Keywords
oocyte donation - bioethics - infertility - reproduction
Palavras-chave
doação de oócitos - bioética - infertilidade - reprodução
Introduction
Fecundation and the desire to have children and to form a family have always had a
divine connotation. In the 1970s, rumors surfaced that scientists could play God by
performing ‘conception’ in the laboratory rather than by sexual intercourse, causing
concern to religious groups and to those who prioritize ethical behavior in society.
This moment, which coincides with the emergence of bioethics, demonstrates the type
of concern that guides the reflection in this field, which has grounds for action
in the area of reproductive health.[1]
Bioethics is a new discipline that establishes a bridge between the scientific and
humanistic cultural dimensions[2] and combines human values and biological knowledge. It is a new ethical science
that combines humility, responsibility, interdisciplinarity, and intercultural competence,
thus enhancing humanity; it is based on the study of human conduct in the life sciences
and health care considering moral principles and values.[3] The technological advances in reproductive medicine, particularly in vitro fertilization
(IVF), with the manipulation, production, and freezing of embryos and experimentation
with embryos, refers to the ethical, legal, and ontological statute of human life
since its inception and development.[4] Therefore, bioethics is linked to assisted reproduction, embryo genetic studies,
cloning, embryonic stem cell research, organ donation, human participation in experimentation,
gene therapy, gene sequencing, and end-of-life issues.[5]
These questions are based on the principles of bioethics related to principlism.[6] Principlism is not a theory or an ethical doctrine; rather, it defines the ethical
basis for the protection of human beings by mediating tools in the deliberation and
decision of bioethical subjects and questions, helping with self-regulation and legislation.[7] It is based on four main pillars of autonomy, nonmaleficence, beneficence, and justice.
Autonomy is the principle of greater weight in bioethics; it reflects respect for
a person's will according to their point of view, values, and convictions. In the
medical practice, professionals should respect their patient's autonomy to consent
to diagnostic testing, procedures, and treatments. Nonmaleficence is a fundamental
Hippocratic principle of medical ethics, primum non nocere – first, do no harm. It is a moral requirement of the medical profession not to incur
malpractice or negligence; the expected benefit should outweigh the known risks. In
turn, beneficence is the moral obligation to benefit others whether it is desired
or not, and is within the Hippocratic oath. And finally, justice refers to the possibility
of accessing services and resources in an egalitarian way to equate the opportunities
made available to all human beings in the same conditions. Dignity, freedom, equity,
solidarity, and dialogue are other topics of principlism that must be considered.[8]
Therefore, we see an intimate relationship between bioethics and oocyte donation,
which is a growing practice in assisted reproductive treatments. Donors and recipients
deserve a detailed reflection because of this approach. Traditionally, the birth of
a child symbolizes a ‘divine gift,’ and assisted reproduction (AR) counteracts this
concept. Numerous philosophical questions and doubts arise with the technological
advances related to the AR techniques (ARTs) that are available for infertile couples.
Infertility, which is defined by the World Health Organization (WHO) as failure to
achieve pregnancy after one year of unprotected sex, is a public health problem. However,
infertility raises issues regarding individual and family well-being and the social
insertion of couples,[9] and ARTs are an alternative method to achieve procreation.[4] From the list of problems associated with infertility, ovulatory factors comprise
the main female cause.[10] Today, because of work overload, eating habits, and lifestyle choices, a significant
percentage of women are beginning menopause at an early age. Moreover, with maternity
occurring later in life, there is an increased incidence in infertility due to ovarian
failure, and ARTs enable procreation in this context.[11] Furthermore, IVF using donated oocytes becomes a tool to assist with the reproductive
goal in cases of ovarian failure.[9]
Despite several advances in recent years, reproductive medicine and ARTs are not regulated
by specific laws in Brazil. Rather, they are regulated by ethical resolutions of the
Brazilian Federal Medical Council (Conselho Federal de Medicina, CFM, in the Portuguese
acronym), which have the same effect as laws for the medical class. Spermatozoa were
the first germ cells successfully used in donation procedures, and Brazil currently
has sperm banks, with costs for those who use donor semen.[12]
Oocyte donation is more complex; it involves higher costs and presents risks to the
donor due to the need for ovarian stimulation and surgical oocyte collection. In Brazil,
embryo and gamete donations are regulated by the CFM. The Ethical Directions for Assisted
Reproductive Techniques (CFM Resolution no. 1358/1992)[13] has allowed gamete donation since 1992, but it has not established clear rules for
its practice. Almost 20 years after its first publication, in 2010, the CFM published
(CFM Resolution no. 1957/2010)[14] an update that included no modifications about gamete donation. Only in the update
published in 2013 (CFM Resolution no. 2013/13)[15] did the CFM clarify this issue, establishing that voluntary gamete donation was
allowed in the form of shared oocyte donation, in which both donor and recipient undergoing
infertility can share oocytes and the financial costs of the treatment.[15] However, in 2015, a new resolution established that voluntary donation was permitted
only for male gametes (spermatozoids), and that oocyte donation was only allowed in
a shared model, in which donors and recipients participate in IVF.[16] The latest resolution, which was published in 2017 (CFM Resolution no. 2168/2017),[17] stablished the permission to voluntarily donate semen and oocytes, as well as the
shared oocyte donation, which was similar to the 2013 resolution.
