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Modern medicine has revolutionized family planning. Remarkably, women1 can carry to term embryos with whom they share no genetic connection, a feat made possible through egg donation and/or gestational surrogacy. Our reproductive systems evolved to accommodate embryos that are 50% related to the carrier, not 0% related. Here, we apply evolutionary theory to explain how and why pregnancy is riskier with an unrelated embryo. When a woman gestates an unrelated embryo, she is significantly more likely to develop preeclampsia and other diseases above and beyond the known risks associated with advanced maternal age, IVF, multiple gestation, and subfertility. Such "allogeneic pregnancies" are riskier even in fertile, healthy, commercial surrogates and when the egg is donated by a young, healthy donor. We propose that unrelated embryos present a special immune challenge to the gestational carrier, because they have fewer matching genes to the maternal body-therefore exacerbating symptoms of evolutionary maternal-fetal conflict. Indeed, maternal risks seem lower when the embryo is more related to the carrier, e.g., if a sister donates the egg. Finally, we discuss microchimerism in egg donation pregnancies, whereby wholly foreign cells pass from mother to embryo and vice-versa. We conclude with several medical proposals. First, egg donors and surrogates should be informed of the increased health risks they would face. In considerations of risk, these young, fertile women should not be compared to older, infertile women undergoing IVF; the proper comparison group is other young, fertile women. Second, contrary to some medical advice, perhaps genetically-related egg donors and surrogates should be preferred, all else equal. An immunological matching scheme, like what is used for organ transplants, could improve surrogate pregnancy outcomes. Third, more research is needed on microchimerism, sperm exposure, and the long-term impacts of allogeneic pregnancies on maternal and child health.

