Percepciones y creencias sobre criopreservación embrionaria en mujeres y hombres que se realizan técnicas de reproducción asistida en Santiago, Chile / Perceptions and beliefs about embryo cryopreservation in women and men who have assisted reproductive techniques in Santiago, Chile

RESUMEN Introducción y objetivos: Aunque la criopreservación embrionaria es frecuentemente utilizada como parte de las técnicas de reproducción asistida, no existe información cuantitativa de cómo las parejas infértiles viven la experiencia de tener embriones criopreservados en Chile. El objetivo del estudio fue examinar las percepciones y creencias que tienen mujeres y hombres respecto de sus embriones criopreservados, sus perspectivas respecto de la donación reproductiva y destino de los embriones remanentes. Metodología: 153 mujeres y hombres con embriones criopreservados provenientes de un hospital público, Instituto de Investigaciones Materno Infantil y un centro privado, Clínica Las Condes, en Santiago, Chile, respondieron durante mayo 2015 a mayo 2016 un cuestionario en línea, anónimo, respecto de sus percepciones y creencias sobre criopreservación embrionaria. Resultados: Los encuestados reconocen a sus embriones criopreservados como un hijo (53.2%) o un proyecto de hijo (40.7%). Sólo 8% los considera un grupo organizado de células; sobre el 60% rechaza la opción de descartarlos o usarlos para investigación. Los participantes del hospital público tenían mayor disposición a donar sus embriones remanentes a otras parejas que aquellos del privado (61% vs 40%; P=0.016). Un 34% de las personas encuestadas estuvo de acuerdo con donar embriones a parejas de un mismo sexo. Conclusión: Este estudio muestra que las personas chilenas tienen un vínculo emocional con sus embriones criopreservados y no consideran descartarlos. Los resultados de este estudio pueden servir para dar adecuada consejería a las personas que se realizan técnicas de reproducción asistida, de tal modo de tomar decisiones informadas respecto de la criopreservación.

ABSTRACT Background and objetive: Although embryo cryopreservation is frequently used as part of assisted reproductive technology, quantitave information addressing how infertile couples live the experience of having cryopreserved embryos is lacking in Chile. The aim of this study is to examine men and women's perception and beliefs regarding their cryopreserved embryos, as well as their perspective on embryo donation and disposition. Methods: 153 women and men with frozen embryos from a public hospital, Instituto de Investigactiones Materno Infantil, and a private clinic, Clínica Las Condes, in Santiago, Chile, responded between May 2015 and May 2016 to an anonymous online survey addressing their perceptions and beliefs concerning their cryopreserved embryos. Results: Respondents considered their frozen embryos to be equivalent to a child (53.2%) or a potential child (40.7%). Only 8% regard them as an organized group of cells. Over 60% of respondents disagree with destroying surplus embryos or using them for research. Participants from the public hospital are more willing to donate their embryos to another couple than those from the private center (61% vs 40%; P=0.016); 34% of respondents agreed to donate surplus embryos to same sex couples. Conclusion: This study reveals that Chilean couples are emotionally bound to their frozen embryos, and that discarding them is not an option. The results from this survey will help strengthen counseling for couples to enable them to make informed decisions regarding their surplus embryos.

Consentir na criopreservação de embriões: perceção de casais usuários de medicina da reprodução / Consent on embryo cryopreservation: perception of couples using reproductive medicine / Consentir en la crio-preservación de embriones: percepción de parejas usuarias de medicina de la reproducción

Este estudo qualitativo analisou as perceções de casais quanto aos fatores que contextualizam o consentimento livre e esclarecido na criopreservação de embriões, a partir de 34 entrevistas semiestruturadas, em Portugal. Analisaram-se os dados segundo os princípios da grounded theory. Dos resultados emergiram as seguintes necessidades: provisão de informações detalhadas, rigorosas, coerentes e no tempo adequado sobre os custos e duração da criopreservação e o destino dos embriões; reforço da privacidade física; tempo para refletir sobre o destino dos embriões e a divulgação da identidade dos beneficiários. As condições de aplicação do consentimento parecem ameaçar três dos seus elementos fundamentais: informação, voluntarismo e ponderação. Importa desenvolver orientações ético-profissionais que assegurem um consentimento assente em práticas de aconselhamento e prestação de informação adequadas às necessidades e expectativas dos pacientes.(AU)

