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Nationwide use of postmortem retrieved sperm in Israel: a follow-up report

2011; Elsevier BV; Volume: 95; Issue: 8 Linguagem: Inglês

10.1016/j.fertnstert.2011.04.066

1556-5653

Arieh Raziel, Shevach Friedler, D. Strassburger, S Kaufman, Ana Umansky, Raphaël Ron-El,

Sperm and Testicular Function

A follow-up study of the subsequent use of all postmortem frozen sperm samples during 2003–2010 is reported. Only the sister of one of the 10 unmarried deceased men was in contact with the bank. Four widows elected to discard the frozen sperm and all of the remaining spouses were uninterested in its fate. Because none of the samples were requested for use, the need for sperm procurement should be reconsidered. A follow-up study of the subsequent use of all postmortem frozen sperm samples during 2003–2010 is reported. Only the sister of one of the 10 unmarried deceased men was in contact with the bank. Four widows elected to discard the frozen sperm and all of the remaining spouses were uninterested in its fate. Because none of the samples were requested for use, the need for sperm procurement should be reconsidered. Postmortem sperm retrieval (PMSR) is the extraction of viable sperm from a recently deceased male to be used for fertilization at a later time (1Ahuja K.K. Mamiso J. Emmerson G. Bowen-Simpinks P. Seaton A. Simons E.G. Pregnancy following ICSI treatment with dead husband’s spermatozoa: ethical and policy considerations.Hum Reprod. 1997; 12: 1360-1363Crossref PubMed Scopus (24) Google Scholar). Postmortem sperm retrieval has become a feasible method of procreation (2Bahadur G. Death and conception.Hum Reprod. 2002; 17: 2769-2775Crossref PubMed Google Scholar, 3Batzer F.R. Hurwitz J.M. Caplan A. Postmortem parenthood and the need for a protocol with posthumous sperm procurement.Fertil Steril. 2003; 79: 1263-1269Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar); it was first described three decades ago (4Rothman C.M. A method for obtaining viable sperm in the postmortem state.Fertil Steril. 1980; 34: 512PubMed Google Scholar). Much has been written on the timing of sperm retrieval (5Shefi S. Raviv G. Eisenberg M.L. Weissenberg R. Jalalian L. Levron J. et al.Posthumous sperm retrieval: analysis of time interval to harvest sperm.Hum Reprod. 2006; 21: 2890-2893Crossref PubMed Scopus (51) Google Scholar) and on the medical, legal, and ethical dilemmas that it poses (6Benshushan A. Schenker J.G. The right to an heir in the era of assisted reproduction.Hum Reprod. 1998; 13: 1404-1410Crossref Scopus (28) Google Scholar). The publications on PMSR involve a very small number of men, and there are few data on the eventual use of the thawed sperm for fertilization. It is currently common practice to freeze sperm of male patients before they undergo chemotherapy, despite the fact that less than 10% of the samples will be used by the patients later in life (7Tournaye H. Goossens E. Verheyen G. Fredericks V. De Block G. Devroy P. et al.Preserving the reproductive potential of men and boys with cancer: current concepts and future prospects.Hum Reprod Update. 2004; 6: 525-532Crossref Scopus (128) Google Scholar). All sperm retrievals for The Israeli National Pathology Institute are carried out in our center. The aim of this observational study was to survey the first 8 years of performing PMSR to report on the subsequent use of the frozen thawed samples for reproduction.Removal of the whole testis en bloc (orchiectomy) enables sperm retrieval from the vas deferens, epididymis, and testis (8Webb S.M. Raising sperm from the dead.J Androl. 1996; 17: 325-326PubMed Google Scholar). Aspiration of the vas deferens is a relatively easy procedure. After the isolation of the vas deferens through a scrotal incision, the vas is hemitransected and a catheter is advanced through the lumen toward the epididymis. The vas is then irrigated several times with 0.1–0.3 mL of medium. Extraction of sperm can be also performed either from the epididymis in a closed procedure (percutaneous sperm aspiration [PESA]) or from the testis (testicular sperm extraction [TESE]) (9Check M.L. Check J.H. Summers-Chase D. Choe J.K. Check D.J. Nazari A. Live birth after posthumous testicular sperm aspiration and ICSI with cryopreserved sperm: case report.Clin Exp Obstet Gynecol. 