Abstract
Purpose
To assess factors associated with embryo donation among individuals interested in donation in the United States.
Methods
An invitation to complete the 123-item survey was emailed from June to September 2022 to patients at a private practice fertility clinic with interest in donation at the time of IVF. Survey questions included disposition decision, attitudes about embryo status and genetic relatedness, donation disclosure, ideal donation arrangement, and decision satisfaction.
Results
Three hundred thirty-seven completed the survey. Two hundred thirty donated to another person(s), 75 discarded embryos, 25 remained undecided, and disposition was unknown for 7 respondents. There were no demographic differences between groups based on final disposition or use of donor gametes. Few gamete recipients were interested in donation due to biological attachment to embryos. Final embryo disposition was associated with religious factors, not wanting to waste embryos, and storage fee concerns. Final disposition was also significantly associated with concern about donor-conceived children’s (DCP) welfare, being denied the ability to complete donation, personal IVF outcomes, financial or legal issues, future contact with DCP, cognitive appraisal of disposition, beliefs about embryos, someone else raising their genetic child, anonymity, and beliefs about DCP not knowing genetic relationships (p < .001). Donation to others was associated with less regret and greater satisfaction with the emotional/medical aspects of donation and counseling compared to those who discarded embryos (p < .001).
Conclusion
The decision to donate embryos to another person(s) is complex. Counseling that considers individual circumstances, values, and evolving dynamics may facilitate informed decision-making for those navigating infertility treatment, family building, and embryo disposition.
Supplementary Information
The online version contains supplementary material available at 10.1007/s10815-024-03156-z.
Keywords: Embryo donation, Third-party reproduction, Embryo disposition, Motivation
Introduction
Substantial technological advancements in assisted reproduction over time have resulted in the creation of supernumerary embryos and have enabled the utilization of donated embryos for family building. In vitro fertilization (IVF) stimulation protocols have also become more efficient [1], live birth rates with euploid blastocyst transfer exceed 60–70% [2–4], fewer embryos are transferred per cycle [5], and vitrification has improved post-thaw survival of blastocysts [6, 7]. This has resulted in an unintended consequence: a growing number of patients with supernumerary embryos in storage who have completed family building and are now facing challenging decisions about embryo disposition [8, 9]. The dilemma of the disposition of unused frozen embryos is not new [10] but is likely to only compound over time. Although it is difficult to ascertain the exact number of embryos stored in fertility centers in the United States (U.S.), a study in 2003 [11] approximated around 400,000 embryos were in storage. More recent updated analyses [12, 13] have conservatively estimated over one million cryopreserved embryos in the U.S. In the context of the growing numbers of supernumerary embryos, fertility clinics and patients are increasingly being tasked with navigating complex embryo disposition decisions. Patients have several options for disposition of supernumerary embryos: maintenance of embryos in storage for a future transfer, donation towards medical research, thaw and discard, donation to another intended parent(s), or indefinite storage with no intention to transfer.
Despite the multiple options for embryo disposition, a significant percentage of cryopreserved embryos remain in abeyance, without a clearly delineated plan as many patients delay disposition decisions altogether [14]. It appears likely that the decision for supernumerary embryo disposition is emotionally distressing for many patients [15, 16] as well as a dynamic decision-making process; both factors may play a role in delayed decision-making [8, 15, 17–19]. For example, De Lacey et al. reported that patients who initially indicated a desire to donate their embryos to another patient changed their minds after subsequently becoming parents [15], suggesting that parenthood may change their beliefs and attachment to their embryos. Several studies have also identified that new parents may experience a shift in their conceptualization of their stored embryos as becoming their “virtual children” in storage [15, 20, 21].
Embryo donation introduces uniquely complex psychosocial issues that may influence disposition decisions. Patients must grapple with their beliefs about the meaning of parenthood, about the status/value of embryos, and thoughts about disclosure of embryo donation to their children as well as potential future contact from embryo donation conceived individuals. The latter issue is no longer theoretical; the broad public utilization of direct-to-consumer DNA testing for ancestral information also can be used to identify genetic relatives [22–25]. A growing proportion of embryos are screened for aneuploidy [26–28] and patients may assign a higher value to euploid embryos. Whether the possible identification of genetic relatedness (and thus lack of anonymity) through consumer DNA testing or altered perception of embryo value due to aneuploidy screening contributes to embryo donation decisions has yet to be studied.
Limited research has examined the beliefs and experiences of embryo donors with studies related to motivation for embryo donation often being conducted with small samples of donors. The few studies of embryo donors have found that motivation for donation may be influenced by the desire to give their embryos a chance to become children, valuing the genetic connection to children conceived through their donation or limited attachment to genetic relatedness, and/or openness to disclosure of conception to donor-conceived children among other factors [14–21]. A prior retrospective analysis from our group [29] found that those who used donor gametes to grow their families were more likely to donate their embryos than those using autologous gametes, and it was hypothesized that decreased attachment to genetic relatedness, openness to disclosure of donor conception, and/or the desire to help others given that they have benefitted from gamete donation may motivate them to donate their embryos. Finally, although there are multiple studies on gamete donor satisfaction, post-embryo donation satisfaction remains unexplored [30] which limits healthcare professionals’ ability to provide comprehensive counseling related to the donation experiences.
The present study aims to assess factors and motivations associated with embryo donation with supernumerary embryos within a population of individuals who initially intended to donate. Although previous studies have examined final embryo disposition decisions among patients who have completed IVF, most studies have not specifically examined factors associated with motivations for or satisfaction with completed embryo donation for family building. Because this study focuses on the embryo donor and not the embryo recipient, we have defined “completed donation” to be synonymous with a patient’s final decision to donate at least one remaining embryo to another individual. A secondary objective of this study is to explore motivations for embryo donation within a subpopulation of patients who used donor gametes to create their embryos.
