There's a whole lot of noise out there from everyone -- and I mean everyone -- about what ought to be done with frozen embryos. I'm impressed that so many pundits, politicians, religious leaders, scientists, and celebrities can be so confident about making the right choice for others when they've never been up against reproductive difficulties themselves.

I know it took me and my husband years of intense wrangling to figure out what to do with our remaining embryos after we were fortunate enough to have our children. From my perch as founder and executive director of one of the largest US fertility patient advocacy groups, I know we're not unique. I hear from thousands of people how grueling it is to reach a decision about when and how to relinquish embryos forever.

It wasn't until our two sons -- both conceived via in vitro fertilization, the process by which embryos are created in a laboratory -- were little kids that we even talked about our four unused embryos. Those microscopic cell clusters weren't surplus or extras until we discussed whether to try for a third child. I wanted to; he didn't.

Embryos do not come easily. IVF is arduous, stressful, life altering, and expensive. It can be heartbreaking when it doesn't work. And even when things look optimal, embryos don't assure a live birth. That's one critical fact that's lost in the cacophony of strident opinions. The three- to five-day-old fertilized eggs IVF patients produce are the embodiment of potential, not a guarantee. Fortunate people end treatment with children. The others don't. In either case, the cryogenically protected embryos not used by those who made them are just as much the result of love and great sacrifice as the ones they do use.

Frankly, most of us trekking down IVF Street never believed we'd have any embryos, let alone a surplus. When there are extras, we do not make our decisions lightly.

Given that I wasn't going to add to the family without my husband's enthusiastic consent, we began to tussle over the limited options for embryo disposition. ''Embryo disposition" is a very clinical-sounding term for one of the most emotionally fraught decisions the infertile confront. The alternatives are limited: donation to other infertile couples willing to take the odds, donation to research, nonviable thawing, or keeping embryos in the deep freeze.

Each route is laden with psychological and emotional grenades. They don't necessarily detonate, but people must be prepared. Like me and my husband, the infertile must weigh each option against their consciences, personal ethics, and morality, their cultures, religious convictions, and community values. Ultimately the choice each individual or couple makes must be a function of what gives them the most comfort as they close the book on their struggles to procreate. Each decision is hard won and deserves respect.

The debate in our house stretched from days to months to years -- flaring, then subsiding. Parenting our sons pushed disposition to the back burner until time forced it to the front.

First, my husband proposed that we transfer our embryos to my uterus at a time when it was certain no pregnancy would result. I balked. Why not let them thaw without transferring? For many, that option provides the solace of finally grieving all that will never be.

We made neither choice and kept paying for storage while we dickered. There were protracted conversations about donating to another couple. The more we considered this option, the more we recognized its profound generosity. Donors must accept that they may have a full genetic son or daughter they will never know; that their children, if they have any, may have a full sibling living as a stranger. They must be at peace with those possibilities. We weren't. I realized then that if we were forced to surrender our genetic material -- if it was pushed on us -- we would be haunted forever.

In the end, we opted to donate our four embryos to stem cell research (a surprisingly complicated endeavor, but that's another story). It's our life-affirming hope that they will help some other mother's child in need of a cure. But that's us.

And that's the point. What happens to these embryos is a personal decision that belongs to no one but the people who created them. Those of us who undergo IVF -- a technology for which we are inexpressibly grateful and which we will fight to preserve -- are already laboring under enormous pressures. We get little, if any, support, financial or otherwise, to pursue assisted reproductive technologies. Certainly not from the grandstanding politicians, religious, social, or scientific leaders who want to lay claim to our embryos.

If they want to provide us with information about and support for disposition options, that's great. That's important. Just don't try to mandate or legislate what we do with our embryos. At the end of the day, it's our choice and ours alone.

Preimplantation Embryo Potential
By Doris J. Baker Ph.D., HCLD (ABB), MT (ASCP)

An embryo is defined as an organism in its early stages of development, especially before it has reached a distinctively recognizable form. In humans, this is the developing organism from conception until approximately the end of the second month. Following fertilization in the Fallopian tube, the resulting zygote moves along the uterine tube and undergoes rapid divisions (cleavage) which result in individual cells or blastomeres. By day three, the embryo is composed of eight-ten blastomeres that compact by day four to form a ball, the morula. The morula enters the uterus and differentiates into a blastocyst consisting of an inner cell mass, which will form the embryo proper, and a trophoblast, which will become the embryonic placenta. The blastocyst implants in the uterus on day five following fertilization.