Due to the complexity of voluntary oocyte donation and to the modifications in the
CFM resolutions, oocyte banks are difficult to establish. Shared donation in IVF cycles,
in which donors and recipients participating in ARTs share biological material and
financial costs, is common, and has been allowed since 2013. Because there are many
more recipients than donors, the recipients must wait to receive oocytes in AR clinics.
Accordingly, conflicting and innovative situations arise regarding the rights and
duties of those who seek AR clinics for procedures performed with donated gametes,
giving rise to bioethical questions that merit analysis. The bioethical view is indispensable
to examine situations, postures, and procedures when considering how to avoid injustice
and inequality.[4]
A recent systematic review about the motivations and experiences of oocyte donors,
recipients, and egg sharers demonstrated that the attitudes and feelings of patients
involved on all sides of the donation process were extremely positive. Moreover, the
motivations for the donors were the wish to help another couple have a child and to
obtain a cheaper treatment, which are equally important.[18]
The present study evaluated the ideas and expectations of oocyte donors and recipients
in an egg-sharing program in Brazil. The data was collected through a semi-structured
questionnaire, and the researchers discussed the viewpoints of the studied population
in a bioethical argument regarding AR issues that involve medical professionals, patients,
society, and the entities responsible for the resolutions.
Methods
The present study was developed as a collaboration between Universidade do Vale do
Sapucaí and Pró Criar, a private reproductive medicine clinic, both located in the
city of Pouso Alegre, state of Minas Gerais, Brazil. This study received approval
from the Ethics Committee of the university (Univás, protocol no. 61451416.8.0000.5102),
and all patients signed a free and informed consent form, guaranteeing their anonymity.
A total of 20 candidates for a shared oocyte donation program (10 oocyte recipients,
10 oocyte donors) who were examined at Pró Criar were consecutively invited to participate
and answer the questionnaire between November 2016 and January 2017. All 20 invited
women agreed to participate and answer the questions, and were included in the study.
No patients were excluded.
The present qualitative study employed the Collective Subject Discourse (CSD) methodology
for data analysis and systematization.[19] A semi-structured questionnaire asked the following two questions: ‘What does it
mean to you to be an oocyte donor/recipient?’; and ‘What are your expectations regarding
infertility and oocyte donation?’
These questions were previously validated and applied to two patients (one oocyte
donor, one oocyte recipient) to verify whether they actually provided the data that
the researchers meant to collect.[20] After validation, the interviews were performed with the 20 patients (10 donors,
10 recipients). The interviews lasted an average of 30 minutes. The patients had no
connection to one another, and the interviews were conducted individually, recorded,
and later transcribed for analysis.
Results
The participants' demographic characteristics are described in [Table 1]. According to Brazilian law, the oocyte donor must be ≤ 35 years of age, and most
oocyte recipients are of advanced maternal age. Thus, as expected, the women in the
donor group were younger than the recipients, and, consequently had infertility for
a shorter period of time. All women were married, and most had college degrees (70%
of each group). The most common cause of infertility among the oocyte recipients was
ovarian failure; as or the oocyte donors, in most cases, the infertility did not affect
them, but their partners.
Table 1
Mean demographic characteristics of the study participants
|
Donors
|
Recipients
|
p-value
|
|
Age (years)
|
29.7 ± 2.5
|
41.1 ± 4.9
|
< 0.001
|
|
Body mass index (kg/m2)
|
23.4 ± 2.1
|
24.9 ± 2.3
|
0.145
|
|
Infertility time (years)
|
2.7 ± 0.7
|
5.0 ± 2.6
|
0.014
|
The results of this study were obtained through key expressions (KEs), central ideas
(CIs), analysis, and a discussion about the interview contents. From the patients'
transcribed responses, the KEs of each discourse were categorized into CIs and quantified
as percentages of the total number of patients. [Table 2] describes the CIs regarding question 1 (‘What does it mean to you to be an oocyte
donor/recipient?’), while [Table 3] describes the responses for question 2 (‘What are your expectations regarding infertility
and oocyte donation?’).