2002; 29: 95-96PubMed Google Scholar).Data from the database of the sole PMSR center in Israel were retrieved and the relevant information on all the cases and follow-up were obtained from the time the facility went into operation in 2003 until December 2010. Follow-up information consisted of the actions taken by the spouses and families after retrieval and freezing of the samples.Of 21 deceased men from whom viable sperm were retrieved, 10 were unmarried and 11 were married. Their mean age was 28.2 ± 7.3 years (range 19–51 years). Their characteristics and follow-up data on the use of the sperm are listed in Table 1.Table 1Clinical characteristics and use of postmortem sperm retrieval (PSMR) procedures.PatientFreezing dateAge (y)Marital statusCause of deathPMSR sanctioned by petitionerFollow-up14/200331Married + 1Work accidentWifeSperm thawedaThe thawed sperm was discarded as requested by the deceased’s wife.211/200322UnmarriedSuicideParent36/200532Married + 2Cardiac arrest /MIWifeSperm thawedaThe thawed sperm was discarded as requested by the deceased’s wife.49/200525MarriedCar accidentWife55/200519UnmarriedGunshot woundCourt/parent68/200625UnmarriedCombat injuriesCourt/parent78/200624UnmarriedCombat injuriesCourt/parent88/200621UnmarriedMotorcycle accidentCourt/parent912/200622UnmarriedGunshot woundCourt/parent103/200728UnmarriedMotorcycle accidentCourt/parent115/200751MarriedCardiac arrest /MIWife127/200725MarriedWork accidentWifeSperm thawedaThe thawed sperm was discarded as requested by the deceased’s wife.1310/200719UnmarriedMotorcycle accidentCourt/parent143/200836MarriedPneumoniaWife155/200829MarriedWork accidentWifeSperm thawedaThe thawed sperm was discarded as requested by the deceased’s wife.165/200831MarriedMotorcycle accidentWife171/200928MarriedCombat injuryWife185/200936MarriedWork accidentWife1910/201035MarriedCardiac arrestWife2010/201025UnmarriedCardiac arrestCourt/parent2111/201028UnmarriedMotorcycle accidentCourt/parenta The thawed sperm was discarded as requested by the deceased’s wife. Open table in a new tab The mean age of the 10 unmarried men was 23.3 ± 3.3 years (range 19–28 years). Four of the unmarried men died in motorcycle accidents, two during military service, two of gunshot injuries, one of cardiac arrest, and one committed suicide. The mother of the latter man agreed to other organ transplantation on the condition that sperm retrieval would be carried out. In 9 of these 10 cases, sperm retrieval was done under order of the court after petition on the part of the parents. Only the sister of one of the deceased men has remained in contact with the sperm bank, and she wants the cryopreservation to continue.The mean age of the 11 married men was 32.4 ± 7.6 years (range 25–51 years). Four of the 11 married men died as a result of work accidents, three from cardiac arrest, two from road accidents, one during military service, and one from pneumonia. One of these four, who died of work accidents, had fathered a child after an IVF procedure and the couple were undergoing another IVF treatment when the husband died several days before ovum collection was scheduled. Three years after the fatal accident, his wife requested that his sperm be thawed and not put to any use. Three men died from cardiac arrest: one was the father of two children whose wife requested that his sperm be thawed and not used 1 year later. Four of the 11 widows elected to having the frozen sperm thawed and discarded. Upon examination, the sperm cells of two of those samples were of acceptable morphology but without any motility. Another six widows were not interested in the fate of the frozen sperm and they continue to remain frozen. The sperm of the last case remain frozen after a short follow-up of only 4 months, as the intention of the widow is uncertain.In 1997, the Diane Blood case in the United Kingdom received international attention when she sought permission from the courts to be inseminated with her dead husband’s sperm (10Shenfeld F. Consent and intent in assisted reproduction.Med Law. 2000; 3: 317-325Google Scholar). Two years later, the first use of PMSR was described in the United States (11Planchon S. Comment: the application of the dead man’s status in family law.J Am Acad Matrimonial Lawyers. 