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STUDY QUESTION: How are ART and IUI regulated, funded, and registered in European countries, and how has the situation changed since 2018? SUMMARY ANSWER: Of the 43 countries performing ART and IUI in Europe, and participating in the survey, specific legislation exists in only 39 countries, public funding varies across and sometimes within countries (and is lacking or minimal in four countries), and national registries are in place in 33 countries; only a small number of changes were identified, most of them in the direction of improving accessibility, through increased public financial support and/or opening access to additional subgroups. WHAT IS KNOWN ALREADY: The annual reports of the European IVF-Monitoring Consortium (EIM) clearly show the existence of different approaches across Europe regarding accessibility to and efficacy of ART and IUI treatments. In a previous survey, some coherent information was gathered about how those techniques were regulated, funded, and registered in European countries, showing that diversity is the paradigm in this medical field. STUDY DESIGN, SIZE, DURATION: A survey was designed using the SurveyMonkey tool consisting of 90 questions covering several domains (legal, funding, and registry) and considering specific details on the situation of third-party donations. New questions widened the scope of the previous survey. Answers refer to the situation of countries on 31 December 2022. PARTICIPANTS/MATERIALS, SETTINGS, METHODS: All members of the EIM were invited to participate. The received answers were checked and initial responders were asked to address unclear answers and to provide any additional information considered relevant. Tables resulting from the consolidated data were then sent to members of the Committee of National Representatives of ESHRE, requesting a second check. Conflicting information was clarified by direct contact. MAIN RESULTS AND THE ROLE OF CHANCE: Information was received from 43 out of the 45 European countries where ART and IUI are performed. There were 39 countries with specific legislation on ART, and artificial insemination was considered an ART technique in 33 of them. Accessibility is limited to infertile couples only in 8 of the 43 countries. In 5 countries, ART and IUI are permitted also for treatments of single women and all same sex couples, while a total of 33 offer treatment to single women and 19 offer treatment to female couples. Use of donated sperm is allowed in all except 2 countries, oocyte donation is allowed in 38, simultaneous donation of sperm and oocyte is allowed in 32, and embryo donation is allowed in 29 countries. Preimplantation genetic testing (PGT)-M/SR (for monogenetic disorders, structural rearrangements) is not allowed in 3 countries and PGT-A (for aneuploidy) is not allowed in 10; surrogacy is accepted in 15 countries. Except for marital/sexual situation, female age is the most frequently reported limiting criterion for legal access to ART: minimal age is usually set at 18 years and the maximum ranges from 42 to 54 with some countries not using numeric definition. Male maximum age is set in very few countries. Where third-party donors are permitted, age is frequently a limiting criterion (male maximum age ranging from 35 to 50; female maximum age from 30 to 37). Other legal restrictions in third-party donation are the number of children born from the same donor (or, in some countries, the number of families with children from the same donor) and, in 12 countries, there is a maximum number of oocyte donations. How countries deal with the anonymity is diverse: strict anonymity, anonymity just for the recipients (not for children when reaching legal adulthood age), a mixed system (anonymous and non-anonymous donations), and strict non-anonymity. Inquiring about donors' genetic screening showed that most countries have enforced either mandatory or scientific recommendations that exclude the most prevalent genetic diseases, although, again, diversity is evident. Reimbursement/compensation systems exist in more than 30 European countries, with around 10 describing clearly defined maximum amounts considered acceptable. Public funding systems are extremely variable. One country provides no financial assistance to ART/IUI patients and three offer only minimal support. Limits to the provision of funding are defined in the others i.e. age (female maximum age is the most used), existence of previous children, BMI, maximum number of treatments publicly supported, and techniques not entitled for funding. In a few countries reimbursement is linked to a clinical policy. The definitions of the type of expenses covered within an IVF/ICSI cycle, up to which limit, and the proportion of out-of-pocket costs for patients are also extremely dissimilar. National registries of ART are in place in 33 out of the 43 countries contributing to the survey and a registry of donors exists in 19 of them. When comparing with the results of the previous survey, the main changes are: (i) an extension of the beneficiaries of ART techniques (and IUI), evident in nine countries; (ii) public financial support exists now in Albania and Armenia; (iii) in Luxembourg, the only ART centre expanded its on-site activities; (iv) donor-conceived children are entitled to know the donor identity in six countries more than in 2018; and (v) four more countries have set a maximum number of oocyte donations. LIMITATIONS, REASONS FOR CAUTION: Although the responses were provided by well-informed and committed individuals and submitted to double checking, no formal validation by official bodies was in place. Therefore, possible inaccuracies cannot be excluded. The results presented are a cross-section in time, and ART and IUI frameworks within European countries undergo continuous modification. Finally, some domains of ART activity were deliberately left out of the scope of this survey. WIDER IMPLICATIONS OF THE FINDINGS: Our results offer a detailed updated view of the ART and IUI situation in European countries. It provides extensive answers to many relevant questions related to ART usage at the national level and could be used by institutions and policymakers at both national and European levels. STUDY FUNDING/COMPETING INTEREST(S): The study has no external funding, and all costs were covered by ESHRE. There were no competing interests.

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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.

