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{{Theme
|Theme Type=Other
|Title=The decision on ice
|Is About=In 1983, Trounson and Mohr<ref>Trounson A, Mohr L. Human pregnancy following cryopreservation, thawing and transfer of an eight-cell embryo. Nature. 1983 Oct 20-26;305(5936):707-9. doi: 10.1038/305707a0. PMID: 6633637.</ref> announced the first human pregnancy following cryopreservation, thawing, and transfer of an eight-cell embryo. Since then, embryo cryopreservation became a crucial tool that complements a standard in vitro fertilization (IVF) procedure by maximizing its effectiveness and reducing the risk of multiple pregnancies by limiting the number of embryos transferred. However, as a consequence, a growing supply of embryos in cryostorage has been reported worldwide<ref>Hoffman DI, Zellman GL, Fair CC, Mayer JF, Zeitz JG, Gibbons WE, Turner TG Jr; Society for Assisted Reproduction Technology (SART) and RAND. Cryopreserved embryos in the United States and their availability for research. Fertil Steril. 2003 May;79(5):1063-9. doi: 10.1016/s0015-0282(03)00172-9. PMID: 12738496.</ref><ref>Boulton A. Britain poised to extend storage of frozen embryos. BMJ. 1996 Jan 6;312(7022):10. doi: 10.1136/bmj.312.7022.10a. PMID: 8555843.</ref>.
|Important Because=When it is decided that no further fertility treatments will be pursued, couples are facing the challenging decision regarding the disposition of their frozen embryos, also known as “embryo disposal decision” (EDD) <ref>Bruno C, Dudkiewicz-Sibony C, Berthaut I, Weil E, Brunet L, Fortier C, Pfeffer J, Ravel C, Fauque P, Mathieu E, Antoine JM, Kotti S, Mandelbaum J. Survey of 243 ART patients having made a final disposition decision about their surplus cryopreserved embryos: the crucial role of symbolic embryo representation. Hum Reprod. 2016 Jul;31(7):1508-14. doi: 10.1093/humrep/dew104. Epub 2016 May 10. PMID: 27165623.</ref>. Essentially, at the end of the storage period, which varies amongst different countries and institutions, couples have 4 outcomes to choose from: to continue storage by paying an additional cost, to discard, or to donate embryos to research or to another couple. There is also the complex matter of “abandoned embryos” that refers to the cases where the couple cannot be reached and/or fails to provide the clinic with a decision pertaining to the embryos’ fate<ref>Newton CR, Fisher J, Feyles V, Tekpetey F, Hughes L, Isacsson D. Changes in patient preferences in the disposal of cryopreserved embryos. Hum Reprod. 2007 Dec;22(12):3124-8. doi: 10.1093/humrep/dem287. Epub 2007 Oct 24. PMID: 17962212.</ref>, so the embryologists become their custodians and guardians, which raises ethical questions, as well as bureaucratic challenges. To avoid such complications, some have advocated the use of a “properly prepared legal document, i.e., a pre-freeze agreement,”<ref>Jones HW Jr, Muasher SJ, Nusbaum RC. A step toward solving some of the problems of cryopreservation. Fertil Steril. 1992 Feb;57(2):278-84. doi: 10.1016/s0015-0282(16)54830-4. PMID: 1735476.</ref>. There are numerous studies describing patients’ views on the disposal procedure of their excess embryos. Some couples perceive them as barely, more than a group of cells, or a tissue, while others consider them as their unborn children<ref>Klock SC. Embryo disposition: the forgotten "child" of in vitro fertilization. Int J Fertil Womens Med. 2004 Jan-Feb;49(1):19-23. PMID: 15038505.</ref><ref>Nachtigall RD, Becker G, Friese C, Butler A, MacDougall K. Parents' conceptualization of their frozen embryos complicates the disposition decision. Fertil Steril. 2005 Aug;84(2):431-4. doi: 10.1016/j.fertnstert.2005.01.134. PMID: 16084886; PMCID: PMC2811165.</ref><ref>Nachtigall RD, Becker G, Friese C, Butler A, MacDougall K. Parents' conceptualization of their frozen embryos complicates the disposition decision. Fertil Steril. 2005 Aug;84(2):431-4. doi: 10.1016/j.fertnstert.2005.01.134. PMID: 16084886; PMCID: PMC2811165.</ref><ref>Provoost V, Pennings G, De Sutter P, Gerris J, Van de Velde A, De Lissnyder E, Dhont M. Infertility patients' beliefs about their embryos and their disposition preferences. Hum Reprod. 