This qualitative study analyzed couples' perceptions about the factors that contextualize informed consent regarding embryo cryopreservation, through 34 semi-structured interviews, in Portugal. Data were analyzed according to the principles of grounded theory. The results revealed the following needs: timely provision of detailed, accurate and intelligible information about the costs of cryopreservation, embryo storage limit and embryo disposition; reinforcement of physical privacy; availability of time to reflect about embryo disposition and disclosure of users' identities. The conditions of administration of the informed consent appear to threaten three of its fundamental elements: information, voluntarism and reflection. The development of professional and ethical guidelines is necessary to ensure the implementation of a consent process characterized by practices of counseling and information adapted to patients' needs and expectations.(AU)

Este estudio cualitativo analizó las percepciones de parejas en lo que se refiere a los factores que contextualizan el consentimiento libre e informado en la crio-preservación de embriones, a partir de 34 entrevistas semi-estructuradas realizadas en Portugal. Se analizaron los datos según los principios de la grounded theory. De los resultados surgieron las necesidades siguientes: provisión de informaciones detalladas, rigurosas, coherentes y en el tiempo adecuado sobre los costos y duración de la crio-preservación y el destino de los embriones; refuerzo de la privacidad física, tiempo para reflexionar sobre el destino de los embriones y la divulgación de la identidad de los beneficiarios. Las condiciones de aplicación del consentimiento parecen amenazar tres de sus elementos fundamentales: información, voluntarismo y ponderación. Es importante desarrollar orientaciones ético-profesionales que aseguren un consentimiento pleno en prácticas de aconsejamiento y prestación de informaciones adecuadas a las necesidades y expectativas de los pacientes.(AU)

Using fertile couples as embryo donors: an ethical dilemma

The use of donated embryos has offered hope for infertile couples who have no other means to have children. In Iran, fertility centers use fertile couples as embryo donors. In this paper, the advantages and disadvantages of this procedure will be discussed. We conclude that embryo-donation should be performed with frozen embryos thus preventing healthy donors from being harmed by fertility drugs. There must be guidelines for choosing the appropriate donor families. In countries where commercial egg donation is acceptable, fertile couples can be procured as embryo donors thus fulfilling the possible shortage of good quality embryos. Using frozen embryos seems to have less ethical, religious and legal problems when compared to the use of fertile embryo donors

Zoroastrians support oocyte and embryo donation program for infertile couples

The main goal was to evaluate the attitudes and knowledge of Zoroastrians living in Iran towards oocyte donation [OD] and embryo donation [ED] program. This cross sectional study consisted of 318 Zoroastrians [n=175 for OD and n=143 for ED] of both sexes. The questionnaire form comprised two parts of general demographic characteristics of the participants and twenty multiple-choice questions about attitude and knowledge of participants towards OD and ED. For statistical analysis, the chi-square test was applied for comparison of data generated from ED and OD groups. Majority of the participants supported OD [69.7%] and ED [71.3%] for infertile patients. In addition, 40% and 42% preferred donation program [OD and ED, respectively], compared to adoption. About 60% of the respondents believed that the donors have no right to find the child and claim it as their own. In addition, more than half of the respondents thought that the recipients of oocyte/embryo should never know the name and address of the donors. More than half of the participants did not know whether their religion accepts donation program or not. Approximately, 80% of respondents supported psychological counseling for both donors and recipients. Moreover, about 56% of the participants necessitated the advertisement on OD/ED program in the mass media. Our preliminary data showed that Zoroastrians supported both OD and ED program equally for infertile couples

Turismo con células madre y requisitos para su uso clínico: desafíos bioéticos más allá del embrión / Bioethical challenges of stem cell tourism