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BACKGROUND: Disclosure of donor conception has been advocated in several jurisdictions in recent years, especially in those that practice identity-release donation. However, research on disclosure decisions has not been consolidated systematically in the last 10 years to review if parents are telling and what factors may be impacting their decisions. OBJECTIVE AND RATIONALE: Are parents disclosing to their donor-conceived children, and what factors have influenced their disclosure decisions across different contexts and family forms in the last 10 years? SEARCH METHODS: A bibliographic search of English-language, peer-reviewed journal articles published between 2012 and 2022 from seven databases was undertaken. References cited in included articles were manually scrutinized to identify additional references and references that cited the included articles were also manually searched. Inclusion criteria were articles focused on parents (including heterosexual, single mothers by choice, same-sex couples, and transsexual) of donor-conceived persons in both jurisdictions with or without identity-release provisions. Studies focused solely on surrogacy, donors, donor-conceived persons, or medical/fertility staff were excluded as were studies where it was not possible to extract donor-recipient parents' data separately. Both quantitative and qualitative studies were included. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed and Joanna Briggs Institute Critical Appraisal Tools for Systematic Reviews were used to assess article quality and bias. OUTCOMES: Thirty-seven articles met the inclusion criteria representing 34 studies and 4248 parents (including heterosexual, single, same-sex, and transsexual parents although the majority were heterosexual) from countries with anonymous donation and those with identity-release provisions or who had subsequently enacted these provisions (Australia, Belgium, Finland, France, Hong Kong, Middle East, Spain, Sweden, the UK, and the USA) A general trend towards disclosure was noted across these groups of parents with most disclosing to their donor-conceived children before the age of 10 years. Further, the majority of those who had not yet told, reported planning to disclose, although delayed decisions were also associated with lower disclosure overall. Same-sex and single parents were more likely to disclose than heterosexual parents. There was recognition of disclosure as a process involving ongoing conversations and that decisions were impacted by multiple interacting intrapersonal, interpersonal, and external contextual and social factors. Methodological limitations, such as the different population groups and contexts from which participants were drawn (including that those parents who choose not to disclose may be less likely to participate in research), are acknowledged in integrating findings. WIDER IMPLICATIONS: This review has reinforced the need for a theoretical model to explain parents' disclosure decisions and research exploring the role of legislative provisions, culture, and donor/family type in decision-making. Greater ongoing access to psychological support around disclosure may be important to promote parent and family well-being.

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OBJECTIVES: The aim of this study is to survey the current situation in Belgium regarding embryo donation (ED) practices and to explore the potential reasons for not offering this treatment option. STUDY DESIGN: A questionnaire was sent to all fertility centers in Belgium that are allowed to perform IVF regarding whether or not they perform ED for third parties, their overall experience with ED and the possible reasons for not doing it. The questionnaire was divided into three different sections, depending on whether the center currently performs ED for third parties, has never performed it or once performed it but no longer does. All respondents were anonymized. RESULTS: The questionnaire was returned by 16 out of 18 centers. Only three out of 16 centers currently perform ED. All these centers require additional actions before ED can be performed. Sometimes ED is not performed although it was indicated in the contract; the most important reasons are the need for additional investigations, the administrative obstacles and the non-eligibility of the embryos. Between 2017 and 2021, few ED were performed in these centers (n = 2, 38 and 6). Eight out of 16 centers previously offered ED but ceased. In two centers, patients who want to donate their supernumerary embryos are referred for treatment to a center where ED is performed, but none of these centers transfer embryos to a center performing ED. The main reasons for discontinuing ED were the additional investigations required and the unprofitable investment in time and personnel. Five out of 16 centers never offered ED. At one center, patients who still indicate ED for their supernumerary embryos are referred to a center performing ED. The reduction of the administrative burden and avoiding additional testing are the most indicated measures that could facilitate the introduction of an ED program. CONCLUSIONS: Embryo donation, although legally allowed, is currently hardly performed in Belgium. The reasons for this are mainly associated to additional mandatory post-hoc testing and the extra administrative burden which is not financially covered. Poor transparency and communication between Belgian centers may be an additional factor explaining the country's low embryo donation rate.

