title: Survey of 243 ART patients having made a final disposition decision about their surplus cryopreserved embryos: the crucial role of symbolic embryo representation.
abstract: In couples who have chosen and confirmed the fate of surplus frozen embryos, which factors influence their decision, with a special emphasis on their symbolic representation of the embryo(s)?
  
  
  
  Embryo representation and gamete donation use significantly influence the fate of surplus cryopreserved embryos.
  
  
  
  Previous studies report difficulties for couples to decide whether or not to continue storing their frozen embryo(s) and different factors have been already highlighted which influence their decision, including embryo conceptualization, information and support provided by the medical institution, quality of embryo(s) and life events. Little is known, however, about couples who definitely decided to stop their parental project and finalized the process of decision-making about the fate of their cryopreserved embryo(s).
  
  
  
  This prospective study was conducted over a period of 3 years (2007-2010) and included IVF/ICSI patients with surplus frozen embryos, who made a final embryo disposition decision. Among the 280 eligible IVF/ICSI patients, 247 agreed to participate in the study. According to the available options, 91 persons chose to 'stop cryopreservation', 77 chose donation to 'research' and 48 'embryo donation' to infertile couples. Furthermore, 31 participants who chose embryo donation for a parental project were refused by the center as not compatible with their mandatory medical conditions. Among them, 27 participants then selected donation to research as a new option and were included in a fourth group: 'donation to research after Refusal of Embryo Donation for parental project' or 'research-RED' (n = 27). Four participants chose 'stop cryopreservation', however, given the small number of subjects this latter group was not included in the analysis. In all, 243 participants who made a final choice concerning the fate of their cryopreserved embryos were included in this study.
  
  
  
  Participants were sent a letter of invitation to a semi-structured interview of 30 min with a psychologist. Interviews were conducted separately for each partner, including a questionnaire with a common part and a specific part, according to the chosen option, and allowing a quantitative evaluation. A multivariate logistic regression model was used to assess the link between their embryo representation and their decision about their embryos' fate.
  
  
  
  After adjustment for age, gender, gamete donation, number of children and the different embryo representations, a choice to 'stop cryopreservation' is more frequent if the embryo is represented as a child [odds ratio (OR) adjusted = 3.29, 95% confidence interval (CI) = 1.62-6.66], P = 0.0009. Representing the embryo as a project prompts patients to choose 'donation to research' [OR adjusted = 3.76, 95% CI = 1.56-9.06], P = 0.0032. Respondents are more likely to choose 'embryo donation' if they represent the embryo as a potential person [OR adjusted = 3.77, 95% CI = 1.45-9.80], P = 0.0064. Furthermore, patients who benefited from gamete donation are ∼10 times more likely to donate their embryos to another couple [OR adjusted = 10.62, 95% CI = 3.99-28.30], P < 0.0001. For more than half the participants (57%) the decision-making was easy, however, deciding to stop cryopreservation was significantly more difficult than choosing research or embryo donation (P < 0.0001).
  
  
  
  Socio-economic status, moral and religious affiliations are known to influence the choice of couples but analyzing these factors was not an aim of the present study.
  
  
  
  When couples definitely decide to stop their parental project, the embryo symbolic representation remains the main factor that influences the fate of their frozen embryo(s). Moreover, this representation can evolve when influenced by external events and information provided. In order to support patients who are making this difficult decision, it could be helpful to explore this symbolic representation early in the IVF/ICSI procedure, before surplus embryo freezing, as a new tool enhancing the accuracy of counseling.
  