Table 2
Central idea categories for Question 1: What does it mean to you to be an oocyte donor/recipient?
|
Central idea
|
Donors, n (%)
|
Recipients, n (%)
|
p-value
|
|
Acceptance
|
|
|
|
|
Accepted the donation/reception
|
4/10 (40%)
|
6/10 (60%)
|
0.656
|
|
View with caution
|
|
|
|
|
Difficulty accepting donation/reception
|
4/10 (40%)
|
3/10 (30%)
|
1.000
|
|
Lower treatment costs
|
3/10 (30%)
|
0/10 (0%)
|
0.211
|
|
Considered donation the same as donating a son/daughter
|
2/10 (20%)
|
3/10 (30%)
|
1.000
|
|
Concerned about donor characteristics
|
0/10 (0%)
|
1/10 (10%)
|
1.000
|
|
Afraid of treatment success
|
0/10 (0%)
|
3/10 (30%)
|
0.211
|
|
Motivation
|
|
|
|
|
Possibility of motherhood
|
7/10 (70%)
|
10/10 (100%)
|
0.211
|
|
Donation due to lower treatment costs
|
7/10 (70%)
|
2/10 (20%)
|
0.070
|
|
Donation/reception to help other women
|
8/10 (80%)
|
6/10 (60%)
|
0.629
|
|
Imagined another woman's position
|
6/10 (60%)
|
2/10 (20%)
|
0.170
|
|
Male infertility
|
2/10 (20%)
|
0/10 (0%)
|
0.474
|
|
Oocyte surplus
|
2/10 (20%)
|
1/10 (10%)
|
1.000
|
|
Desiring physical/emotional motherhood stages
|
1/10 (10%)
|
6/10 (60%)
|
0.057
|
Table 3
Central idea categories for Question 2: What are the expectations regarding infertility
and oocyte donation?
|
Central ideas
|
Donors, n (%)
|
Recipients, n (%)
|
p-value
|
|
Expectations
|
|
|
|
|
Search for alternatives to infertility
|
4/10 (40%)
|
3/10 (30%)
|
1.000
|
|
Donation due to lower treatment costs
|
4/10 (40%)
|
2/10 (20%)
|
0.629
|
|
In vitro fertilization to achieve motherhood
|
9/10 (90%)
|
8/10 (80%)
|
1.000
|
|
Donation of oocytes as a last option
|
1/10 (10%)
|
5/10 (50%)
|
0.033
|
|
Fear regarding treatment success
|
2/10 (20%)
|
2/10 (20%)
|
1.000
|
|
Oocyte donation as an exchange of favors
|
3/10 (30%)
|
0/10 (0%)
|
0.211
|
|
Oocyte donation to help other women
|
8/10 (80%)
|
4/10 (40%)
|
0.170
|
Question 1: What Does it Mean to You to be an Oocyte Donor/Recipient?
Three CI subgroups were created based on the participants' responses regarding the
meaning of being a donor/recipient (question 1): 1) the positive meaning (acceptance)
subgroup included the discourses that did not express any restrictions; 2) the view
with caution subgroup included discourses in which some restrictions or difficulties
regarding acceptance were expressed; and 3) the motivation subgroup included the CIs
that lead to the reasons why the women opted to be oocyte donors/recipients ([Table 2]).
The acceptance of oocyte donation was mentioned by 40% of the donors and by 60% of
the recipients, which shows that, on average, half of the women did not present difficulty
accepting egg sharing. Those who had some initial restrictions expressed difficulty
accepting the donation, fear that the lower treatment costs due to egg sharing are
not significant for donors, and concern about the treatment success of the recipients.
Approximately 25% of the women (20% of donors and 30% of recipients) initially interpreted
oocyte donation as the donation of a son/daughter.
Regarding the motivations for treatment, the two groups demonstrated that the possibility
of motherhood was the primary reason for oocyte donation/reception, as both donors
and recipients were infertile women seeking ARTs to become pregnant and realize their
dream of being mothers. This motivation was reinforced by the statement that most
donors (80%) agreed to donate to help another woman, and 60% of the recipients stated
that they desired to feel the physical and emotional stages of motherhood. The financial
issue was also important, primarily for the donors (70%), because they share the costs
of the treatment with the recipients.
Question 2: What are your Expectations regarding Infertility and Oocyte Donation?
Regarding the expectations about infertility and oocyte donation (question 2), the
KEs were categorized into CIs and quantified as percentages of patients. The following
subgroup was created: 1) expectations related to oocyte donation/reception ([Table 3]).