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STUDY QUESTION: What are parents' perceptions of their relationships with and the psychosocial adjustments of their children who are born via embryo donation? SUMMARY ANSWER: Families created through embryo donation have well-adjusted parent-child relationships and reassuring child psychosocial outcomes. WHAT IS KNOWN ALREADY: Embryo donation is an effective and growing form of third-party reproduction, but there is limited research in this field. Prior studies suggest that families created through gamete donation function well regarding parent-child relationship quality and child behavioral and socioemotional adjustment. STUDY DESIGN, SIZE, DURATION: This is a cross-sectional survey study with 187 total participants. PARTICIPANTS/MATERIALS, SETTING, METHODS: Parents of children born via embryo donation were recruited nationally by contacting all embryo donation programs registered with the Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) as well as medically directed embryo donation or 'embryo adoption' centers. Participants completed three online Qualtrics questionnaires. The first was a survey including 33 questions on demographics, the procurement process, and self-reported obstetric outcomes. Participants also completed two standardized measures assessing children's behavior and parents' adjustment to parenthood: the Strengths and Difficulties Questionnaire (SDQ) and the Parental Acceptance-Rejection Questionnaire (PARQ). Scoring of the SDQ and PARQ was totaled and compared to standardized values (SDQ) or previously published results on other forms of gamete donation (PARQ), such as oocyte donation and sperm donation. MAIN RESULTS AND THE ROLE OF CHANCE: On the SDQ (n = 46), the average total difficulties scores by age were: 8.2 ± 0.98 for ages 2-4, 7.6 ± 0.93 for ages 5-10, and 3.5 ± 0.77 for ages 11-17; this is compared to the normal reported range of 0-13, which indicates that clinically significant psychosocial problems are unlikely. Across all ages and individual categories (emotional symptoms, conduct problem, hyperactivity, peer problem, prosocial), scores on the SDQ were within the normal ranges. The average PARQ score (n = 70) for all respondents was 27.5 ± 1.18 (range: 24-96), suggesting perceived parental acceptance. LIMITATIONS, REASONS FOR CAUTION: Because this study was cross-sectional, it could not capture familial relationships over time. This survey-based study design allows for potential selection bias (parents of well-adjusted children may be more likely to participate). Additionally, the overall sample size is relatively small; however, it remains one of the largest published to date. Another significant limitation to this study is the lack of generalizability: most participants were recruited from private, faith-based, embryo donation programs who are demographically similar. WIDER IMPLICATIONS OF THE FINDINGS: Though embryo donation is an established form of third-party reproduction, it is significantly less robustly studied compared to other forms of gamete donation (oocyte or sperm donation). This study provides a larger data set with a more expanded age range of children compared to the limited number of previously published studies. Furthermore, these findings indicate a high parental disclosure rate with respect to the use of embryo donation which contrasts previous findings. STUDY FUNDING/COMPETING INTEREST(S): No external funding source was utilized for the completion of this study. No conflicts are disclosed. TRIAL REGISTRATION NUMBER: N/A.

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With the growing challenge of abandoned surplus embryos in the ART arena, and the limited traction of embryo donation as a viable embryo disposition choice, it is important to better understand barriers to wider adoption of this opportunity. We aim to learn about perspectives and experience of participants in directed and non-identified embryo donation programmes. This was a longitudinal cohort survey study, of all participants in an embryo donation programme in a single university affiliated clinic between 2016 and 2020. Clinical data were extracted from counselling reports. Based on these data, non-identified online questionnaires were constructed and refined via Delphi procedure for face and content validity. Sixty-five online questionnaires were emailed between March-April 2021. Descriptive statistics, cross-tabulation, Fisher's exact test and t-test were used for analyses. Source of patient awareness, factors influencing the decision-making process, patient perspective and satisfaction were explored. The response rate was 67.2%. Most participants in the non-identified programme learned of it through their treating physicians, whereas most participants in the directed programme learned of it online. The main driver to donate across both cohorts was wanting to give others the opportunity to experience the joy of parenthood. Overall, 45% described moderate to marked difficulty in decision making related to donating their embryos, and this did not differ between cohorts. Non-identified donors reported feeling highly attached to the donated embryos more often than directed donors. Level of satisfaction was higher in the directed donation programme. Participants were more satisfied following directed than non-identified donation, and some even consider their counterparts as extended family. Our findings should be validated in various settings, and on larger samples.

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Embryo donation (ED) involves the donation of surplus embryos post family formation to others in need. Commensurate with Australian and New Zealand legislation and policy, ED is practiced as an identity-release programme shaped by four paramount principles. These include: the need to consider the longitudinal health and well-being of donor-conceived children born from assisted reproductive technologies (ART); recognition that offspring should be made aware of and be able to access information about their genetic origins; awareness that the short and long-term health and psychological welfare of other stakeholders (i.e., recipients and donors) should be ensured; and finally, that all donations are altruistic. Whilst embedded in ART legislation or professional guidelines, how these principles are operationalized through counselling in both countries remains variable. In this paper, we draw upon Australian and New Zealand research, legislation and policy shaping the counselling milieu. We highlight some of the key clinical issues that counsellors need to explore with participants of an ED arrangement and the implications of these as they apply to dilemmas within counselling practice such as counsellor roles and responsibilities.