Fertilization and pre-implantation embryonic development can be accomplished using assisted reproductive technology (ART). Following in vitro insemination of aspirated oocytes, fertilization is documented and developing embryos are monitored and assessed. Several embryos are typically available for culture since the ovaries have been hormonally stimulated to produce multiple oocytes. Depending on the ART laboratory and the protocol selected, embryos may be transferred to the uterus on day three (cleavage stage) or on day five after the culture has reached the blastocyst stage. In vivo a cleavage stage embryo would still be traversing the Fallopian tube and would not yet have reached the uterus. Culture to the blastocyst stage results in a more developed embryo at the developmental stage that implants in vivo and is therefore in synchrony with uterine preparation for pregnancy. Many cleavage stage embryos do not develop to the blastocyst stage in vitro; however, this lack of further development may be due either to culture limitations in the laboratory or the inability of the embryo to continue to progress.

Regardless of the in vitro developmental stage, the “best” embryos are selected for transfer. Unless a blastomere from a cultured embryo has been genetically tested (preimplantation genetic diagnosis), the only methods for evaluating the “best embryos” for transfer is cleavage rate and overall morphology, which have been associated with the potential for continued growth and implantation. Approximately 50% of women undergoing in vitro fertilization have “extra embryos”. Embryos that are not transferred and meet the laboratory’s criteria for freezing are cryopreserved to provide the couple with a less expensive and less stressful option for future family planning.

Frozen embryos may remain stored in liquid nitrogen indefinitely. According to Dr. Dayong Gao, cryobiologist and Endowed Professor of Mechanical and Biomedical Engineering at the University of Kentucky, damage to embryos is due to the freezing and/or thawing process and not from storage in liquid nitrogen. Although data for century-cryopreservation is not available, he noted that there is no evidence that extended storage is detrimental to the treatment outcome. There are no regulations in the United States that limits the term of storage for embryos; however, the American Society for Reproductive Medicine guidelines recommends that storage should not exceed the donor’s age of reproducibility.

Couples electing not to use their frozen embryos usually do not opt for continued storage due to practical considerations such as annual storage fees. These couples may then exercise one of three options for embryo disposition: (1) non-vital thaw; (2) donating to stem cell research; or (3) donating to another infertile couple. Recently there has been appreciable pressure from special interest groups for couples to choose the latter option and donate their frozen embryos to another infertile couple, referring to the process as embryo “adoption” and to the embryos as “future children”. Embryos cannot be adopted (except in Louisiana) and the reference to embryos as future children is misleading. A large percentage of pre-implantation stage embryos do not have a “future” of developing into a live birth, based on embryo potential in general and the cryopreserved pool in particular.

In nature, embryos that are abnormal or damaged are eliminated. The International Birth Defects Association estimates that as many as 50% of all pregnancies may end in miscarriage, because many losses occur before a pregnancy is recognized or confirmed. Since the freezing and thawing embryos may lead to cellular and chromosomal damage, the cryopreservation process will render additional embryos incapable of further development.

In a good freezing program, 10-35% of embryos will not survive the process, depending on the developmental stage they are in when they are frozen. There are additional concerns regarding embryos created in vitro from an infertile couple with several factors affecting embryo quality: (1) the diagnosis of the infertile couple creating the embryos; (2) the age of the female since oocyte quality decreases with increasing age; (3) the ovarian stimulation protocol; (4) oocyte retrieval and (5) laboratory manipulations such as insemination using intracytoplasmic sperm injection. Furthermore cultured embryos that are vital do not guarantee a successful pregnancy since a sub-optimal transfer may prevent implantation.

Successful implantation does not ensure a positive outcome since the recipient may be unable to maintain the pregnancy or may continue a pregnancy that does not result in a live birth. The most recent data from the Centers for Disease Control and Prevention (CDC) for ART success rates, reported in 2002, documented that 69,857 embryo transfers using fresh non-donor eggs or embryos resulted in 29,423 pregnancies and 24,324 subsequent live-birth deliveries or 34.8% live births per embryo transfer. When cryopreservation was factored into the formula, success rates were decreased significantly, dropping to 24.8%. When donor oocytes were used to create the embryos, eliminating any problem associated with oocytes, the success rate soared to 50% with fresh embryos, but only moved to 28.8% when the embryos created with donor oocytes had been frozen and thawed for transfer.