The CI concerning the expectations was the assertion that IVF would be the means to
realize the dream/desire of motherhood (70% of donors, 100% of recipients). A total
of 60% of the patients stated aiding another woman as the expectation, and this occurred
more frequently among the donors (80%). A total of 30% of the donors mentioned the
fact that oocyte donation works as an exchange of favors.
Relevant Issues Mentioned during the Interviews
Relevant Issues Mentioned during the Interviews
Among the relevant issues raised in the patients' discourse for questions 1 and 2,
the most preponderant discourse included the anguish, sadness, and frustration generated
by infertility, which demonstrates the importance of infertility among the emotional
issues of women. In this context, reports that ARTs bring emotional relief stand out.
The women also reported the lack of adequate information about ARTs and the high cost
of the treatment. The issue of adoption only after all ART resources were exhausted
was mentioned by 40% of the patients (both donors and recipients). An average of 50%
of the women questioned the rules and difficulties for oocyte donation/reception in
Brazil, and did not find them fair.
Discussion
Gamete donation consists of the use of gametes donated by couples who cannot procreate
but wish to have children.[21] Spermatozoa were the first germ cells used in ARTs with donated gametes. In sperm
banks, donors voluntarily cooperate altruistically after various laboratory examinations,
and the semen is marketed by authorized clinics.[22] The Brazilian rules for oocyte donation were not clear during the first years of
its practice in the country, and many changes were made in the past few years.[14]
[15]
[16]
[17] In the period in which this study was performed (2016–2017), only the egg-sharing
model was allowed in IVF cycles, in which donors and recipients with reproductive
problems shared both biological material and financial costs.[16] According to the CFM, the donor age limit is 35 years; anonymity is mandatory; and
one should seek greater phenotypic similarity and compatibility between donors and
recipients, and not produce 2 pregnancies of different sexes in an area of 1 million
inhabitants with donor oocytes. The Resolution of the CFM also advocates 50 years
of age as a limit for IVF recipients.[16]
[17]
Scientific advances, economic globalization, international dialogue, and cultural
factors have created ethical and moral questions that impose limits on procedures
performed in human beings. Bioethics arises out of this multicultural set of factors,[23] and it is based on the study of human conduct in the life sciences and health care,
considering moral principles and values.[3] Bioethics includes safeguarding individual rights and protecting human beings from
the deleterious effects of technology, while simultaneously ensuring their access
to fundamental advances.[24] The technological advancements in reproductive medicine, particularly in IVF with
embryo manipulation, are related to the ethical, legal, and ontological statute of
human life since its inception and development.[4] Accordingly, we see an intimate correlation between bioethics and oocyte donation,
the central theme of the present study.
The results of the present research reveal the ideas of donors and recipients regarding
shared oocyte donation. The KEs of the transcribed speeches were categorized into
CIs and quantified and grouped into social representations of acceptance, issues with
caution, motivation, and expectations. We also highlighted the relevant issues that
were raised in the responses of the interviewed women, and the suffering caused by
infertility was the most prominent point. The lack of adequate knowledge of AR resources,
such as oocyte donation/reception and shared cycles, reveals the need for multidisciplinary
support and to provide clear information to couples, respecting their autonomy and
their freedom to decide how they will seek treatment for their infertility. A systematic
review of European studies also identified a lack of knowledge of egg-sharing outside
of fertility clinics, which was expressed by a minority of patients, and concerns
about whether participating in the egg-sharing program would impact their success
were raised,[25] as they were in the present study.
The CIs of helping other women and financial issues are some of the points highlighted
by the donors, while the main motivation expressed by the recipients was their desire
to feel the physical and emotional stages of motherhood. The desire to help others
and the financial advantages are common motivations also described by other authors
studying egg-sharing patients.[26] However, our data demonstrated that the maternal desire was the leading factor for
both donors and recipients, as is expected among women undergoing ARTs to have a child.
This desire for a family should be valued without compromising autonomy and freedom.[27]
Donors, even those suffering from infertility, perceive that the recipients' situation
is worse, and, out of solidarity, dignity, beneficence, justice, dialogue and equity,
are willing to donate their oocytes. However, the financial contribution of the recipients
to the donors, which enables their treatment, must also be considered.[28] The high cost often makes treatment impossible, leaving the patients that cannot
afford the treatment frustrated, which raises the issue of social inequality,[29] an important issue in countries like Brazil, where there are very restricted numbers
of public ART programs, and the costs of treatment in a private clinic are high. The
recipients feel the physical need to become pregnant and raise a child; these women
compare oocyte donation with organ donation, and mention the lack of other options.