Stem cells have drawn extraordinary attention from scientists and the general public due to their potential to generate effective therapies for incurable diseases. At the same time, the production of embryonic stem cells involves a serious ethical issue concerning the destruction of human embryos. Although adult stem cells and induced pluripotential cells do not pose this ethical objection, there are other bioethical challenges common to all types of stem cells related particularly to the clinical use of stem cells. Their clinical use should be based on clinical trials, and in special situations, medical innovation, both of which have particular ethical dimensions. The media has raised unfounded expectations in patients and the public about the real clinical benefits of stem cells. At the same time, the number of unregulated clinics is increasing around the world, making direct offers through Internet of unproven stem cell therapies that attract desperate patients that have not found solutions in standard medicine. This is what is called stem cells tourism. This article reviews this situation, its consequences and the need for international cooperation to establish effective regulations to prevent the exploitation of patients and to endanger the prestige of legitimate stem cell research.

Un estudio exploratorio sobre la donación hipotética de embriones humanos en el Perú / An exploratory study regarding the hypothetical human embryo donation in Peru

Objetivo: Explorar opiniones de pacientes que han acudido a técnicas de reproducción asistida (TRA) complejas, respecto a la donación de gametos y embriones, así como las razones para hacerlo o no. Diseño: Estudiotransversal de bioética descriptiva, con metodología cualitativa etnográfica, mediante entrevista semiestructurada, aplicando análisis del discurso al texto resultante. Lugar: Clínica privada, en Lima, Perú. Participantes: Veinte mujeres y 12 hombres, quienes habían acudido por lo menos a una TRA compleja. Intervenciones: Entrevista semiestructurada, aplicando análisis del discurso al texto resultante. Principales medidas de resultados: Opinión sobre donación de gametos y embriones. Resultados: Respecto a la donación de embriones, 11 de los hombres los donarían con fines de terapia de fertilidad, 6 con fines de investigación y solamente uno rechazó ambas posibilidades de donación. Las 20 mujeres entrevistadas, por su parte, los donarían para terapia de fertilidad y 8 de ellas con fines de investigación. Los participantes que han aceptado gametos donados, no necesariamente piensan que donarían los propios en caso de poder hacerlo. Conclusiones: La donación de gametos es más comentada y generalmente aceptada; la donación de embriones es un tema menos discutido y más conflictivo, tanto para donar como para aceptar. La criopreservación es un tema complejo, comentado pero también conflictivo, cuya aceptación o no, así como el destino de los embriones probablemente criopreservados, depende de las concepciones que se tiene respecto al origen de la vida, la ética personal, entre otros. Se puede plantear una hipótesis, a ser verificada en estudios cuantitativos, de que la donación de embriones podría efectuarse, principalmente, para terapia de fertilidad y excepcionalmente con fines de investigación.

Objective: To explore patients undergoing complex assisted reproductive technologiesÆ (ART) opinions on both gamete and embryo donation, as well as the reasons to do it or not. Design: Cross-sectional study of descriptive bioethics, with ethnographic qualitative methodology using a semi-structured interview, applying speech analysis to the resulting written transcript. Setting: Private medical institution, in Lima, Peru. Participants: Twenty women and 12 men who had had at least one complex ART. Interventions: Semi-structured interview, applying speech analysis to the resulting written transcript. Main outcome measures: Opinion on both gamete and embryo donation. Results: Regarding embryo donation, 11 men would donate their embryos for infertility treatment, 6 for research purposes, and only one rejected both possibilities. On the other hand, all 20 women would donate embryos for infertility treatment and only 8 for research purposes. Participants who accepted gamete donations did not necessarily think they would donate their own gametes. Conclusions: Results suggest gamete donation is more commented and generally accepted; embryo donation, either to donate or to accept donation, is a more conflicting and less discussed subject. Cryopreservation is a complex subject, commented but also conflicting, whose acceptance or not as well as the probable cryopreserved embryos destiny depend on participants beliefs on life origin, personal ethics, etc. Hypothesis resulting from this study to be verified in future quantitative researches is that embryo donation could take place mainly for infertility treatment and exceptionally for research.