2001; 13: 561-577Google Scholar). Several case reports and pregnancies resulting from PMSR have been published since then (12Check M. Summers-Chase D. Check J.H. Choe J. Nazari A. Sperm extracted and cryopreserved from testes several hours after death results in pregnancy following frozen embryo transfer: case report.Arch Androl. 1999; 43: 235-237Crossref PubMed Scopus (13) Google Scholar, 13Belker A.M. Swanson M.D. Cook C.L. Carrillo A.J. Joffe S.C. Live birth after sperm retrieval from a moribund man.Fertil Steril. 2001; 76: 841-843Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 14Dostal J. Utrata R. Loyka S. Brezinova J. Svoboda M. Shenfield F. Post-mortem sperm retrieval in new European Union countries: case report.Hum Reprod. 2005; 8: 2359-2361Crossref Scopus (14) Google Scholar). The total number of children known to have been born worldwide as a result of PMSR is unknown. Shefi et al. (5Shefi S. Raviv G. Eisenberg M.L. Weissenberg R. Jalalian L. Levron J. et al.Posthumous sperm retrieval: analysis of time interval to harvest sperm.Hum Reprod. 2006; 21: 2890-2893Crossref PubMed Scopus (51) Google Scholar) published one of the largest series of PMSR. They reviewed 17 consecutive procedures in 14 deceased and 3 brain dead patients at Israeli and American male infertility centers. Of these 17 procedures, two of the deceased American patients’ partners elected to use the retrieved sperm to conceive, and a healthy child was born to each of them.There are no laws concerning PMSR in Israel. The Israeli Attorney General’s guidelines for posthumous reproduction were published in 2003, but they are not legally binding, although it is assumed by the authorities that they will be followed. According to the Israeli regulations for PMSR, sperm retrieval should be attempted only when there is a reasonable probability of using these gametes for reproductive attempts. In addition, when there is a wife or partner of the deceased, it is she and not his nuclear family that is legally entitled to petition the court for sperm. Cryopreservation and the future use of cryopreserved sperm is allowed only after court approval. A 6-month period for bereavement and further reflection by the widow is mandatory. Sperm retrieval and freezing from an unmarried man is not recommended according to current Israeli guidelines (15Rubinstein E. Postmortem sperm retrieval and its use.Israel Attorney General Guidelines. 2003; 1: 1-13Google Scholar). They were done under court order in contradiction to The Israeli Attorney General guidelines. Proof of explicit or inferred consent of the deceased is needed in cases of perimortem retrieval or the use of stored sperm. Similar application of local guidelines, which excluded unmarried patients from PMSR, have been reported in a review article by Anger et al. (16Anger J.T. Gilbert B.R. Goldstein M. Cryopreservation of sperm: indications, methods and results.J Orology. 2003; 170: 1079-1084Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar).None of the 21 postmortem frozen tissue samples in our national sperm bank were requested for fertilization use during the past 8 years. Theoretically, there are two possible ways to use frozen sperm samples on request of the family of an unmarried deceased man. One is by court approval of the fertilization of donated oocytes with the thawed sperm sample using intracytoplasmic sperm injection (ICSI) and transferring the embryos to a surrogate mother. This option is not permitted by the 1996 Israeli law of surrogacy (17Frenkel D.A. Legal regulation of surrogate motherhood in Israel.Med Law. 2001; 20: 605-612PubMed Google Scholar). The other possibility is court approval of nonanonymous insemination of the deceased thawed sperm to a single woman, something that has never been presented to our courts for approval. Yet, there has been one case in which an unmarried woman requested the use of perimortem frozen ejaculated sperm of a man before he underwent chemotherapy. The petition was accepted by the Israeli court and she conceived and delivered a healthy child.Sperm retrieval and freezing from an unmarried man is not recommended according to current Israeli guidelines but was practically performed under pressure of involved families and time limits (18Raziel A. Friedler S. Strassburger D. Kaufman S. Umansky A. Ron-El R. Using sperm posthumously: national guidelines versus practice.Fertil Steril. 