In conclusion, embryos that have been created by an infertile couple, cryopreserved, and remain in storage, may or may not have the potential to result in a live birth. Those with such potential may be lost to the thawing process or the subsequent transfer. Statistically, frozen embryos created with donor oocytes and successfully transferred have less than a one in three chance of becoming a baby. Therefore one should be very cautious when referring to the pool of frozen embryos whose disposition is yet to be determined as “future children”.

As you consider adoption as a means to build your family it is extremely important that you are aware of all facets of the adoption process. This will help separate fear, anxiety and misinformation from reality. Adoption is, and should be, a warm and pure undertaking where new families are created. While the adoption process is enveloped by strong emotions, stress can be mitigated by following a straight path with appropriate professional support.

In last month’s article, “The Adoption ABCs,” Carolyn Berger, thoughtfully indicated, “The adoption choices you ultimately make will reflect your personal values, styles and desires.” Many times the over-riding “desire” is to find a baby the quickest way possible. But adoption creates a lifelong undertaking and looking for the quick fix can create disaster in both the short and long run.
As you consider adoption, you have two primary options: domestic adoption, either privately or through an agency, or international adoption. Although each is procedurally different, there is no one path that in and of itself works quicker than the other. Today we are going to look at domestic, private adoption-which is also known as independent adoption.

If it is your style and nature to be in control of your destiny, to have hands on involvement, and be proactive in seeking and selecting the birth parent and the child to be adopted, then private (independent) adoption is probably the way to go. When you are about to step over the threshold to domestic private adoption, you must seek out and engage the services of a qualified adoption attorney, one that will guide you throughout the process. This attorney will support your effort and protect you legally in accordance with the laws of the State in which you reside. It should be noted that each of our United States has their own set of adoption laws and requirements. The first thing your attorney will do is prepare and file the necessary papers with the Court in your jurisdiction so you become certified (approved) as a qualified adoptive parent.

Working with your attorney, the paths to locating a viable adoption situation are: (1) tell every person you come in contact with that you are seeking to adopt a child (2) reach out to obstetricians and pregnancy crises centers (3) place family profiles on appropriate internet sites that deal with adoption. (4) Consider placing classified ads in newspapers locally and in other parts of the country reaching out directly to potential birth parents. Interestingly, birth mothers look for these and this method of finding a child available for adoption accounts for about 80% of successful adoptions and has been around for over 25 years.

Many domestic agencies also utilize some of these methods. However, in their search for birth parents they are looking to serve a large pool of individuals also looking for in similar circumstances. Whether you do the work yourself and take charge of the process or rely on the expertise of an adoption agency, your attorney will guide you on which states might be the better ones to advertise; guide you on how to write an ad, prepare a profile and will provide hints on how you may engage with a potential birth mother. The attorney should ultimately evaluate each situation and determine its viability so as to protect you legally, financially and emotionally. The attorney will assist you in obtaining all social and medical reports from the OB and hospital relating to the pregnancy and birth, including genetic background and the results of appropriate testing such as HIV, drugs and hepatitis; the attorney will also recommend the need for birth parent counseling prior to placement.

On the subject of costs and expenses, private adoption is usually the least expensive and should average (save for the cost of advertising, if utilized) between $8,000 and $15,000 (the higher figure if the birth parent is not covered for medical expenses (in many cases the birth mother does have Medicaid which will lessen the financial burden). If you do utilize the classified ads, it will add to the cost, but you control your budget. It should be noted that many individuals will qualify for the Federal tax credit for qualified adoption expenses. The maximum credit is a bit more than $10,000.

How long should it take one to succeed? Human nature has established that regardless of which process you use, mentally it may first seem forever. In fact, on average one should succeed within the period of between 9 to 12 months to adopt privately. If one is more proactive, it could be sooner. If your effort is minimal, it will be longer.

In most domestic adoptions, the physical custody of the child is transferred when the child is released from the hospital – at usually 2 to 3 days of age. With domestic agency adoption, although not universal, there may be some requirement for a short period of foster care.

Although this is a capsulated version of the private adoption process, we hope you will join with us in future AFA Connections when you will receive information on agency adoption and international adoption, and other informative articles. If you have any particular questions which could clear up any misunderstanding or require further clarification, please send questions to our website, www.theAFA.org.

Please bear in mind no one should go down the path of adoption unless they feel comfortable and committed. If you start the process, make adoption your goal and not your obsession. With effort and some degree of perseverance, whichever path you choose, you will ultimately succeed in building your family.

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