory discard; continued storage; and release to patients for disposal outside of the clinic (2).

Decisions regarding the disposition of supernumerary embryos can be emotionally complex or distressing and ethically challenging, leading some patients to avoid acting upon their documented disposition decision even when they are certain that they have completed their family plan. Some research indicates that indecision about embryo disposition can result in an estimated 20% of patients leaving their embryos in storage indefinitely (1,3). Patients who do not discard or donate their embryos may feel that embryos continue to have significance to them, representing the potential to become a child even when they have no desire to use the embryos for reproduction (4). Some may find it challenging to reconcile their view about the moral status of the embryos with the dispositional options available to them. Research on patients’ decisions about disposition has found that many patients would prefer options such as being present for or involved in the disposal or holding a ceremony at the time of disposal or burial at a place and in a manner that state regulations governing the disposal of biological material may prohibit (1,5).

Compassionate transfer may be desired because the process closely mirrors the in vivo failure of implantation, which occurs with both spontaneous and assisted reproduction (6). One of the few studies to examine patient views about compassionate transfers found that approximately 20% would be interested in this alternative (6). Patients who prefer this disposition see it as more respectful, personal, or natural than disposal in the laboratory. Moreover, compassionate transfer may be the only available option in IVF clinics that do not offer discard in the laboratory for religious, ethical, or other reasons (2). Although compassionate transfer generally refers to embryos, this may also be considered for cryopreserved oocytes and semen samples.

Data on the availability of compassionate transfers are limited. One study indicated that fewer than 5% of all US fertility clinics offered this dispositional option to patients (6). A more recent survey of members of the Society for Reproductive Endocrinology and Infertility (SREI) found that 83.2% of SREI members had heard of compassionate transfer, and of those, 44.6% had offered it (7).

The extent to which compassionate transfer might address an unmet need is unknown (8). One study found that the leading reason practitioners do not perform compassionate transfers is the lack of patient interest—reported by 97 out of 162 respondents—rather than objections on the basis of ethics, religion, or practical barriers (7). However, it is not known whether patients were, in reality, not aware of this option or did not know that they might request it.

ETHICAL CONSIDERATIONS

The ethical arguments in favor of compassionate transfer include:

Reproductive liberty

This is a broad-based principle that protects against outside interference with patient control over reproductive decision-making, including decisions about the disposition of embryos (9). It focuses on the harms that may result from infringement on this choice.

Patient autonomy

This principle also includes the right to control one’s embryos as a feature of patient self-determination and the exercise of reproductive liberty.

Beneficence

This principle supports the physician’s decision to honor patient requests as a duty to act in support of the patient’s best interests. This Committee has previously asserted that beneficence includes patient treatment goals that focus on purely psychological benefit, and enhance a patient’s emotional, psychological, and social welfare (10,11). Importantly, physicians should ensure that patients are counseled that there is no expectation that a pregnancy will occur, and that they should not consider a physician’s offer to transfer compassionately as an indication of potential pregnancy.

The ethical arguments against offering compassionate transfer include:

Medical futility

Physicians are not obligated to meet every patient's request, particularly when treatment is futile or not expected to provide any medical benefit. Physicians may decline requests for compassionate transfer on the basis of ethical concerns regarding performing a procedure that has no medical benefit, while at the same time requiring additional patient financial outlay because the procedure is not eligible for insurance coverage. As the Committee has previously discussed (10), clinicians may ethically refuse to provide treatment when, in their professional judgment, they regard such treatments as futile with minimal or no chance of pregnancy.

Nonmaleficence

This principle dictates that physicians should avoid harming patients and act in ways to minimize harm, even when trying to do good. Physicians may decline to honor patient requests for compassionate transfer out of concern for potential harms or unnecessary risks to patient well-being, including the remote possibilities of pelvic infection, ectopic pregnancy, and uterine implantation, leading to miscarriage or an unintended pregnancy.

Distributive justice

This ethical principle concerns the fair and equitable allocation of societal resources, benefits, and burdens among individuals and groups, aiming for equitable distribution of resources with an aim toward minimizing societal inequities. Physicians may view compassionate transfer as an inappropriate use of resources, including physician and staff time, which might limit access to care for others. Since patients intend the ultimate outcome of compassionate transfer to be embryo discard, physicians might feel that the additional resources required to achieve this result, compared with the traditional means of discard in the laboratory, cannot be ethically justified (12). This argument, however, fails to account for any emotional or psychological benefits a patient might gain as a result of directing embryo disposition in a manner of their choosing.

Physician autonomy

This principle is rooted in the concept that physicians should be free to make independent decisions about patient care, on the basis of their expertise, and with the goal of promoting the patient’s best interests. Physicians may decline compassionate transfer because they feel it conflicts with other ethical principles such as beneficence, nonmaleficence, and distributive justice.

One study notes that compassionate transfer involves inherent contradictions, pointing out that IVF routinely results in embryos being discarded for various reasons, such as compromised quality or genetic concerns (13). They also dispute characterizations of placing embryos into the uterus as a ‘‘natural’’ process, emphasizing that these embryos originated outside the body and have never been within the woman before transfer (13).