2009 Apr;24(4):896-905. doi: 10.1093/humrep/den486. Epub 2009 Jan 9. PMID: 19136479.</ref>. In a model of patients’ decision-making processes for the fate of frozen embryos, developed by Takahashi et al.<ref>Takahashi S, Fujita M, Fujimoto A, Fujiwara T, Yano T, Tsutsumi O, Taketani Y, Akabayashi A. The decision-making process for the fate of frozen embryos by Japanese infertile women: a qualitative study. BMC Med Ethics. 2012 May 20;13:9. doi: 10.1186/1472-6939-13-9. PMID: 22607034; PMCID: PMC3405475.</ref>, this burden was expressed as “Mottainai,” a prevalent, culturally embedded moral standard in Japan. “Mottai” is a Buddhist term that refers to the intrinsic dignity or sacredness of a material entity. “Nai” is negation<ref>Selected Version of the Great Japanese Dictionary, 3rd edition. Tokyo:

Shougakukan Inc; 2006 (in Japanese).</ref>. Therefore, “Mottainai” is an expression of sadness and guilt over the disrespectful and wasteful treatment of valuable entities<ref>Takahashi S, Fujita M, Fujimoto A, Fujiwara T, Yano T, Tsutsumi O, Taketani Y, Akabayashi A. The decision-making process for the fate of frozen embryos by Japanese infertile women: a qualitative study. BMC Med Ethics. 2012 May 20;13:9. doi: 10.1186/1472-6939-13-9. PMID: 22607034; PMCID: PMC3405475.</ref>.
|Important For=health care professionals; Clinical researchers; Educators; Decision makers; Human rights defenders; Other; Patients; Physicians; Reserchers
|Has Best Practice=Worldwide, governmentally regulated limitations for maintaining embryos in cryostorage vary from 24 months to an infinite duration<ref>Klock SC. Embryo disposition: the forgotten "child" of in vitro fertilization. Int J Fertil Womens Med. 2004 Jan-Feb;49(1):19-23. PMID: 15038505.</ref>. Although consensus regarding the ethics of thawing and discarding does not exist, in the absence of explicit, contemporaneous consent, approaches to the issue of unclaimed embryos have been proposed by other advisory bodies. The European Society of Human Reproduction and Embryology (ESHRE) Task Force on Ethics and Law has advocated standard time limits that can be renewed a limited number of times on a couple’s demand<ref>Shenfield F, Pennings G, Sureau C, Cohen J, Tarlatzis B; European Society of Human Reproduction and Embryology Task Force on Ethics and Law. II. The cryopreservation of human embryos. Hum Reprod. 2001 May;16(5):1049-50. doi: 10.1093/humrep/16.5.1049. PMID: 11464803.</ref>, while the ASRM committee concluded that a clinic can consider embryos abandoned and discard them if 5 years has passed since the last contact with the couple and if significant efforts have been made to contact that couple<ref>Ethics Committee of the American Society for Reproductive Medicine. Electronic address: asrm@asrm.org. Disposition of unclaimed embryos: an Ethics Committee opinion. Fertil Steril. 2021 Jul;116(1):48-53. doi: 10.1016/j.fertnstert.2021.02.020. PMID: 34148589.</ref>. Spanish regulations mandate that embryos should only be used for reproductive purposes, which makes embryo donation the only legal solution when couples do not want the embryos for their own transfer<ref>Bankowski BJ, Lyerly AD, Faden RR, Wallach EE. The social implications of embryo cryopreservation. Fertil Steril. 2005 Oct;84(4):823-32. doi: 10.1016/j.fertnstert.2005.02.057. PMID: 16213829.</ref>. Meanwhile, Malta is one of the countries whose legislation does not permit embryo discarding and allows to inseminate up to three oocytes while all resulting embryos are required to be transferred<ref>Mallia P. Problems faced with legislating for IVF technology in a Roman Catholic country. Med Health Care Philos. 2010 Feb;13(1):77-87. doi: 10.1007/s11019-009-9224-9. PMID: 19763882.</ref>. Although this immensely complicated issue is substantially discussed in the bioethical and philosophical literature, it is still one of the most significant ethical dilemmas in the world of Assisted Reproduction Technology (ART)<ref>Tonkens R. The moral unacceptability of abandoning human embryos. Monash Bioeth Rev. 2016 Mar;34(1):52-69. doi: 10.1007/s40592-016-0060-4. PMID: 27468864.</ref>
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