A importância do uso das células tronco para a saúde pública / The importance of the use of stem cells for public health

Em 1999, as células-tronco foram eleitas "Scientific Breakthrough of the Year" (avanço científico do ano) pela revista Science¹. Naquele ano, foi demonstrado que células-tronco de tecidos adultos mantinham a capacidade de se diferenciar em outros tipos de tecidos. No ano anterior, as primeiras linhagens de células-tronco embrionárias humanas foram estabelecidas. Desde então, o número de artigos científicos sobre células-tronco vem crescendo exponencialmente, onde novos paradigmas são estabelecidos. Neste artigo, farei uma revisão da área de células-tronco com um foco especial em seu uso como agente terapêutico em doenças comuns como diabetes e cardiopatias. As células-tronco serão tratadas em dois grupos distintos: as embrionárias e as adultas. Enquanto o potencial de diferenciação das primeiras está bem caracterizado em camundongos e em humanos, seu uso em terapia celular e em pesquisa tem sido dificultado por questões de histocompatibilidade, segurança e ética. Em contraste, células-tronco adultas não apresentam estes empecilhos, apesar da extensão de sua plasticidade ainda estar sob investigação. Mesmo assim, diversos testes clínicos em humanos estão em andamento utilizando células-tronco adultas, principalmente derivadas da medula óssea. Discutirei ainda a importância de se trabalhar com as duas classes de células-tronco humanas de forma a se cumprir suas promessas terapêuticas.

Stem cells were elected 'Breakthrough of the Year' by Science¹ magazine in 1999, having shown that stem cells from adult tissues retained the ability to differentiate into other tissue types. During the previous year, the first human embryo stem cell lines were established. Since then, the number of scientific papers on stem cells has been increasing exponentially, establishing new paradigms that are rapidly challenged by subsequent experiments. This paper reviews the stem cell research field, divided into two groups: embryo and adult stem cells. While the differentiation potential of the former is well characterized in mice and humans, their use in cell therapy and research has been hampered by histocompatibility, safety and ethical issues. In contrast, adult stem cells do not present these problems. However, the extent of their plasticity is still under investigation. Nevertheless, numerous clinical trials in humans are under way, mainly with stem cells derived from bone marrow. This paper discusses discuss the importance of working with both classes of human stem cells in order to fulfill the promise of stem cell therapies.

Embriones híbridos como fuente de células troncales embrionarias: [editorial] / Hybrid embryos as a source of embrionic stem cells: [editorial]

The HFEA (Human Fertilisations & Embryology Authority) recently accepted to perform research in hybrid embryos generated by transferring human somatic cell nucleus to cow enucleated oocytes, named cytoplasmatic hybrids. The aim is to obtain a source of embryonic stem cells without the use of human oocytes. The arguments for the approval are to avoid the risk of obtaining human oocytes and that these embryos will not be transferred to a female's womb for its development. Those who oppose the technique argue that it is a manipulation of the beginning of life and a disrespect to the dignity of human life because of the destruction of embryos. Nevertheless, the real nature of this new entity has not been established. Biologically it is an embryo with 99 percent of human genome and animal's cytoplasm, not generated from human gametes, it is not a new genome and it will be used only to cultivate stem cells. It does not seem possible to define its nature beyond any doubts. If it were considered as a human embryo it should be respected and protected as every human being. Once more, scientific progress opens new ethical and legal questions that we cannot answer in a definitive way. Researchers are exploring new roads to obtain pluripotential stem cells which should favor the development of innovative therapies. The main objection is the unavoidable destruction of human embryos, although in this case its origin and nature are not clear.

Caracterização da inviabilidade evolutiva de embriões visando doações para pesquisas de células-tronco / Characterization of unviable embryos suitable for donation to stem-cell research