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Third-party reproduction refers to the use of eggs, sperm, or embryos that have been donated by a third person (the donor) to enable individuals or couples (the intended parents) with infertility to have a child. This differs from the traditional father-mother family model with no third parties involved. Third-party reproduction is also used by couples that are unable to reproduce by traditional means, same-sex couples, and men and women without a partner. This has emerged as a treatment option with great success rates in a scene of changing family constellations. Consequently, this therapeutic alternative has become a realistic solution which has brought great satisfaction and happiness to people who otherwise would have not been able to achieve parenthood if these options were not medically and legally available.

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Embryo donation raises unique challenges for donors, recipients, and the resultant child, yet little is known about the outcomes for those involved. This review summarizes research on the motivations for donating and receiving embryos from others and the experiences that follow, including the outcomes for parenting and child adjustment. Research has shown that given the varied ways in which embryo donation is practiced, understanding the outcomes within different legislative and cultural contexts is vital. The lack of information on outcomes means that counselors and psychologists have little empirical evidence to guide them. Gaps in existing knowledge are identified as well as areas for future research.

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BACKGROUND: In 2016, the US Food and Drug Administration amended existing regulations to increase access to donated embryos for reproductive use. Current information regarding the characteristics and outcomes of embryo donation cycles could benefit patients and providers during counseling and decision making. OBJECTIVE: This study aimed to examine the trends in the utilization of embryo donation, pregnancy rates, and live birth rates per transfer between 2004 and 2019 and to describe the recipients of donated embryos and outcomes of frozen donated embryo transfer cycles during the most recent time period, that is, 2016 to 2019. STUDY DESIGN: We conducted a retrospective, population-based cohort study of frozen donated embryo transfer cycles in United States fertility clinics reporting to the National Assisted Reproductive Technology Surveillance System during 2004 to 2019. The trends in the annual number and proportion of frozen donated embryo transfers, pregnancy rates, and live birth rates from 2004 to 2019 were described. During 2016 to 2019, the rates of cycle cancellation, pregnancy, miscarriage, live birth, singleton birth, and good perinatal outcome (delivery ≥37 weeks, birthweight ≥2500 g) of frozen donated embryo transfers were also calculated. Transfer and pregnancy outcomes stratified by oocyte source age at the time of oocyte retrieval were also described. RESULTS: From 2004 to 2019, there were 21,060 frozen donated embryo transfers in the United States, resulting in 8457 live births. During this period, the annual number and proportion of frozen donated embryo transfers with respect to all transfers increased, as did the pregnancy rate and live birth rate. Among all initiated cycles during 2016 to 2019, the cancellation rate was 8.2%. Among 8773 transfers with known outcomes, 4685 (53.4%) resulted in pregnancy and 3820 (43.5%) in live birth. Among all pregnancies, 814 (17.4%) resulted in miscarriage. Among all live births, 3223 (84.4%) delivered a singleton, of which 2474 (76.8%) had a good perinatal outcome. The clinical pregnancy rate and live birth rate per frozen donated embryo transfer decreased with increasing age of oocyte source. CONCLUSION: The outcomes of embryo donation cycles reported in this national cohort may aid patients and providers when considering the use of donated embryos.