  
  
  this study was supported by a grant from the 'Agence de la biomedicine (ABM)', the national regulatory ART agency, under the authority of the French Ministry of Health. The authors have no conflict of interest to declare.
authors.affiliation: Laboratoire de Biologie de la Reproduction - CECOS (Centre d'étude et de conservation des œufs et du sperme humains), Centre Hospitalier Universitaire, Dijon 21000, France celine.bruno@chu-dijon.fr.
authors.forename: C
authors.initials: C
authors.lastname: Bruno
authors.affiliation: Service de Biologie de la Reproduction - CECOS, Assistance Publique-Hôpitaux de Paris (APHP), UPMC (Paris VI), Centre Hospitalier Universitaire Tenon, Paris 75020, France Service de Gynécologie-Obstétrique et médecine de la Reproduction, APHP, UPMC (Paris VI), Centre Hospitalier Universitaire Tenon, Paris 75020, France.
authors.forename: C
authors.initials: C
authors.lastname: Dudkiewicz-Sibony
authors.affiliation: Service de Biologie de la Reproduction - CECOS, Assistance Publique-Hôpitaux de Paris (APHP), UPMC (Paris VI), Centre Hospitalier Universitaire Tenon, Paris 75020, France.
authors.forename: I
authors.initials: I
authors.lastname: Berthaut
authors.affiliation: Service de Biologie de la Reproduction - CECOS, Assistance Publique-Hôpitaux de Paris (APHP), UPMC (Paris VI), Centre Hospitalier Universitaire Tenon, Paris 75020, France.
authors.forename: E
authors.initials: E
authors.lastname: Weil
authors.affiliation: UMR de droit comparé de Paris, CNRS-Université de Paris I, Equipe du Centre de recherche "Droit, sciences et techniques", Paris 75004, France.
authors.forename: L
authors.initials: L
authors.lastname: Brunet
authors.affiliation: CNRS - Laboratoire d'Anthropologie Sociale, 52, rue du cardinal Lemoine, Paris 75005, France.
authors.forename: C
authors.initials: C
authors.lastname: Fortier
authors.affiliation: Clinique de la Dhuys, 1 rue Pierre et Marie Curie, Bagnolet 93170, France.
authors.forename: J
authors.initials: J
authors.lastname: Pfeffer
authors.affiliation: Laboratoire de Biologie de la Reproduction - CECOS, Maternité, Centre Hospitalier Universitaire, Rennes 35203, France.
authors.forename: C
authors.initials: C
authors.lastname: Ravel
authors.affiliation: Laboratoire de Biologie de la Reproduction - CECOS (Centre d'étude et de conservation des œufs et du sperme humains), Centre Hospitalier Universitaire, Dijon 21000, France.
authors.forename: P
authors.initials: P
authors.lastname: Fauque
authors.affiliation: Service de Gynécologie-Obstétrique et médecine de la Reproduction, APHP, UPMC (Paris VI), Centre Hospitalier Universitaire Tenon, Paris 75020, France.
authors.forename: E
authors.initials: E
authors.lastname: Mathieu
authors.affiliation: Service de Gynécologie-Obstétrique et médecine de la Reproduction, APHP, UPMC (Paris VI), Centre Hospitalier Universitaire Tenon, Paris 75020, France.
authors.forename: J M
authors.initials: JM
authors.lastname: Antoine
authors.affiliation: Assistance Publique-Hôpitaux de Paris (APHP), URC EST, Saint-Antoine Hospital, Paris 75012, France.
authors.forename: S
authors.initials: S
authors.lastname: Kotti
authors.affiliation: Service de Biologie de la Reproduction - CECOS, Assistance Publique-Hôpitaux de Paris (APHP), UPMC (Paris VI), Centre Hospitalier Universitaire Tenon, Paris 75020, France.
authors.forename: J
authors.initials: J
authors.lastname: Mandelbaum
mesh_terms: D000328:Adult; D002755:Choice Behavior; D003657:Decision Making; D019924:Embryo Disposition / Q000523:psychology / Q000706:statistics & numerical data*; D033041:Embryo Research; D005260:Female; D006801:Humans; D011446:Prospective Studies; D027724:Reproductive Techniques, Assisted / Q000523:psychology
keywords: IVF; embryo disposition decision; embryo donation; fate of cryopreserved embryos; frozen embryo; gamete donation; human embryo symbolic representation