Other studies cited in a systematic review of European populations reported that women
would prefer to use their own oocytes in the first place, but this was not feasible.[18]
The CIs for the question regarding the expectations reveal the realization of the
common dream of motherhood as the most common response among donors and recipients.
For the recipients, the delay in motherhood forces them to seek ART clinics, where
they will have the possibility of fulfilling the dream of pregnancy by receiving oocytes.
However, they feel hurt by the obligation to perform the procedure in shared cycles;
these women were unaware of the rules and did not know that oocyte banks are not available;
they had imagined equal and fair rules. Moreover, adoption is not their first choice
because they want to feel the physical stages of pregnancy.
Our data also demonstrated that most of the same motivations, concerns, and expectations
were mentioned by both donors and recipients, which demonstrates that both groups
have similar views regarding egg-sharing programs. Gürtin et al[30] showed that donor and recipient experiences and opinions have very few differences,
and highlighted the positive assessment of the egg-sharing program, and the words
that best described the experience were rewarding and satisfying. However, this study evaluated patients who underwent treatment, and our study interviewed
women before treatment. Thus, the experiences about egg-sharing described by Gürtin
et al[30] differ from the ones we noted, as we observed both positive motivations and concerns.
Objective criteria must be determined to reduce inequalities. The limited number of
donors and the financial costs of the treatment should be evaluated by the authorities
and professionals involved in seeking justice and breaking down barriers.[29] The current ARTs, such as shared oocyte donation, are a wide bioethics field of
discussion that involves both donors and recipients.[31] An ethical discussion arises regarding the fact that donor care can be can be ethically
compromised by the conflict of interests and incentives inherent in the current egg-sharing
program in the IVF process, as not all donors undergo an adequate informed consent
process.[32]
Donors and recipients deserve detailed reflection because of this approach. These
questions are based on the principles of bioethics related to principlism.[6] The reference to principlist bioethics is important to the professionals working
in AR and the patients (donors and recipients) because it enables a deep reflection
of ART methods. In 1979, due to multidisciplinary dilemmas and bioethical problems,
Tom Beauchamp and James Childress published the book Principles of Bioethical Ethics.[33] In it, they proposed a theory based on four basic principles of beneficence, autonomy,
justice, and nonmaleficence, which became the foundations of the bioethics principles
that are widely used in clinical bioethics in Brazil. By urging compliance, this set
of ethical norms was called principlism by Dan Clouser and Bernard Gert in 1990.[34] These principles complement one another and are rules for guiding actions against
the bioethical dilemmas of present-day society that occur as a result of the advancements
in biological and medical sciences.[35]
The references of bioethics should be included in the discussion to formulate resolutions
and laws in the face of advances in technology and science, seeking egalitarian rules
for beneficence, autonomy, freedom, solidarity, equity, nonmaleficence, dialogue,
and justice.[12] Advancements have been made in the CFM rules regarding oocyte donation: voluntary
donation that is not necessarily shared was first authorized in 2017. This resolution
makes egg donation similar to sperm donation regarding the freedom of a fertile woman
to choose to donate, and it enables the creation of an oocyte bank.
Conclusion
The objective of the present study was to understand the motivations and expectations
of patients regarding shared oocyte donation and to foster a discussion about this
topic from a bioethical perspective. The data obtained showed that infertile women
are generally frustrated due to the inability to become pregnant; they search for
information, and believe the IVF may be the treatment they need. They want to have
a child, and are not against adoption, but desire to feel the physical and emotional
stages of pregnancy. They face the high cost of the treatment, and oocyte donation/reception
appears as a way to reduce the costs for the donor and to enable treatment and the
recipients to become pregnant. They note that it is necessary to share the treatment,
which makes it difficult and time-consuming; they also stated that the rules are not
fair and egalitarian, and that financial assistance is not substantial and becomes
a secondary condition. Solidarity, with mutual help, is the most important factor
in the quest to achieve the common dream of being a mother. These women believe that
children are essential in the constitution of the family, and scientific advances
and innovative technologies enable the constitution of new forms of family, which
has repercussions in the social, economic, political, and family contexts, leading
to modern bioethical questions. New medical technologies have created uncertainty
and new questions regarding moral and ethical principles; thus, this creates the possibility
to practice a bioethics that aims to join scientific knowledge and human values within
a multidisciplinary approach, particularly in ARTs. Bioethics references should guide
and assist in the formulation of resolutions in assisted human reproduction. Further
studies are needed to add knowledge and encourage debate regarding this current and
comprehensive issue.
