Can you believe what happened?
The number of healthy babies born around the world after transfer of so-called “aneuploid” embryos (now at times called “euploid-mosaic”) after preimplantation genetic screening (PGS) is steadily growing. Even a reproductive endocrinologist in NYC advised us very recently of the birth of his own perfectly healthy daughter after transfer of allegedly “aneuploid” embryos. Altogether, we are now aware of nearly 50 healthy births after such transfers worldwide, with the total number, likely, being even higher.
Already in late 2014, transferring selected allegedly “aneuploid” embryos, CHR was the first IVF center in the world reporting to immense attention at the Annual Meeting of the American Society for Reproductive Medicine (ASRM) in October of 2015 three healthy births. It, however, took until 2016 before the Preimplantation Genetic Diagnosis International Society (PGDIS) reinforced this practice in new guidelines. The Ethics Committee of the ASRM, finally, did so recently as well (Ethics Committee of the American Society for Reproductive Medicine. Transferring embryos with genetic abnormalities detected in preimplantation testing: An Ethics Committee Opinion. Fertil Steril 2017;107:1130-1135).
This, of course, does not mean that all colleagues have endorsed this practice. Indeed, several are still totally opposed to transferring any aneuploid/mosaic embryos, whatever their classification under whatever nomenclature. While we obviously disagree, and believe that available evidence strongly supports transfer of many, if not most, aneuploid/mosaic embryos, we accept their right to refuse a treatment, which they (rightly or wrongly) believe may be damaging to their patients. We, indeed, strongly feel that no physician should ever be forced to apply treatments against better judgment or over moral objections (an opinion also supported by the above noted Ethics Opinion _of the ASRM_).
In reverse, physicians, however, also do not have the right to represent personal beliefs, not shared by others, as undisputed medical facts and, thereby, impose their personal opinions on patients. Indeed, ethics standards require that physicians who refuse to provide certain medical services, still advise patients that such services may be available through other medical providers. Though such professional behavior, fortunately, is generally the norm in our specialty, on occasion there are exceptions, as we recently were reminded, when a couple with residence in another U.S. city presented to CHR for a Second Opinion Consultation.
They had undergone three IVF cycles at another nationally prominent center, which almost routinely utilizes PGS in association with IVF and, therefore, equally routinely cultures embryos to blastocyst stage. After three IVF cycles at that center, they ended up with only three blastocyst-stage embryos, which all after PGS were reported as “aneuploid.” Colleagues at that center then categorically refused to even consider transferring any of these embryos, even though such transfers are now accepted as a potential treatment option for couples with no euploid embryos after PGS (see also the CHR Opinion on this topic). At that point, the couple decided to reconsult with CHR (they had previously consulted with a CHR physician long-distance prior to their IVF cycles at the other center but then decided to stay local for their IVF treatments). CHR physicians reviewed the couple’s history, including the genetic analyses of their embryos, and concluded that at least some of their still cryopreserved, allegedly “aneuploid,” embryos could be transferred.
Based on this opinion, the couple contacted their local IVF center to move out their embryos to CHR. Such transfers of embryos between IVF centers are quite common, and are usually processed by the respective embryology teams at the two centers in a rather routine fashion. Not so, however, this time: To patients’ and CHR’s surprise, their local IVF center refused to transfer the embryos to CHR under the explanation that “they do not transfer abnormal embryos to other centers.” The couple’s argument that those embryos under the law were their property and, therefore, subject to their and not the center’s decisions, was also unsuccessful in changing minds at the IVF center.
It took the intervention of a lawyer on behalf of the couple before their local IVF center, suddenly, agreed to release the embryos. The IVF center’s lawyers, very obviously and quickly, read their clients the riot act, and explained to them that they simply had no legal leg to stand on. Physicians entrusted with their patients’ embryos should, however, know better in the first place!
As we are describing this episode in these pages, the embryos are on the way to CHR. We, of course, have no idea whether their transfer will lead to a pregnancy and birth. But we do know that what happened to this couple was not only illegal (because under the U.S. law, embryos are considered property of the parents) but also highly unethical.
It is simply inappropriate for any physician to usurp a patient’s (or in this case, a couple’s) responsible, and well thought-out, clinical decision-making process. It is even more inappropriate when physicians presume to possess decision-making rights over embryos produced by patients. The last time (and fortunately the only time we are aware of in the history of IVF) physicians in our field erroneously felt entitled to insert themselves into parental ownership of gametes and embryos, it led to the by now infamous University of California Fertility Scandal in 1995.
We by no means want to equate the unauthorized use of eggs in creating embryos for other women/couples (which is what happened in 1995 in Irvine, CA) to the experience of here-described couple, but there is a degree of analogy in the impertinence of physicians in presuming they have the right (whatever the reasons) to usurp the absolute rights of mothers and fathers to embryos created with their own gametes. Even most radical “ideological” beliefs in the validity of PGS as a diagnostic procedure and, therefore, even most strenuous opposition to transfer of embryos, by PGS determined to be aneuploid/mosaic, does not excuse such behavior.
Differences of opinions between practicing physicians are common in all medical specialties. Such differences, indeed, play an important role in quality control and progress in the medical field. All such benefits are, however, lost when zealousness turns opinions into ideologies and/or dogmas, and alternatives are viewed as moral sins.
Following this recent experience, we here at CHR have started to wonder what it will take to avoid the obvious zealousness that has crept into the ongoing PGS debate. Both sides of the debate, very obviously, must learn to objectively assess biological and clinical evidence and move away from convictions of absolute certainty since nothing in science is ever absolutely certain.
If we are lucky, a pregnancy and live birth from here discussed embryos may just do that for at least the colleagues in that other city. But can you believe what happened!
This is a part of the June 2017 issue of the VOICE.
Norbert Gleicher, MD, leads CHR’s clinical and research efforts as Medical Director and Chief Scientist. A world-renowned specialist in reproductive endocrinology, Dr. Gleicher has published hundreds of peer-reviewed papers and lectured globally while keeping an active clinical career focused on ovarian aging, immunological issues and other difficult cases of infertility.
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