Methods
Ethics approval
This study was approved by the WIRB-Copernicus Group® (WCG) Institutional Review Board. Funding was provided by The National Human Genome Research Institute/National Institute of Health (1RM1HG009037; Rothwell/Tabery (MPIs)). All study participants answered an online waiver of documentation of consent before beginning the survey.
Study population
Study data was collected from Shady Grove Fertility, a large acedemically affiliaited private practice located primarily in Rockville, Maryland. Most embryos in storage at this center date from 2009 onward. Criteria for embryo donation included the following: embryos vitrified onsite at the blastocyst stage on day 5 or 6, oocyte age < 40 years, and sperm age < 50 years. All those who at the time of IVF strongly considered donation in our study met with the Embryo Donation team and a mental health professional (MHP) at the completion of IVF and created a profile on Embryo Options (Cooper Surgical, Inc.) declaring their interest in embryo donation for family building.
Survey instrument
A novel questionnaire was developed to assess patient characteristics and motivations for considering and completing embryo donation. The initial development of questions was identified after a thorough review of the gamete and embryo donation literature. The survey was subsequently developed and reviewed for content validity and readability by a robust team. The survey included 123 items with some of the questions allowing for open-ended responses (see supplementary information). Questions included patient demographic information, infertility treatment history, genetic embryo testing, motivation towards embryo donation, and retrospective patient experiences (at the initial introduction to embryo donation). Respondents were then asked what their final embryo disposition was (if a decision had been made) and what factors were associated with their final disposition decision. Lastly, the survey queried participants long-term satisfaction with the experience of disposition decision.
Recruitment
The survey was administered via RedCap and respondents were offered a $25 gift card for participation. Given financial constraints and the desire to have a balanced view of study participants’ experiences, the study was designed to have 400 respondents in four groups of patients who considered embryo donation for family building: 100 who generated autologous embryos and ultimately chose not to donate, 100 who were gamete donor recipients in the creation of supernumerary embryos and chose not to donate, 100 who generated autologous embryos and ultimately donated, and 100 who were gamete donor recipients in the creation of supernumerary embryos and donated. Embryo Options generated four randomized lists of 150 potential participants in each representative sample group, ensuring that all patients (and partners if applicable) selected “Donate to another person or couple” between 2015 and January 2021. Contact information for both the person listed as the primary fertility patient and their partner (if applicable) was obtained. Patients from each of the four lists were selected for inclusion in the study using GraphPad Prism software and sent a link to the RedCap survey via email between June and September 2022 with a single reminder email that was sent approximately 4 to 6 weeks later. Partners were copied on the survey invitation, but the survey link could only be used to submit one survey. Due to the lower-than-anticipated response rate from those who chose not to donate, an additional randomized list of 150 participants was generated by Embryo Options to help with study recruitment and they were sent an email in August 2022 and similarly received a follow-up reminder email. The overall response rate was 44.9% (337/750). However, when analyzed separately, the response rates of those who donated to another individual were greater (76.7%, 230/300) when compared to those who had not donated to another individual (23.8%, 107/450). Of those who had chosen not to donate to others, the initial response rate was 23.7% (71/300) and 24.0% (36/150) for the second wave of recruitment for this group. Demographic information was not available for non-respondents.
Statistical analysis
SPSS 23.0 was used for all analyses. Data were analyzed using chi-square followed by Bonferroni adjusted Z-test or Fisher’s exact test for multiple pairwise comparisons. One-way ANOVA was used when analyzing age. We compared motivations and experiences of those who donated versus thawed and discarded embryos. The cohort (n = 25) of those who indicated that they were uncertain about embryo disposition was too small to include in the sample for group comparisons. Due to cell sizes, all Likert scales were combined and analyzed to only have three options (not important, neutral, important; disagree, neutral, agree). We considered p < .05 statistically significant.
Results
Demographics
Of the 337 respondents (including those who were uncertain as to donation intention), most identified as female (91.3%), as Caucasian (85.7%), were married (86.7%), with ≥ 2 children (69.6%), with at least a graduate level degree (59.4%), identified as Christian (65.4%), and had a household income greater than $100,000 per year (81.7%). Respondents were on average 42.82 ± 6.08 years old at the time of survey completion, 38.47 ± 5.66 years old at the time of the first discussion of embryo disposition, with an average of 5.74 ± 8.60 months between the last embryo transfer and first inquiry regarding embryo donation. Just over a third (n = 126, 37.3%) used donor oocytes and n = 49 (14.5%) used donor sperm in the creation of their supernumerary embryos. Nearly a quarter (n = 82, 24.3%) of respondents used PGT-A and n = 173 (51.3%) underwent personal genetic carrier screening (Table 1).
Table 1.