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Cryopreservation of embryos has become an essential aspect of assisted reproductive technology, allowing for greater clinical efficiency and increased safety. However, the increasing numbers of cryopreserved embryos in clinics worldwide pose challenges to all stakeholders with respect to the disposition and donation of one's embryos when the gamete providers have completed their family building. The following series of articles provides an update of outcomes, challenges, and controversies related to embryo disposition. The first article describes the current and future medical potential of donated embryos for human stem cell research and other applications. Second, the practice of embryo donation to other intended parent(s) is summarized, and a review of the literature on child outcomes is presented. Third, the logistics and programmatic steps in managing embryos designated for disposal are discussed, including the option for compassionate transfer. Fourth, legal experts summarize precedent setting cases in the United States and the current legal environment of unused embryo management in the setting of the recent Supreme Court decision in Dobbs v. Jackson Women's Health Organization.

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OBJECTIVE: To determine whether pregnancies with donated embryos are at a higher risk of complications than the pregnancies from autologous frozen-thawed embryo transfer (FET). DESIGN: Anonymous, multicenter, comparative, observational, retrospective, matched-cohort study. SETTING: Six French assisted reproductive technique centers from 2003 to 2018. PATIENT(S): Seventy-three singleton pregnancies with donated embryos (exposed) and 136 singleton pregnancies after autologous FET (nonexposed) were matched at 7-8 weeks of gestation (pregnancy date, parity, and women's age) (2:1 ratio, respectively). In accordance with French practices, all women were <44 years old and donated embryos were discarded frozen embryos from other couples. INTERVENTION(S): Not applicable. MAIN OUTCOME MEASURE(S): Percentages of hypertensive disorders of pregnancy (HDPs) with donated embryos versus autologous FET. RESULT(S): Groups were comparable (mean age: 34.5 years) and HDPs (24.6% vs. 11.9%) were significantly more frequent among the donated-embryo pregnancies, mostly in its severe forms (17.5% vs. 4.6%). In contrast, their respective isolated hypertension frequencies were comparable (7.0% vs. 7.3%). Multivariate analysis retained increased severe HDP risk with donated embryos (odds ratio 2.08 [95% confidence interval: 1.08-4.02]). No significant effect of endometrial preparation was observed. C-sections were more frequent for donated-embryo pregnancies (47.3% vs. 29.2%). Newborns from embryo donation or autologous FET were comparable for prematurity, birth weight and length, Apgar score, small for gestational age, large for gestational age, neonatal malformations, and sex ratio. CONCLUSION(S): Even for young women, the risk of severe HDP was 4 times higher for donated-embryo pregnancies than for autologous-FET pregnancies. The HDP risk must be acknowledged to inform donated-embryo recipients and provide careful pregnancy monitoring.

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In vitro fertilization (IVF) involves making embryos outside of the human body, which has spurred debate about the status of the embryo, embryo research and donation. We explore couples' perceptions about embryos and their thoughts and acceptability about various disposition decisions in Norway. Based on an ethnographic study including interviews and observations in an IVF clinic, we show that couples do not perceive their pre-implantation IVF embryos to be human lives; rather, they consider successful implantation the start of life. We suggest that this response indicates a change in the perception of the human embryo or the fertilised egg from incipient life-a viewpoint that was dominant in the discussions of embryo research in the 1980s and 1990s. We also show how this view of the pre-implantation embryo elucidates why donating embryos to research appears acceptable but donating to other infertile couples seems rather difficult. Before transfer to a woman's uterus, the embryo exists in a liminality; it is not yet human life but a living cell with potential for both research and pregnancy. When an embryo is implanted and pregnancy is confirmed, human life activates; the embryo becomes potential kin, influencing couples' struggles with donating embryos to other couples.

