Ethical Considerations in Pediatric Fertility Preservation: Pediatric...

The first live birth with in vitro fertilization was in 1978, approaching 40 years ago at the time of this discussion.

The field of bioethics emerged in the post-Nuremberg era and gained footing in the 1960s and 1970s, founded by philosophers and theologians grappling with new technologies including transplantation, life support, and assisted reproduction.

Some religious traditions, particularly Catholicism, are opposed to any form of assisted reproduction.

There are gendered moral burdens in fertility preservation: suggesting fertility preservation for a post-pubertal male is qualitatively different than for a female of any age due to differences in invasiveness of procedures.

There is very little tracking of offspring of fertility treatments nationally, though data collection is increasingly starting for children born from in vitro fertilization.

Connecticut recently changed its definition of infertility from 6-12 months of inability to conceive to anyone with medical necessity.

Some patients undergoing fertility preservation today are anticipated to keep tissues or cells in storage for 20 to 30 years, but there is no data on success rates for tissues stored that long.

There are no clear national guidelines on disposition of gametes for reproductive purposes after patient death, and court decisions on posthumous reproduction vary widely by state.

In pediatric decision-making, there is a gradation of consent: informed consent (typically age 18+), pediatric assent (typically ages 11-13), and best-interest standard for younger or less mature patients.

Embryo cryopreservation has a 33-52% success rate.

Oocyte cryopreservation transitioned from experimental to established standard of care in the last five years (prior to this discussion), so success rates are not as well established as for embryo cryopreservation.

Testicular tissue cryopreservation currently has no live birth rates in humans.

Fair equality of opportunity theory argues that fertility preservation ought to be made equally available to all who could benefit, requiring changes to institutional and societal practices around healthcare access.

Reproductive justice scholars describe 'stratified reproduction' as distribution between haves and have-nots in reproductive terms; assisted reproduction is already stratified by privilege.

A hub-and-spoke model is proposed where large centers with fertility preservation programs provide consultation and resources to smaller centers, with patients traveling to the hub for experimental procedures requiring specialized expertise.

Most adult gynecologists are comfortable doing adolescent gynecology, but the discomfort comes with how young a patient they are comfortable operating on; ovarian tissue cryopreservation may require oophorectomy on a 1-2 month old infant.

Cincinnati Children's has sent 2-3 patients under 16 years old for oocyte cryopreservation pre-treatment to the University of Cincinnati REI group, not under an IRB protocol.

Embryo cryopreservation is impractical for most pediatric patients and many young adults (18-25) because the average age of first birth in the US is increasing and people are partnering later.

The American Society for Reproductive Medicine removed the experimental designation from oocyte cryopreservation in 2012, marking a landmark shift in the field.