Demographic and fertility characteristics of total sample respondents and comparison for respondents who donated versus those who discarded
| Patient characteristics | Overall (N = 337) | Donated (N = 230) | Discarded (N = 75) |
|---|---|---|---|
| Gender | N (%) | N (%) | N (%) |
| Female | 308 (91.4) | 210 (91.3) | 70 (93.3) |
| Male | 25 (7.4) | 18 (7.8) | 4 (5.3) |
| Unavailable or gender variant/non-conforming | 1 (0.3) | 1 (0.4) | 0 (0.0) |
| Prefer no response | 3 (0.9) | 2 (0.9) | 1 (1.3) |
| M (SD) | M (SD) | M (SD) | |
| Age at survey completion (yrs) | 42.8 ± 6.1 | 43.3 ± 6.2 | 41.7 (6.0) |
| Age at first discussion of embryo disposition (yrs) | 38.5 ± 5.7 | 38.0 ± 5.8 | 37.1 (5.3) |
| N (%) | N (%) | N (%) | |
| Number of children | |||
| 0 children | 13 (3.9) | 11 (4.8) | 1 (1.3) |
| 1 child | 87 (25.8) | 59 (25.7) | 20 (26.7) |
| ≥ 2 children | 235 (69.7) | 160 (69.4) | 53 (72.0) |
| Marital status | |||
| Married | 292 (86.6) | 202 (87.8) | 66 (88.0) |
| Single | 23 (6.8) | 17 (7.4) | 3 (4.0) |
| Widowed | 1 (0.3) | 1 (0.4) | 0 (0.0) |
| Divorced | 16 (4.7) | 8 (3.5) | 6 (8.0) |
| Separated | 3 (0.9) | 2 (0.9) | 0 (0.0) |
| Missing | 2 (0.6) | 0 (0.0) | 0 (0.0) |
| Ethnicity | |||
| Asian | 35 (10.4) | 18 (7.8) | 17 (22.0) |
| Black/African | 8 (2.4) | 4 (1.7) | 4 (3.0) |
| Caucasian | 264 (78.3) | 190 (82.6) | 74 (61.7) |
| Hispanic/Latino | 11 (3.3) | 7 (3.0 | 4 (5.3) |
| Native American | -- | ||
| Pacific Islander | -- | ||
| Multiracial | 9 (2.7) | 3 (1.3) | 6 (8.0) |
| Prefer no response | 2 (0.6) | 2 (1) | 0 (0.0) |
| Religious affiliation | |||
| Christian | 221 (65.6) | 109 (47.4) | 29 (38.7) |
| Muslim | 1 (0.03) | 1 (0.4) | 0 (0.0) |
| Jewish | 18 (5.3) | 12 (5.2) | 6 (8.0) |
| None | 63 (18.7) | 36 (15.7) | 19 (25.3) |
| Other or missing | 23 (6.8) | 18 (7.8) | 2 (2.7) |
| Annual family income | |||
| <% 50,000 | 7 (2.1) | 5 (2.2) | 0 (0.0) |
| $50,000–100,000 | 53 (15.7) | 35 (15.2) | 15 (20.0) |
| $101,000–200,000 | 150 (44.5) | 98 (42.6) | 39 (52.0) |
| ≥ % 200,000 | 125 (37.1) | 92 (40) | 21 (28.0) |
| Missing | 2 (0.6) | ||
| Level of education | |||
| High school | 19 (5.6) | 12 (5.2) | 6 (8.0) |
| Associate degree | 22 (6.5) | 18 (7.8) | 4 (5.3) |
| Bachelor’s degree | 90 (26.7) | 59 (25.7) | 23 (30.7) |
| Master’s degree | 139 (41.2) | 96 (41.7) | 30 (40.0) |
| Advanced degree (PhD,MD,JD) | 61 (18.1) | 42 (18.3) | 11 (14.7) |
| Other or missing | 6 (1.8) | 3 (1.3) | 1 (1.3) |
| ART characteristics | |||
| Completed donation | |||
| Yes | 230 (68.2) | ||
| No (donated to research or discarded) | 75 (22.3) | ||
| Undecided | 25 (7.4) | ||
| Unknown | 7 (2.1) | ||
| Donor oocytes used | 126 (37.3) | 93 (40.4) | 24 (32.0) |
| Donor sperm used | 49 (14.5) | 35 (15.2) | 8 (10.7) |
| PGT-A testing on embryos | 82 (24.3) | 52 (22.6) | 20 (26.7) |
| Genetic carrier screening used | 173 (51.3) | 116 (50.4) | 41 (54.7) |
| Diagnosis | |||
| Diminished ovarian reserve (DOR) | 82 (24.3) | 58 (25.2) | 19 (25.3) |
| Male factor infertility | 61 (18.1) | 42 (18.3) | 15 (20.0) |
| Unexplained infertility | 121 (35.9) | 88 (38.3) | 23 (30.7) |
| Ovulation disorder/PCOS | 43 (12.8) | 29 (12.6) | 12 (16.0) |
| Tubal disease | 9 (2.7) | 5 (2.2) | 2 (2.7) |
| Uterine factor | 34 (10.1) | 17 (7.4) | 10 (13.3) |
| Same sex (male) | 3 (0.9) | 3 (1.3) | 0 (0.0) |
| Same sex (female) | 9 (2.7) | 8 (3.5) | 0 (0.0) |
| Single female | 12 (3.6) | 9 (3.9) | 2 (2.7) |
| Tubal ligation | 10 (3.0) | 6 (2.6) | 3 (4.0) |
| Other | 38 (11.3) | 23 (10.0) | 12 (16.0) |
| Missing | 0 (0.0) | 0 (0.0) | 0 (0.0) |
| Children from ART | |||
| Yes | 319 (95.2) | 219 (95.2) | 71 (94.7) |
| No | 16 (4.7) | 11 (4.8) | 4 (5.3) |
| Missing | 2 (0.6) | 0 (0.0) | 0 (0.0) |
Although all respondents initially expressed consideration to donate their embryos to another individual(s), most respondents (n = 230, 68.2%) actually completed donation to another individual(s), n = 75 (22.3%) had their excess embryos donated to research or discarded, n = 25 (7.4%) still remained undecided about what to do with their excess embryos, and embryo disposition was unknown for n = 7 (2.1%) of participants (Table 1). When thinking about donation to another person, nearly half (n = 150/337, 44.5%) of respondents saw “anonymous” donation as the “most ideal” option, approximately a third (n = 110, 32.6%) saw a semi-open donation arrangement as “most ideal,” and only 18.7% (n = 63) saw open donation as the “most ideal” choice. Additionally, 60.5% (n = 204) saw open donation as the “least desired” option, anonymous donation was “least desired” by 29.4% (n = 99) respondents, and semi-open donation was “least desired” by 2.4% (n = 8) respondents. There were no demographic differences between the group of respondents, including whether embryos were generated autologously or with use of a gamete donor, based on the final choice of embryo disposition.