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The number of pregnancies achieved through gamete donation has escalated over the last decades. It has been hypothesized that double gamete donation pregnancies would have a higher risk of preeclampsia compared to single gamete donation pregnancies due to cumulative risk of preeclampsia in oocyte donation pregnancies and the separate risk associated with sperm donation. Therefore, a systematic review and meta-analysis was conducted to explore the association between double gamete donation pregnancies and the development of preeclampsia and gestational hypertension, comparing it with oocyte donation alone. A systematic search of five databases was conducted and meta-analysis was performed using a random-effects model. Of 795 screened articles, five met our selection criteria for a systematic review, and four were included in the meta-analysis.No statistically significant differences were found in the risk of preeclampsia between study subgroups (odds ratio [OR] 0.82; 95% confidence interval [95%CI] 0.29-2.36), even after subgroup analysis considering only high-quality studies (OR 1.30; 95%CI 0.61-2.76; I2 = 0%). Regarding gestational hypertension risk, neither the pooled analysis (OR 0.52; 95%CI 0.18-1.49; I2 = 84%) nor the high-quality studies subgroup analysis (OR 0.67; 95%CI 0.33-1.35; I2 = 0%) find any significant differences between oocyte donation or double gamete donation pregnancies. There appears to be little difference in gestational hypertension or preeclampsia risk between pregnancies resulting from double gamete donation and those from oocyte donation alone. Strict obstetrical surveillance should be considered standard of care for these women, in an attempt to perform early diagnosis and management of hypertensive disorders.

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BACKGROUND: Previous studies have shown that embryo donation can be a successful treatment for infertile couples,
however the willingness of Dutch couples to donate or accept embryos was unknown. The aim of this article is to
describe the protocol and results for altruistic embryo donation of the only embryo bank in the Netherlands.
Materials and Methods: This is a descriptive study. Since 2011, donated cryo-embryos from couples that have undergone
in vitro-fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatments, are being stored in our embryo
bank. The majority of the donated embryos were frozen on day 3 or 4 by slow freezing techniques. We perform a
thorough medical and psychological screening of donor couples and recipients, according to the protocol drawn up in
close collaboration with the Dutch Ministry of Health.
Results: Up to June 2021, 54 women have received embryos from our embryo bank, all single embryo transfers.
While the clinical pregnancy rate in 'unknown' embryo donations was relatively high (25.3%), the live birth rate
shows limited success (12.6%), partly due to high pregnancy loss through miscarriage. In known donation procedures,
the recipients tend to undergo more procedures, depending on the number of donated cryo-embryos. Twentyeight
women received embryos from known donors, with a clinical pregnancy rate per embryo transfer of 24%, and
live birth rate of 14%. In total, 82 recipients were granted donated cryo-embryos, twenty had an ongoing pregnancy
(24.4%), nineteen of whom have given birth to a healthy child (23%).
Conclusion: Altruistic embryo donation of embryos appears to be satisfying for the donors, as they are not obliged to destroy
their embryos, but instead help others build a family. Although success rates are still limited, partly due to the relatively high
miscarriage rates and inferior freezing techniques, to this date nineteen out of 82 recipients have given birth to a healthy child.

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This research project is pioneering in that it is the first to provide empirical data regarding the ethical standards of Sunni Muslim physicians toward religiously prohibited reproductive technologies, a topic which is considered taboo in Muslim society. A total of 689 Sunni Muslim physicians rated their acceptance of 14 fertility treatments. They expressed objections to assisted reproductive technologies entailing gender selection, egg, sperm and embryo donation, and surrogacy. The findings show that the Sunni Muslim medical establishment avoids fertility options that are considered in violation of Islamic law, and Sunni Muslim physicians tend to obey religious law.

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Huele and colleagues started a debate on the comparison between embryo donation and double donation. Although I largely agree with their final conclusion, I believe that the perspective of the recipients needs to be added to get a more complete picture. The present contribution focuses on that perspective and advances other arguments to balance the two methods. The main argument in favour of double donation is the difference in perceived meaning for the recipients compared to surplus embryos. The main arguments in favour of embryo donation are the fair distribution of scarce resources (i.e. donor gametes) and the principle of non-maleficence through the avoidance of unnecessary oocyte donation cycles. The balance would be to put both treatments on an equal footing.