2010; 94: 1154-1156Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar). The court’s desire is not to be in confrontation with the families in their situation of agony and to abstain from making irreversible decisions.Several investigators have suggested that PMSR provides psychological relief for families after loss of a loved person. Whether medical resources should be used for such application is a matter of debate.Of the 11 married women who requested sperm retrieval at the time of their spouses’ death, 10 were available for follow-up; four of them requested that the sample be thawed and not put to further use. Two of the latter four already had children with their deceased husbands and the possibility of enlarging the family had been potentially relevant at the time of retrieval. The remaining six spouses were not interested in the fate of the frozen sperm. There is general consensus in various guidelines that no use be made of the procured sperm for a period between 6 and 12 months (15Rubinstein E. Postmortem sperm retrieval and its use.Israel Attorney General Guidelines. 2003; 1: 1-13Google Scholar). It is reasonable to expect that recent bereavement will strongly affect such important decisions. The current observational study looked at decisions that were made after those waiting periods and longer. No requests were submitted for the use of frozen sperm for reproduction during a period of 8 years. Postmortem sperm retrieval (PMSR) is the extraction of viable sperm from a recently deceased male to be used for fertilization at a later time (1Ahuja K.K. Mamiso J. Emmerson G. Bowen-Simpinks P. Seaton A. Simons E.G. Pregnancy following ICSI treatment with dead husband’s spermatozoa: ethical and policy considerations.Hum Reprod. 1997; 12: 1360-1363Crossref PubMed Scopus (24) Google Scholar). Postmortem sperm retrieval has become a feasible method of procreation (2Bahadur G. Death and conception.Hum Reprod. 2002; 17: 2769-2775Crossref PubMed Google Scholar, 3Batzer F.R. Hurwitz J.M. Caplan A. Postmortem parenthood and the need for a protocol with posthumous sperm procurement.Fertil Steril. 2003; 79: 1263-1269Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar); it was first described three decades ago (4Rothman C.M. A method for obtaining viable sperm in the postmortem state.Fertil Steril. 1980; 34: 512PubMed Google Scholar). Much has been written on the timing of sperm retrieval (5Shefi S. Raviv G. Eisenberg M.L. Weissenberg R. Jalalian L. Levron J. et al.Posthumous sperm retrieval: analysis of time interval to harvest sperm.Hum Reprod. 2006; 21: 2890-2893Crossref PubMed Scopus (51) Google Scholar) and on the medical, legal, and ethical dilemmas that it poses (6Benshushan A. Schenker J.G. The right to an heir in the era of assisted reproduction.Hum Reprod. 1998; 13: 1404-1410Crossref Scopus (28) Google Scholar). The publications on PMSR involve a very small number of men, and there are few data on the eventual use of the thawed sperm for fertilization. It is currently common practice to freeze sperm of male patients before they undergo chemotherapy, despite the fact that less than 10% of the samples will be used by the patients later in life (7Tournaye H. Goossens E. Verheyen G. Fredericks V. De Block G. Devroy P. et al.Preserving the reproductive potential of men and boys with cancer: current concepts and future prospects.Hum Reprod Update. 2004; 6: 525-532Crossref Scopus (128) Google Scholar). All sperm retrievals for The Israeli National Pathology Institute are carried out in our center. The aim of this observational study was to survey the first 8 years of performing PMSR to report on the subsequent use of the frozen thawed samples for reproduction. Removal of the whole testis en bloc (orchiectomy) enables sperm retrieval from the vas deferens, epididymis, and testis (8Webb S.M. Raising sperm from the dead.J Androl. 1996; 17: 325-326PubMed Google Scholar). Aspiration of the vas deferens is a relatively easy procedure. After the isolation of the vas deferens through a scrotal incision, the vas is hemitransected and a catheter is advanced through the lumen toward the epididymis. The vas is then irrigated several times with 0.1–0.3 mL of medium. Extraction of sperm can be also performed either from the epididymis in a closed procedure (percutaneous sperm aspiration [PESA]) or from the testis (testicular sperm extraction [TESE]) (9Check M.L. Check J.H. Summers-Chase D. Choe J.K. Check D.J. Nazari A. Live birth after posthumous testicular sperm aspiration and ICSI with cryopreserved sperm: case report.Clin Exp Obstet Gynecol. 