Final motivations regarding embryo disposition
With regard to final motivations for donation, the three most frequently reported important reasons for considering donation were not wanting embryos to go to waste, personal experiences with infertility, and age (80.7%, 69.1%, and 53.4%, respectively). The three least important reasons when considering donation were major changes in relationship status such as divorce, a history of previous abortion, and legal considerations (2.8%, 3.2%, and 4.6%, respectively). The same factors were most and least important when only examining those who donated their supernumerary embryos.
For those who used gamete donation to create their embryos (N = 247), less than a third agreed that the use of donor gametes made embryo donation easier (N = 45, 32.4%), that they considered donation to continue what the donor had begun (N = 42, 30.0%), or that they did not feel biologically attached to their embryos (N = 16, 11.5%). The majority of gamete recipients (N = 89, 63.6%) did however agree that they had a strong desire to “give back” because they used donor gametes (see Fig. 1).
Fig. 1.
Gamete recipients’ beliefs about embryo donation (N = 147)
Factors potentially associated with the final embryo disposition decision were analyzed using chi-square analysis including the number of months between family completion and final disposition, multiple factors related to disposition decision (e.g., REI, MHP counseling, personal outcomes with IVF, religion, desire to not discard embryos), cognitive appraisal of final disposition as distressing or agonizing, beliefs about embryos, desire for anonymity, and concerns about genetic relatedness of donor-conceived children (see Table 2). Significant overall variable chi-square analyses with more than four cells were subjected to pairwise Bonferroni adjusted Z-tests. Results showed that among participants’ final thoughts and experiences associated with embryo disposition, personal IVF outcomes, religion, not wanting to waste valuable embryos, concern about the welfare of donor-conceived children, concern related to storage fees, legal concerns, concerns about donor-conceived children contacting them in the future, cognitive appraisal of final decision making, beliefs about embryos (i.e., have rights, should be treated with dignity, were “virtual children,” embryo donation is similar to adoption), difficulty coping with the idea of someone else raising their genetic child, concerns related to anonymity, and beliefs about donor-conceived children not knowing they are genetically related to others were associated with final embryo disposition decision (see Table 2).
Table 2.
Final decision variable group comparisons
| Variable | Donated, N (%) | Discarded, N (%) | χ2 (df) | N |
|---|---|---|---|---|
| Not wanting to waste something extremely valuable | 18.73 (2) | 301 | ||
| Not importanta | 9 (4.0) | 13 (17.6) | ||
| Neutral | 20 (8.8) | 11 (14.9) | ||
| Importanta | 198 (87.2) | 50 (67.6) | ||
| Concern for welfare of children | 16.15 (2) | 303 | ||
| Not Important | 58 (25.4) | 23 (30.7) | ||
| Neutrala | 86 (37.7) | 10 (13.3) | ||
| Importanta | 84 (36.8) | 42 (56.0) | ||
| Personal IVF outcomes | 36.99 (2) | 302 | ||
| Not importanta | 14 (6.1) | 21 (28.8) | ||
| Neutrala | 29 (12.7) | 17 (23.3) | ||
| Importanta | 186 (81.2) | 35 (47.9) | ||
| Motivated by religious reasons | 7.41 (2) | 301 | ||
| Not importantc | 129 (57.1) | 56 (74.7) | ||
| Neutral | 39 (17.3) | 7 (9.3) | ||
| Important | 58 (25.7) | 12 (16.0) | ||
| The storage bill was due | 35.63 (2) | 303 | ||
| Not importanta | 98 (43.0) | 13 (17.3) | ||
| Neutrala | 63 (27.6) | 11 (14.7) | ||
| Importanta | 67 (29.4) | 51 (68.0) | ||
| Influence of legal counsel | 14.37 (2) | 303 | ||
| Not Important | 161 (70.6) | 48 (64.0) | ||
| Neutral | 54 (23.7) | 12 (16.0) | ||
| Importantb | 13 (5.7) | 15 (20.0) | ||
| Concern about future contact | 8.43 (2) | 303 | ||
| Not important | 93 (40.8) | 35 (46.7) | ||
| Neutralc | 75 (32.9) | 12 (16.0) | ||
| Important | 60 (26.3) | 28 (37.3) | ||
| Appraisal of decision as agonizing | 40.98 (2) | 305 | ||
| Yesa | 57 (24.8) | 46 (61.3) | ||
| Noa | 163 (70.9) | 22 (29.3) | ||
| Unsure | 10 (4.3) | 7 (9.3) | ||
| An embryo has a right to life | 10.37 (2) | 304 | ||
| Disagreeb | 59 (25.8) | 31 (41.3) | ||
| Neutral | 67 (29.3) | 25 (33.3) | ||
| Agreeb | 103 (45.0) | 19 (25.3) | ||
| An embryo has same dignity and right as a human being | 7.55 (2) | 304 | ||
| Disagree | 97 (42.4) | 41 (54.7) | ||
| Neutral | 58 (25.3) | 22 (29.3) | ||
| Agreec | 74 (32.3) | 12 (16.0) | ||
| Consider my embryos as virtual children | 8.94 (2) | 304 | ||
| Disagreec | 84 (36.7) | 42 (56.0) | ||
| Neutral | 67 (29.3) | 17 (22.7) | ||