Finally, the Committee acknowledges that disposition decisions for supernumerary embryos can be psychologically, emotionally, and morally difficult for patients. The availability of compassionate transfer as a disposition option might lessen the sense of moral distress for some patients by allowing them to conclude that the ultimate outcome for their embryo was beyond their control, which may serve as a source of comfort for them. Some physicians object to this practice as they interpret it as colluding in a patient’s self-deception, preferring to encourage patients to address and resolve psychological, emotional, and/or moral dilemmas regarding supernumerary embryos.

CONSENT AND DISCLOSURE CONSIDERATIONS

The principles of consent for compassionate transfer are the same as patient requests for reproductive embryo transfer. Informed consent for embryo transfer, including compassionate transfer, must be obtained from both the patient and any other intended parent with dispositional control of the embryo(s), and must address all reasonably foreseeable risks. Additionally, patients must be informed of the costs associated with such procedures. In the event that a patient and their partner disagree over the disposition of embryos, a physician can seek guidance from existing dispositional instructions or any other prior agreements that the parties have entered into. In the event of ambiguity or uncertainty, physicians are strongly encouraged to seek counsel from a qualified legal expert. Under no circumstances should compassionate transfer be performed without the express written informed consent of the patient into whom the embryos are being transferred and any other individual(s) who have dispositional control over the embryos.

Physicians may accommodate requests for compassionate transfer either by performing it themselves or transferring the embryos to another physician or facility that is willing to provide this service. Additionally, embryo thaws or transfers should be thoroughly documented in the patient’s medical record. Clinics are strongly encouraged to develop and make available written policies to inform patients of their options for supernumerary embryos.

LEGAL CONSIDERATIONS

In the aftermath of the Dobbs decision, IVF clinics in the United States are facing new legal risks, especially in jurisdictions that consider life to begin at fertilization or recognize embryos as legal persons (14). These shifts may pose legal risks to physicians performing routine IVF procedures, including embryo disposition and compassionate transfers. One study emphasizes the importance of fertility clinics in closely monitoring and adapting to the evolving legal landscape when shaping their policies and practices (15). One study reports that, since the Dobbs decision, 89.6% of surveyed fertility patients expressed concern about embryo creation; 95.4% about control over embryos; and 94.4% about discarding embryos (16). As such, compassionate transfer as a disposition option may be increasingly desired by patients in the current legal environment.

Fertility clinics should develop embryo disposition policies in accordance with applicable law in their jurisdiction. These policies should incorporate scientific and practical considerations, while respecting diverse moral perspectives and preserving patient autonomy (17).

CONCLUSION

Decisions relating to embryo transfer and the disposition of supernumerary embryos are complex. Patient requests for compassionate transfer often reflect deeply held individual preferences and values and are entitled to respect. Principles of reproductive liberty and patient autonomy support compassionate transfer as a method of exercising control over a broad range of reproductive choices. It is ethically permissible for physicians to honor such requests, provided they are not influenced by bias and recipients are given proper informed consent. Physicians are not obligated to provide such services on the basis of physician autonomy, concerns about the provision of nonbeneficial treatment, and the distribution of scarce medical resources. Clinics are strongly encouraged to develop and make available written policies regarding patient requests for compassionate transfer of supernumerary embryos.

Acknowledgments

This report was developed under the direction of the Ethics Committee of the American Society for Reproductive Medicine (ASRM) as a service to its members and other practicing clinicians. Although this document reflects appropriate management of a problem encountered in the practice of reproductive medicine, it is not intended to be the only approved standard of practice or to dictate an exclusive course of treatment. Other plans of management may be appropriate, taking into account the needs of the individual patient, available resources, and institutional or clinical practice limitations. The Ethics Committee and the Board of Directors of ASRM have approved this report.

This document was reviewed by ASRM members, and their input was considered in the preparation of the final document. The following members of the ASRM Ethics Committee participated in the development of this document: Sigal Klipstein, M.D.; Sina Abhari, M.D.; Aishwarya Arjunan, M.S., M.P.H., C.G.C.; Tolulope Bakare, M.D.; Kim Bergman, Ph.D.; Zeki Beyhan, Ph.D.; Michelle Beyefsky, M.D.; Katherine Cameron, M.D.; Susan Crockin, J.D.; Colleen Denny, M.D.; Jessica Goldstein, R.N.; Insoo Hyun, Ph.D.; Jennifer Kawwass, M.D.; Jeanne O’Brien, M.D.; Torie Comeaux Plowden, M.D., M.P.H.; Gwendolyn Quinn, Ph.D.; Robert Rebar, M.D.; Jared Robins, M.D., M.B.A.; Chevis N Shannon, Dr.PH, M.P.H., M.B.A.; Puala Amato, M.D.; Sean Tipton, M.A. The Ethics Committee acknowledges the special contribution of Kim Bergman, Ph.D., in the preparation of this document. All Committee members disclosed commercial and financial relationships with manufacturers or distributors of goods or services used to treat patients. Members of the Committee who were found to have conflicts of interest on the basis of the relationships disclosed did not participate in the discussion or development of this document.

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