2002; 29: 95-96PubMed Google Scholar). Data from the database of the sole PMSR center in Israel were retrieved and the relevant information on all the cases and follow-up were obtained from the time the facility went into operation in 2003 until December 2010. Follow-up information consisted of the actions taken by the spouses and families after retrieval and freezing of the samples. Of 21 deceased men from whom viable sperm were retrieved, 10 were unmarried and 11 were married. Their mean age was 28.2 ± 7.3 years (range 19–51 years). Their characteristics and follow-up data on the use of the sperm are listed in Table 1. The mean age of the 10 unmarried men was 23.3 ± 3.3 years (range 19–28 years). Four of the unmarried men died in motorcycle accidents, two during military service, two of gunshot injuries, one of cardiac arrest, and one committed suicide. The mother of the latter man agreed to other organ transplantation on the condition that sperm retrieval would be carried out. In 9 of these 10 cases, sperm retrieval was done under order of the court after petition on the part of the parents. Only the sister of one of the deceased men has remained in contact with the sperm bank, and she wants the cryopreservation to continue. The mean age of the 11 married men was 32.4 ± 7.6 years (range 25–51 years). Four of the 11 married men died as a result of work accidents, three from cardiac arrest, two from road accidents, one during military service, and one from pneumonia. One of these four, who died of work accidents, had fathered a child after an IVF procedure and the couple were undergoing another IVF treatment when the husband died several days before ovum collection was scheduled. Three years after the fatal accident, his wife requested that his sperm be thawed and not put to any use. Three men died from cardiac arrest: one was the father of two children whose wife requested that his sperm be thawed and not used 1 year later. Four of the 11 widows elected to having the frozen sperm thawed and discarded. Upon examination, the sperm cells of two of those samples were of acceptable morphology but without any motility. Another six widows were not interested in the fate of the frozen sperm and they continue to remain frozen. The sperm of the last case remain frozen after a short follow-up of only 4 months, as the intention of the widow is uncertain. In 1997, the Diane Blood case in the United Kingdom received international attention when she sought permission from the courts to be inseminated with her dead husband’s sperm (10Shenfeld F. Consent and intent in assisted reproduction.Med Law. 2000; 3: 317-325Google Scholar). Two years later, the first use of PMSR was described in the United States (11Planchon S. Comment: the application of the dead man’s status in family law.J Am Acad Matrimonial Lawyers. 2001; 13: 561-577Google Scholar). Several case reports and pregnancies resulting from PMSR have been published since then (12Check M. Summers-Chase D. Check J.H. Choe J. Nazari A. Sperm extracted and cryopreserved from testes several hours after death results in pregnancy following frozen embryo transfer: case report.Arch Androl. 1999; 43: 235-237Crossref PubMed Scopus (13) Google Scholar, 13Belker A.M. Swanson M.D. Cook C.L. Carrillo A.J. Joffe S.C. Live birth after sperm retrieval from a moribund man.Fertil Steril. 2001; 76: 841-843Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 14Dostal J. Utrata R. Loyka S. Brezinova J. Svoboda M. Shenfield F. Post-mortem sperm retrieval in new European Union countries: case report.Hum Reprod. 2005; 8: 2359-2361Crossref Scopus (14) Google Scholar). The total number of children known to have been born worldwide as a result of PMSR is unknown. Shefi et al. (5Shefi S. Raviv G. Eisenberg M.L. Weissenberg R. Jalalian L. Levron J. et al.Posthumous sperm retrieval: analysis of time interval to harvest sperm.Hum Reprod. 