| Agreec | 78 (34.1) | 16 (21.3) | ||
| Donating embryos is equal to relinquishing or giving up children for adoption | 9.47 (2) | 304 | ||
| Disagreeb | 157 (68.6) | 41 (54.7) | ||
| Neutral | 36 (15.7) | 10 (13.3) | ||
| Agreeb | 36 (15.7) | 24 (32.0) | ||
| Trouble coping with the idea of someone else bringing up our children | 27.04 (2) | 304 | ||
| Disagreea | 161 (70.3) | 37 (49.3) | ||
| Neutral | 37 (16.2) | 7 (9.3) | ||
| Agreea | 31 (13.5) | 31 (41.3) | ||
| Total anonymity with embryo donation recipients made it more challenging | 7.96 (2) | 303 | ||
| Disagree | 142 (62.3) | 53 (70.7) | ||
| Neutralc | 47 (20.6) | 5 (6.7) | ||
| Agree | 39 (17.1) | 17 (22.7) | ||
| Should not be individuals in a population that are unaware of relatedness | 6.24 (2) | 304 | ||
| Disagree | 151 (65.9) | 44 (58.7) | ||
| Neutral | 61 (26.6) | 18 (24.0) | ||
| Agreec | 17 (7.4) | 13 (17.3) |
ap < .001
bp < .01
cp < .05
Gamete recipients’ beliefs about donation
Gamete recipients most frequently reported disagreement with the statement that they lacked biological connectedness to their cryopreserved embryo(s) and most frequently reported agreement with the statement that their use of donor gametes motivated them to “want to give back” (Fig. 1).
Satisfaction and experiences with embryo disposition
Experiences with the final embryo disposition decision were analyzed using chi-square analysis including emotional, medical, and overall satisfaction with the embryo donation experience and with counseling, regret regarding final disposition decision, plans to disclosure of conception to offspring, feelings/beliefs related to donation (i.e., certainty they would donate), disappointment if unable to donate, difficulty donating, doubts about decision to donate, happy to have helped others, felt gave something away with nothing in return, embryo donation was a life highlight, concern about impact on my children, family and friends are proud of my embryo donation, hard for family and friends to understand my embryo donation, the donation is finished once embryos are donated, I will brood about this for the rest of my life, and frequency of thinking or speaking about the donation decision (see Table 3). Examination of pairwise Bonferroni adjusted Z-test or Fisher’s Exact test results showed that all variables except desired level of openness were associated with the final embryo disposition decision (see Table 3).
Table 3.
Satisfaction and donation experience variable group comparisons
| Variable | Donated, N (%) | Discarded, N (%) | χ2 (df) | N |
|---|---|---|---|---|
| Satisfaction: emotional aspects of donation | 58.88 (2) | 299 | ||
| Not satisfieda | 10 (4.4) | 23 (32.4) | ||
| Neutrala | 43 (18.9) | 24 (33.8) | ||
| Satisfieda | 175 (76.8) | 24 (33.8) | ||
| Satisfaction: medical aspects of donation | 53.95 (2) | 296 | ||
| Not satisfieda | 4 (1.8) | 16 (22.9) | ||
| Neutrala | 38 (16.8) | 24 (34.3) | ||
| Satisfieda | 184 (81.4) | 30 (42.9) | ||
| Overall satisfaction | 104.46 (2) | 297 | ||
| Not satisfieda | 5 (2.2) | 19 (27.1) | ||
| Neutrala | 23 (10.1) | 32 (45.7) | ||
| Satisfieda | 199 (87.7) | 19 (27.1) | ||
| Satisfaction: information and counseling | 43.17 (2) | 297 | ||
| Not satisfieda | 15 (6.6) | 24 (34.3) | ||
| Neutral | 40 (17.6) | 18 (25.7) | ||
| Satisfieda | 172 (75.8) | 28 (40.0) | ||
| Regret final decision | 19.38 (1) | 304 | ||
| Yesa | 8 (3.5) | 14 (18.7) | ||
| Noa | 221 (96.5) | 61 (81.3) | ||
| What are/were plans for disclosure | 15.82 (3) | 297 | ||
| Not to tell | 27 (11.9) | 13 (18.6) | ||
| Uncertainb | 64 (28.2) | 34 (48.6) | ||
| Plan to tellb | 119 (52.4) | 20 (28.6) | ||
| Already told | 17 (7.5) | 3 (4.3) | ||
| Certain right away that I would donate | 8.36 (2) | 291 | ||
| Disagree | 68 (30.2) | 26 (39.4) | ||
| Neutral | 51 (22.7) | 22 (33.3) | ||
| Agreec | 106 (47.1) | 18 (27.3) | ||
| Would have felt disappointed if couldn’t donate | 14.08 (2) | 295 | ||
| Disagreeb | 23 (10.1) | 13 (19.4) | ||
| Neutralb | 24 (10.5) | 16 (23.9) | ||
| Agreeb | 181 (79.4) | 38 (56.7) | ||
| It was a difficult decision to donate | 13.83 (2) | 293 | ||
| Disagreeb | 117 (51.3) | 17 (26.2) | ||
| Neutralb | 36 (15.8) | 19 (29.2) | ||
| Agree | 75 (32.9) | 29 (44.6) | ||
| At times doubted decision to donate | 38.90 (2) | |||
| Disagreea | 152 (67.9) | 21 (32.8) | 288 | |
| Neutrala | 22 (9.8) | 26 (40.6) | ||
| Agree | 50 (22.3) | 17 (26.6) | ||
| Happy to have helped others | 143.4 (2) | 290 | ||
| Disagreea | 2 (0.9) | 3 (4.9) | ||
| Neutrala | 9 (3.9) | 41 (67.2) | ||
| Agreea | 218 (95.2) | 17 (27.9) | ||
| Felt I gave something away without getting something back | 33.08 (2) | 291 | ||
| Disagreea | 167 (72.9) | 30 (48.4) | ||
