A call for institutional policies on postmortem
sperm retrieval
Postmortem sperm retrieval (PMSR) raises signi
fi
cant ethical
and legal concerns, including issuesofimplied consent, debates
regarding ownership and the designation of sperm as property,
controversy involving the inclusion of sperm retrieval as a part
of organ donation, and con
fl
ict over the rights of inheritance
for offspring
(1)
. A lack of consensus exists in regards to the
use ofPMSRonnational,international,and institutional levels.
Tash et al.
(2)
in 2003 reported on the bene
fi
ts of establishing
institutional guidelines to simplify the issues surrounding
PMSR. The implementation of these guidelines stemmed from
four considerations: [1] issues of consent, [2] medical contrain-
dications, [3] resource availability, and [4] a 1-year waiting
period for bereavement and recipient evaluation. The use of
institutional guidelines, in this case, resulted in fewer postmor-
tem retrievals performed and also offered a framework for de-
cision making surrounding this procedure
(2)
.
Although PMSR is relatively uncommon, the advent of
in vitro fertilization with intracytoplasmic sperm injection,
which requires fewer sperm for a pregnancy, has resulted in
an increased frequency of PMSR requests
(3)
. Despite these
increased requests, no governing guidelines exist within the
United States. Policies regarding PMSR have, therefore, been
relegated to the state or institutional level. Similarly, interna-
tional guidelines are widely variable, with a ban on performance
of PMSR in France and Germany in contrast to the mandatory
requirements for prior written consent in the United Kingdom.
Despite prevailing assumptions that men would preferen-
tially choose not to reproduce after death, recent evidence by
Pastuszak et al.
(1)
has called this into question. These investi-
gators found that 85.9% of men presenting for sperm banking
provided consent for postmortem sperm use, including 87.4%
of men with infertility and 83.8% of men with cancer. Men
who were in a relationship or who werefathers were more likely
to agree to postmortem use
(1)
. The paucity of both institutional
policies and regulatory guidelines is magni
fi
ed by the esca-
lating number of requests for PMSR. The increasing demand
for these services has left physicians and institutions ill-
prepared to manage the rising call for PMSR and makes
health-care providers susceptible to unnecessary liability.
The article
‘‘
A Content Analysis of Posthumous Sperm
Procurement Protocols with Considerations for Developing
an Institutional Policy
’’
by Bahm et al.
(4)
expands on the
work by Tash and colleagues through an analysis of nine in-
stitutions and provides a reference point for the adoption of
practice guidelines. The authors identi
fi
ed six common com-
ponents of a working PMSR protocol: [1] standard of evi-
dence, [2] terms of eligibility, [3] sperm designee, [4]
restrictions on use in reproduction, [5] logistics, and [6] con-
traindications. Bahm et al.
(4)
also describe two prevailing ap-
proaches designated as family centered versus limited role. A
family-centered approach includes allowances for substituted
judgment and a required wait period before use of sperm
whereas a limited-role approach characterizes those policies
with stricter consent requirements and limited involvement
in procurement. Although these contrasting frameworks are
primarily descriptive of existing policies, the aforementioned
six components should provide a starting point from which
institutions can compose much-needed protocols to protect
institutional and individual liability and ensure that the pa-
tient's wishes are followed when appropriate.
Of primary importance within the article is the fact that 60%
of contacted institutions reported that they either did not have or
were unaware of anexisting PMSRprotocol
(4)
. Thishighlightsa
potential vulnerability that exists on a national scale for those
practitioners and institutions that may be called on to procure
sperm from deceased individuals. Reliance on guidance from
governmental or professional societies is not currently possible.
For instance, the American Society for Reproductive Medicine,
the governing body of this journal, states that
‘‘
A spouse's
request that sperm or ova be obtained terminally or soon after
death without the prior consent or known wishes of the deceased
spouse need not be honored. Such requests pose judgmental
questions that should be answered within the context of the in-
dividual circumstances and applicable state laws
’’
(5)
.A
l
ltoo
often, these professional society guidelines are called into ques-
tion by the requesting family.
Advances in assisted reproductive technology now allow for
gamete procurement from the dying and deceased at increasing
rates. As such, the reviewers call for an expansion of institu-
tional policies, which are currently limited in number, that
would permit fast, ef
fi
cient, and ethical decisions to protect in-
dividuals and institutions from liability. Employment of both
an ethics committee, if available, and legal counsel allows for
thoughtful deliberation and helps to ensure a comprehensive
strategy. A similar working group is present at our institution
and has assisted in laying the initial framework for local policy.
Decisions regarding PMSR should be made on established ethical
and legal grounds as opposed to reactionary decisions made in
haste. Bahm et al.
(4)
have provided six considerations for insti-
tutions looking to formulate guidelines for their providers. It is
our hope that articles like these will promulgate discussion of
PMSR and hasten the adoption of institutional policies.
Ryan P. Smith, M.D.
Larry I. Lipshultz, M.D.
Scott Department of Urology, Baylor College of Medicine,
Houston, Texas
You can discuss this article with its authors and with other
ASRM members at
http://fertstertforum.com/smithrp-policy-postmortem-
sperm-retrieval-ethics/
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REFERENCES
1.
Pastuszak AW, Lai WS, Hsieh TC, Lipshultz LI. Posthumous sperm utilization in
men presenting for sperm banking: an analysis of patient choice. Andrology
2013;1:251
–
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VOL. 100 NO. 3 / SEPTEMBER 2013