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OBJECTIVE: To gain an in-depth understanding of parents' experiences telling children conceived by gamete and embryo donation about their genetic origins. DESIGN: Qualitative, descriptive. SETTING: Families' homes. PATIENTS: Gamete or embryo donation recipient parents living in the United States and who told their children, from birth to 16 years, about their genetic origins. INTERVENTIONS: Individual semistructured (n = 12) or dyadic (n = 2) parent interviews. MAIN OUTCOME MEASURES: Directed qualitative content analysis. RESULTS: Fourteen families that comprised 16 gamete or embryo donation recipient parents and represented 24 donor-conceived children between the ages of 4 months and 16 years participated in the study. Single parents (n = 3) and both parents in most two-parent families (n = 9) led the initial telling conversations. Parents recounted personal short stories using language that was both developmentally and medically appropriate. Multiple strategies, including children's books, were used by parents to aid them in their telling. The oldest donor-conceived children in each family were first informed of their genetic origins at birth (n = 10 families) or at 6 months (n = 1 family; "practice runs") or from 3.5 to 12 years (n = 3 families). The telling conversations took place during routine family activities that naturally brought parents and children in close proximity, usually in the home. CONCLUSIONS: Awareness of the nuances of parents' telling conversations with their children through the age of 16 years can help guide clinical counseling and the development of tools to aid parents in their telling conversations.

RESUMEN

BACKGROUND: Non-obstructive azoospermia (NOA) with history of cryptorchidism and idiopathic NOA are the most common forms of NOA without genetic aetiology. Of all patients with one of these two types of NOA, only a few will have a positive TEsticular Sperm Extraction (TESE). Of those with positive extraction followed by sperm freezing, not all will have a child after TESE-ICSI. What are the ways and probabilities of taking home a baby for patients with NOA and a history of cryptorchidism compared with patients with idiopathic NOA? RESULTS: Patients with idiopathic NOA or NOA and a history of cryptorchidism who underwent their first TESE were included. The patients were divided into two groups: Group 1 was composed of 125 patients with idiopathic NOA and Group 2 of 55 patients with NOA and a history of surgically treated cryptorchidism. Our results showed that more than half of the NOA patients succeeded in becoming parents. The main way to fulfil their plans for parenthood is to use sperm or embryo donation (72%) for men with idiopathic NOA, whereas the majority of men with NOA and a history of cryptorchidism had a child after TESE-ICSI (58.8%). CONCLUSIONS: In our centre, before considering TESE for a patient with NOA, we explain systematically TESE-ICSI alternatives (sperm donation, embryo donation or adoption). As a result, the couple can consider each solution to become parents.

RESUME: CONTEXTE: L'azoospermie non obstructive (ANO) avec un antécédent de cryptorchidie et l'ANO idiopathique sont les causes les plus fréquentes d'ANO sans étiologie génétique. Parmi les patients présentant un de ces 2 types d'ANO, seuls quelques-uns auront une extraction positive de spermatozoïdes testiculaires (TESE). Parmi les patients ayant une extraction positive suivie d'une congélation de spermatozoïdes, tous n'obtiendront pas de naissance après TESE-ICSI. Quels sont les moyens et les probabilités de « ramener un enfant à la maison ¼ pour les patients avec une ANO associée à un antécédent de cryptorchidie en comparaison à ceux présentant une ANO idiopathique ? RéSULTATS: De tels patients ont été inclus dans notre étude et divisés en deux groupes : Groupe 1 composé de 125 patients avec une ANO idiopathique et Groupe 2 de 55 patients avec une ANO associée à un antécédent de cryptorchidie traitée chirurgicalement. Nos résultats ont montré que plus de la moitié des patients atteints d'ANO ont réussi à devenir parents. Le principal moyen pour réaliser leur projet parental était le recours au don de sperme ou l'accueil d'embryons (72%) pour les hommes avec ANO idiopathique, alors que la majorité des hommes avec ANO et antécédent de cryptorchidie (58.8%) achevaient leur projet parental par TESE-ICSI. CONCLUSIONS: Dans notre centre, avant d'envisager une biopsie testiculaire chez un patient présentant une ANO, les alternatives (don de sperme, accueil d'embryon ou adoption) à la TESE-ICSI sont explicitées systématiquement. En conséquence, le couple peut envisager chaque solution pour devenir parent.