| Neutrala | 29 (12.7) | 28 (45.2) | ||
| Agree | 33 (14.4) | 4 (6.5) | ||
| This is the highlight in my life | 12.73 (2) | 289 | ||
| Disagree | 91 (39.9) | 18 (29.5) | ||
| Neutralb | 79 (34.6) | 36 (59.0) | ||
| Agreeb | 58 (25.4) | 7 (11.5) | ||
| Concerned about impact on my children | 14.16 (2) | 290 | ||
| Disagreeb | 144 (63.2) | 23 (37.1) | ||
| Neutralb | 44 (19.3) | 23 (37.1) | ||
| Agree | 40 (17.5) | 16 (25.8) | ||
| Family/friends are proud of me | 10.05 (2) | 287 | ||
| Disagree | 21 (9.3) | 6 (9.8) | ||
| Neutralb | 129 (57.1) | 47 (77.0) | ||
| Agreeb | 76 (33.6) | 8 (13.1) | ||
| Hard for family/friends to understand my donation | 10.14 (2) | 289 | ||
| Disagreeb | 88 (38.8) | 13 (21.0) | ||
| Neutralb | 80 (35.2) | 35 (56.5) | ||
| Agree | 59 (26.0) | 14 (22.6) | ||
| The donation is totally finished | 40.33 (2) | 289 | ||
| Disagree | 44 (19.3) | 10 (16.4) | ||
| Neutrala | 49 (21.5) | 38 (62.3) | ||
| Agreea | 135 (59.2) | 13 (21.3) | ||
| I will brood about this decision for rest of life | 38.58 (2) | 294 | ||
| Disagreea | 174 (76.3) | 25 (37.9) | ||
| Neutrala | 29 (12.7) | 29 (43.9) | ||
| Agree | 25 (11.0) | 12 (18.2) | ||
| How often think about decision | 16.15 (3) | 299 | ||
| Neverb | 18 (7.9) | 18 (25.4) | ||
| Rarely | 114 (50.0) | 31 (43.7) | ||
| Occasionally | 88 (38.6) | 21 (29.6) | ||
| Frequently | 8 (3.5) | 1 (1.4) | ||
| How often speak about decision | 19.43 (3) | 298 | ||
| Nevera | 64 (28.1) | 37 (52.9) | ||
| Rarely | 109 (47.8) | 29 (41.4) | ||
| Occasionallya | 52 (22.8) | 4 (5.7) | ||
| Frequently | 3 (1.3) | 0 (0.0) |
ap < .001
bp < .01
cp < .05
Use of donor gametes
Initial/current plans for disclosure to offspring differed between embryo disposition groups with those who donated versus discarded their embryos being more likely to report plans to disclose (n = 119, 52.4% vs. n = 20, 28.6%) and greater uncertainty related to disclosure among those who discarded versus donated embryos (n = 34, 48.6% vs. n = 64, 28.2%) (χ2 [n = 297] = 15.82; df = 3, p < .01). Those who discarded versus donated their embryos were also more likely to indicate they never think about their embryo donation decision (n = 18, 25.4% vs. n = 18, 7.9%) (χ2 [n = 299] = 16.15; df = 3, p < .01) and never speak about their embryo donation decision (n = 37, 52.9% vs. n = 64, 28.1%); those who donated their embryos were more like to report occasionally speaking about their donation decision than those who discarded their embryos (n = 52, 22.8%) vs. n = 4, 5.7%) (χ2 [n = 298] = 19.43; df = 3, p < .001).
Discussion
This study is the first to examine factors associated with the completed donation of embryos for family building among a large sample of individuals who expressed interest in embryo donation at the time of IVF treatment in the United States. We found that neither genetic testing, through utilization of PGT-A or genetic carrier screening, nor use of donor gametes was associated with decision-making and that embryo donation was emotionally challenging for some patients. Just over half of the completed donors described their initial engagement and consideration with embryo donation as easy or obvious, while approximately 40% described it as extremely difficult. Additionally, we observed that respondents who found donation distressing or agonizing were more likely to discard supernumerary embryos rather than donate them. Therefore, for some individuals, donating supernumerary embryos may pose little to no dilemma, and they are more likely to follow through with donation, while for others who donate, it may represent a complex and emotionally challenging decision. For the latter group, embryo donation may be perceived as an imperfect solution to the issue of surplus embryos, providing an opportunity for their embryos to help others grow their family. Our study findings differ from prior research which reports embryo donation as an emotionally challenging decision [31, 32] and that genetic testing with PGT-A or genetic carrier screening or use of donated gametes [33, 34] is associated with embryo donation, although the direction of the association was unclear. These differences are likely due to differences in study populations and highlight the importance of understanding the perceptions and experiences of embryo disposition for individuals at the time of IVF, throughout the course of IVF, and at time of disposition decision. Our study population was unique in that all study participants were open to embryo donation at the start of IVF. It is possible that those open to embryo donation at the start of IVF would have different perceptions and experiences related to embryo donation than patients who were not open to embryo donation at the start of IVF.