2006; 21: 2890-2893Crossref PubMed Scopus (51) Google Scholar) published one of the largest series of PMSR. They reviewed 17 consecutive procedures in 14 deceased and 3 brain dead patients at Israeli and American male infertility centers. Of these 17 procedures, two of the deceased American patients’ partners elected to use the retrieved sperm to conceive, and a healthy child was born to each of them. There are no laws concerning PMSR in Israel. The Israeli Attorney General’s guidelines for posthumous reproduction were published in 2003, but they are not legally binding, although it is assumed by the authorities that they will be followed. According to the Israeli regulations for PMSR, sperm retrieval should be attempted only when there is a reasonable probability of using these gametes for reproductive attempts. In addition, when there is a wife or partner of the deceased, it is she and not his nuclear family that is legally entitled to petition the court for sperm. Cryopreservation and the future use of cryopreserved sperm is allowed only after court approval. A 6-month period for bereavement and further reflection by the widow is mandatory. Sperm retrieval and freezing from an unmarried man is not recommended according to current Israeli guidelines (15Rubinstein E. Postmortem sperm retrieval and its use.Israel Attorney General Guidelines. 2003; 1: 1-13Google Scholar). They were done under court order in contradiction to The Israeli Attorney General guidelines. Proof of explicit or inferred consent of the deceased is needed in cases of perimortem retrieval or the use of stored sperm. Similar application of local guidelines, which excluded unmarried patients from PMSR, have been reported in a review article by Anger et al. (16Anger J.T. Gilbert B.R. Goldstein M. Cryopreservation of sperm: indications, methods and results.J Orology. 2003; 170: 1079-1084Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar). None of the 21 postmortem frozen tissue samples in our national sperm bank were requested for fertilization use during the past 8 years. Theoretically, there are two possible ways to use frozen sperm samples on request of the family of an unmarried deceased man. One is by court approval of the fertilization of donated oocytes with the thawed sperm sample using intracytoplasmic sperm injection (ICSI) and transferring the embryos to a surrogate mother. This option is not permitted by the 1996 Israeli law of surrogacy (17Frenkel D.A. Legal regulation of surrogate motherhood in Israel.Med Law. 2001; 20: 605-612PubMed Google Scholar). The other possibility is court approval of nonanonymous insemination of the deceased thawed sperm to a single woman, something that has never been presented to our courts for approval. Yet, there has been one case in which an unmarried woman requested the use of perimortem frozen ejaculated sperm of a man before he underwent chemotherapy. The petition was accepted by the Israeli court and she conceived and delivered a healthy child. Sperm retrieval and freezing from an unmarried man is not recommended according to current Israeli guidelines but was practically performed under pressure of involved families and time limits (18Raziel A. Friedler S. Strassburger D. Kaufman S. Umansky A. Ron-El R. Using sperm posthumously: national guidelines versus practice.Fertil Steril. 2010; 94: 1154-1156Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar). The court’s desire is not to be in confrontation with the families in their situation of agony and to abstain from making irreversible decisions. Several investigators have suggested that PMSR provides psychological relief for families after loss of a loved person. Whether medical resources should be used for such application is a matter of debate. Of the 11 married women who requested sperm retrieval at the time of their spouses’ death, 10 were available for follow-up; four of them requested that the sample be thawed and not put to further use. Two of the latter four already had children with their deceased husbands and the possibility of enlarging the family had been potentially relevant at the time of retrieval. The remaining six spouses were not interested in the fate of the frozen sperm. There is general consensus in various guidelines that no use be made of the procured sperm for a period between 6 and 12 months (15Rubinstein E. Postmortem sperm retrieval and its use.Israel Attorney General Guidelines. 2003; 1: 1-13Google Scholar). It is reasonable to expect that recent bereavement will strongly affect such important decisions. The current observational study looked at decisions that were made after those waiting periods and longer. No requests were submitted for the use of frozen sperm for reproduction during a period of 8 years.