OBJETIVO: estabelecer quais as características que definem um embrião como inviável, tornando-o passível de doação para pesquisa com células-tronco. MÉTODOS: avaliação retrospectiva de ciclos de fertilização in vitro realizados entre janeiro de 1995 a 2005. Foram selecionados ciclos nos quais se transferiram para a cavidade uterina embriões com classificações morfológicas iguais entre si. Desta forma, avaliaram-se as taxas de gravidez, implantação e involução de sacos gestacionais dos embriões frescos e criopreservados, distribuídos em grupos, de acordo com sua morfologia. Foram considerados embriões tipo A aqueles simétricos e sem fragmentação; tipo B, assimétricos ou com até 25 por cento de fragmentação; tipo C, com 25 a 50 por cento do seu volume ocupado por fragmentos, e tipo D, aqueles com 50 por cento ou mais de fragmentação. Para as análises estatísticas utilizaram-se os testes de Kruskal-Wallis e Mann-Whitney. RESULTADOS: em 87 ciclos foram transferidos 172 embriões tipo D, obtendo-se 11 por cento de gravidez, embora somente metade dos embriões inicialmente implantados manteve sua evolução. Já embriões de mesma morfologia quando criopreservados, após descongelamento, não mostraram capacidade evolutiva, apresentando, a partir da transferência de 113 embriões em 36 ciclos, somente uma implantação, perfazendo uma diminuta taxa de 3 por cento de gravidez. A única gestação obtida involuiu antes da 12ª semana de gestação. CONCLUSAO: embriões de baixos escores morfológicos não podem ser considerados inviáveis por serem capazes, embora com uma freqüência muito baixa, de promoverem gestação. Mas estes mesmos embriões, quando criopreservados e posteriormente transferidos após descongelamento, mostraram taxa de gravidez irrisória, além de não resultarem em gravidez viável. Logo, quando extranumerários, os embriões tipo D não deveriam ser criopreservados, podendo então, ao invés de serem descartados, ser doados para pesquisa de células-tronco embrionárias.

Etica científica y embriones congelados / Scientific ethics and frozen embryos

Background: Scientific Ethics is the theory and praxis of decisions. Philosophical Ethics is presented as the theory and praxis of the good. As the good differs among cultures, Philosophical Ethics is dependent on the endo-cultural good conception. The decision (included that one of adhesion or not to a world vision) depends on neuro-psychic specific factors: i) cognitive factors that include mostly the knowledge of the alternatives and their consequences and the ideological or religious conception of good in relation to the alternatives; ii) affective factors that make alternatives pleasant, unpleasant or neutral, attractive, repulsive or neutral; iii) emotional factors that associate to alternatives anger, peace or neutrality, sadness, happiness or neutrality; iv) value factors that assign importance, triviality or neutrality to alternatives, or assign them significance, irrelevancy or neutrality. There are unspecific factors such as the psychic energy, desire or others. Mixed factors such as attitude, motivation, intention and others. Scientific Ethics deals with the mind as a materio-energetic process which is different from the soul, eggs and embryos of any species are full individuals of that species, because, they have initiated a copy of their genome that specify, give autonomy and define them as individuals. For Scientific Ethics to leave frozen embryos like that for ever, to defrost and get rid of them or to use their cells for science are synonymous of killing them. To defrost them to use their cells as stem cells for somatic cell therapy or to implant them into uteri to continue their development is to maintain alive their cells, but only the implantation allows their maintenance as individuals, thus, being the only compatible with the Christian ethics. The compatibility of these alternatives with other ethics is discussed

Princípios da bioética e do biodireito / Principles of bioethics and biolaw

Destaca a origem e o desenvolvimento da bioética até os nossos dias e salienta os princípios do biodireito frente aos problemas éticos gerados pelos avanços nas ciências biológicas e médicas no mundo contemporâneo, dando ênfase, principalmente, à necessidade de normatizaçäo de muitas das situaçöes oriundas desta relaçäo. O biodireito, como integrante do direito, deve, contudo, observar outros princípios estabelecidos pelo direito, ciência com métodos e formulaçäo específicas

A bioética e o conceito de pessoa: a re-significaçäo jurídica do ser enquanto pessoa / Bioethics and the concept of person: the legal re-significance of the human being as a person

Trata da definiçäo de pessoa, cuja importância é fundamental, uma vez que todo ordenamento jurídico dela depende para assegurar direitos e impor deveres aos indivíduos. Busca a compreensäo do conceito de pessoa nas diversas áreas do conhecimento humano, questiona o caráter meramente biológico da vida humana e defende uma concepçäo näo-reducionista de pessoa, cuja marca seja a resignificaçäo do ser e a mais alta consideraçäo de sua dignidade