Although many studies have attempted to characterize motivations for embryo donation, our survey highlights the difficulty understanding who will ultimately donate and challenges many longstanding assumptions about embryo donation, such as religious motivations being the primary catalyst for donation. Previous research has primarily focused on understanding why patients do not donate [14, 15, 18, 35–38] rather than exploring the factors that may be associated with donation completion. Our study demonstrates a broad range of key factors associated with the decision of embryo donation completion. We discovered group differences not only related to core moral beliefs like religion or embryo status, but also with respect to practical considerations, such as the willingness to stop paying for embryo storage, which were associated with completion of embryo donation.
The financial costs of fertility treatments are often burdensome and not covered by insurance. It is likely that some fertility patients will have financed their fertility treatment or used money intended for savings to engage in treatment [39]. The additional costs of embryo storage ($65/mo, $780/year for study participants) may be financially burdensome and therefore be associated with embryo disposition. Further, psychological distress has been found to result in decisional conflict [40], and thus, study participants who were not distressed about their decision may be more likely to report the decision to donate to be an easy decision to make. Participants who believed embryos had value might have also experienced disposition as easy or they might have experienced distress as their belief in the value of an embryo conflicted with their desire to donate the embryo.
Ultimately, our results revealed numerous group differences related to the decision-making process surrounding donation completion; this decision appears to be highly personal and not likely to be solely driven by a single prevailing motivation. It is crucial to acknowledge the uniqueness of each individual’s motivations and circumstances. Group differences in our study highlight that the choice to donate embryos is likely shaped by a combination of the donor’s ethical framework, their perception, and conceptualization of cryopreserved embryos, as well as their personal experiences, including previous outcomes with ART, and concerns post-embryo donation (e.g., legal protections, contact from embryo donation conceived children, well-being of donation conceived children, and disclosure of conception). Furthermore, evolving personal circumstances, such as changes in relationships, parenthood, and financial situations, all may contribute to the complexity of this decision. It is therefore important to avoid assuming who will or will not complete embryo donation, as the decision-making process may vary widely and likely changes over time among patients. An examination of decision-making theory may aid in understanding how complex decisions are made.
Within the field of reproductive medicine, one of the commonly applied theories of decision-making (the Theory of Planned Behavior; TPB) includes focus on how emotions and facts interact with other factors to lead to decisions. According to TPB, the strength of intention to engage in a behavior increases the probability that the behavior will occur. Intention is influenced by feelings/beliefs about the behavior and the consequences of the behavior (in this case, embryo donation), subjective norms (e.g., social/cultural norms and pressure related to embryo donation), and perceived control over engaging in the behavior (e.g., ease of procedures related to donation). TPB has been validated in multiple studies examining engagement in fertility treatments (e.g., gamete donation for family building or research, planned gamete cryopreservation) [41–43]. Although we did not explicitly test a model of TPB, our study findings may be consistent with TPB as factors which appear to be emotion/belief based (e.g., ethical framework, perception and conceptualization of cryopreserved embryos, previous outcomes with ART, changes in relationship/parenthood/ financial situations, and concerns post-embryo donation) were associated with donation. Similarly, some of these factors such as ethical framework and conceptualization of embryos and other factors may be associated with social or other pressures to donate.
It is important to recognize the uniqueness of different study populations and study designs may result in the identification of different significant among motivating factors and embryo donation. For instance, Carpinello et al. [29] found that among n = 438 patients, a significant proportion of patients who expressed interest in donating embryos (42.2%) and who ultimately followed through with donation (48.0%) utilized donor oocytes in embryo creation. It was hypothesized that patients who utilized donor gametes to create their embryos may have had a broader definition of family that is not solely focused on genetics. While the exploration of this topic is limited, and some patients who used donor gametes may indeed have a broader definition of family than those who use autologous gametes, it is clear from our study and other studies [33, 34] that although the use of donor gametes may be associated with thoughts about decision-making, it was not associated with different decision-making or motivations for all those who use donor gametes. We found that recipients of donated gametes mostly reported choosing to pursue embryo donation based on a desire to “give back” or reciprocate with their clinic. It is interesting to note that 26 respondents in the study reported using both donor eggs and donor sperm to create embryos; however, it is unclear if all embryos being considered for donation were created with both donor oocytes and donor sperm or if some individuals underwent multiple rounds of embryo creation and had embryos with a mix of autologous and donor gametes. It is possible that those using only donor gametes to create embryos may have different perceptions about embryo donation and this warrants future study.
It does not appear possible to reliably understand which factors may be associated with donation of supernumerary embryos for reproductive use; however, the results of our study show that there are numerous factors that may make disposition decisions a difficult and/or emotional experience. Although the goal of embryo disposition counseling is not to influence patients to make any one specific choice, we found that patients who were satisfied with the medical counseling they had received were more likely to complete donation than those who were dissatisfied with counseling. Additionally, patients who discarded their supernumerary embryos expressed less satisfaction with counseling and were found to be at greater risk of regret and dissatisfaction regarding their disposition decision as compared to those who completed embryo donation. It therefore appears important for those considering embryo donation to receive personalized counseling and psychosocial education from professionals with expertise in reproductive medicine and ethics (REIs, mental health professionals) to help them navigate the decision-making process [44]. Moreover, it behooves the REI clinic to discuss and address the possibilities of supernumerary embryos and disposition options at multiple timepoints throughout ART and especially prior to embryo cryopreservation. Participants likely engage in the cognitive processes of decision-making for embryos at many junctures (discovering their reality of supernumerary embryos, after embryo transfer, after live birth, during storage fee reminders) before forming a finalized decision and may therefore benefit from ongoing counseling to aid in decision-making.
Our study had several strengths. First, we developed a comprehensive questionnaire that incorporated important themes and findings from previously published surveys ensuring a robust assessment of patient beliefs. Another strength of our study was the inclusion of a large cohort consisting of both gamete recipients and autologous prospective embryo donors who expressed interest in embryo donation at the start of their IVF treatment cycle. Additionally, although existing studies examining motivations for embryo donation have been limited in scope, often involving small sample sizes, and focusing on all disposition options for supernumerary embryos, we examined a large and well-defined cohort of prospective embryo donors within the United States.
Our study has several limitations with potential biases and generalizability, in part due to study design and the unique population, that must be considered. First, there is a possibility of selection bias due to the lower response rate and a larger number of patients in the cohort who ultimately chose not to donate. Further, study participants were asked after embryo disposition, and not at multiple time points, about their related perceptions and experiences, and thus, survey responses may be affected by recall bias or response biases. This could have resulted in responses that support the participant’s disposition decision but may not accurately reflect their true experiences and perceptions.
Aspects of study design, some of which were unmodifiable, also posed limitations to our study. Our sample size and number of study variables also limited our ability to conduct regression analysis. Due to the limited sample size, our study also collapsed participants who chose to discard excess embryos or donate excess embryos to research into one group as in both options embryos are destroyed. Although both groups conceptually would appear to be open to the destruction of embryos, each group may have unique perceptions and experiences related to embryo disposition. Next, the exclusion of participants who were not initially open to donation but may have later engaged in embryo donation as well as our inability to compare study respondents and non-respondents or analyze responses by sexual orientation, gender identity, or concordance of responses between couples limits the generalizability of the study findings. Lastly, although participants and their partners received the initial study invitation, the invitation was addressed to the participant (who was considered the primary patient and who was therefore likely assigned female at birth) with their partner being copied on the invitation. It is likely that this contributed to the large number of female study participants with fewer partners participating in the study. Further, although the survey link could be used to submit only one survey response, both partners may have collaborated to complete the survey.
Our study contributes to the embryo donation literature by examining a unique population in that participants are limited to those who indicated a desire to engage in embryo donation at the start of IVF. Results of our study highlight group differences associated with embryo donation in a large number of patients which may be considered for inclusion in patient counseling for embryo donation. Additionally, our study evaluated factors associated with desire for donation at the onset of IVF and at the final disposition. At the same time, it is important to note that motivations for embryo donation are complex and can be influenced by non-demographic or belief-based factors such as national and local jurisdiction regulations on donation [32], as well as variations in the models of embryo donation practiced (such as open, semi-open, and closed donation models). Our study specifically focused on the United States and employed a closed donation model, where both the donor and intended parent have no identifying information about each other, so caution should be exercised when generalizing our findings to other contexts. Future research could benefit from a greater understanding of the experiences of those who opt to discard or donate excess embryos for research and from longitudinal assessments to minimize the impact of recall bias and provide a more accurate understanding of decision-making dynamics over time.
Our findings highlight that fertility clinics can take important steps to help address the problem of unused or abandoned embryos through optimizing decision-making counseling. All patients utilizing IVF should be transparently educated at the outset on their relative success rates and potential outcomes and disposition options for supernumerary embryos. Patients should fully understand the clinic’s policies, including any time limits for embryo storage, costs, and legal implications. They should also receive counseling at the completion of IVF. At our practice, patients who are postpartum require a waiting period before they may donate embryos. We also discourage patients from only donating a portion of their embryos; patients should only donate if they had completed family building. All clinics should have a third-party reproduction team, and if no embedded counselor at hand, should build relationships with local reproductive psychologists to address their patients’ emotional concerns and help them navigate the decision-making process that aligns with their personal beliefs and values. Psychoeducation may bring to light more information which can impact candidacy for donation.
Cryopreserved embryos that remain unclaimed present dilemmas for all stakeholders including physicians, clinics, and those who created the embryos. Storage of unclaimed embryos is costly due to limitations of space and the need for redundant surveillance systems to guard against unintended loss. Clinics may be left in legal limbo, afraid to discard unclaimed embryos should patients later return to claim them, and patients may experience distress related to decision-making. As embryo donation becomes a more accepted and available option for building families [45, 46], the number of embryo donation transfer cycles is rising. In the United States, less than 2500 embryo transfers using donor embryos are performed each year [47]. Our study highlights that there may be some patients who would donate their excess embryos if they received counseling which fully addresses their legal, personal, emotional, and medical concerns related to donation. One direction for future research may be to implement a decision aid intervention to assist patients with supernumerary embryos. Overall, our study underscores the complexity of embryo donation decisions for prospective donors and highlights the need for personalized approaches that consider individual circumstances, values, and evolving dynamics. By refining our understanding of these motivations for supernumerary embryo decision-making, we can enhance patient care through the provision of improved medical and psychological counseling services and facilitate informed decision-making for individuals and couples navigating the journey of infertility treatment, family building, and embryo disposition.
Supplementary Information
Below is the link to the electronic supplementary material.
Funding
Funding was provided by The National Human Genome Research Institute/National Institute of Health (1RM1HG009037; Rothwell/Tabery (MPIs)).
Declarations
Conflict of interest
The authors declare no competing interests.
Footnotes
Attestation statement
• The subjects in this trial have not concomitantly been involved in other randomized trials (If applicable).
• Data regarding any of the subjects in the study has not been previously published unless specified.
• Data will be made available to the editors of the journal for review or query upon request.
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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