Version 2006

Handbook of WMA Policies
S-2006-01-2006 ⏐ World Medical Association
WMA STATEMENT
ON
ASSISTED REPRODUCTIVE TECHNOLOGIES
Adopted by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
PREAMBLE
1. Assisted reproductive technology encompasses a wide range of techniques designed
primarily to aid couples unable to conceive without medical assistance. Since the birth
of the first so-called ‘test-tube baby’ in 1978, more than 1.5 million children world-
wide have been born following IVF treatment.
2. The term ‘assisted reproductive technology’ includes techniques such as in-vitro fer-
tilisation (IVF) and intra-cytoplasmic sperm injection (ICSI). It can be defined as in-
cluding all treatments that include medical and scientific manipulation of human gam-
etes and embryos in order to produce a term pregnancy. Although some legislatures
have considered artificial insemination, whether using donor semen or semen from the
patient’s partner, as different, many of the issues about regulation in relation to obtain-
ing, storing, using and disposing of gametes and embryos are closely inter-linked. In
this statement treatments such as artificial insemination are excluded.
3. Assisted reproductive technologies raise profound moral issues. Views and beliefs
about the moral status of the embryo, which are central to much of the debate in this
area, vary both within and among countries. Assisted conception is also regulated dif-
ferently in various countries. Whilst consensus can be reached on some issues, there
remain fundamental differences of opinion that cannot be resolved. This statement
identifies areas of agreement and also highlights those matters on which agreement
cannot be reached. Physicians faced with such situations should comply with applica-
ble laws and regulations as well as the ethical requirements and professional standards
established by their National Medical Association and other appropriate organizations
in the community.
4. Physicians involved in providing assisted reproductive technologies should always
consider their ethical responsibilities towards any child who may be born as a result of
the treatment. If there is evidence that a future child would be exposed to serious
harm, treatment should not be provided.
5. As with all other medical procedures, physicians also have an ethical obligation to
limit their practice to areas in which they have relevant expertise and experience and
to respect the rights of patients. These rights include that of personal bodily integrity
and freedom from coercion. In practice this means that valid or real consent is re-
quired as with other medical procedures; the validity of such consent is dependent
upon the adequacy of the information offered to the patient and their freedom to make
a decision, including freedom from coercion or other pressures to decide in a parti-
cular way.
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Assisted Reproductive Technologies
6. Assisted conception differs from the treatment of illness in that the inability to be-
come a parent without medical intervention is not always regarded as an illness.
While it may have profound psychosocial, and thus medical, consequences, it is not in
itself life limiting. It is, however, a significant cause of major psychological illness
and its treatment is clearly medical.
7. Obtaining informed consent from those considering undertaking treatment must in-
clude consideration of the alternatives, including accepting childlessness or pursuing
adoption, the risks associated with the various techniques, and the possibility of failure.
In many jurisdictions the process of obtaining consent must follow a process of infor-
mation giving and the offer of counselling and might also include a formal assessment
of the patient in terms of the welfare of the potential child.
8. Patients seeking assisted reproductive technologies are entitled to the same level of
confidentiality and privacy as for any other medical treatment.
9. Assisted reproductive technology always involves handling and manipulation of hu-
man gametes and embryos. Different individuals regard this with different levels of
concern but there is general agreement that these special concerns should be met by
specific safeguards to protect from abuse. In some jurisdictions all centres handling
such materials require a licence and must demonstrate compliance with high norma-
tive standards.
SUCCESS OF THE TECHNIQUES

1. The success of different techniques may differ widely from centre to centre. Physi-
cians have an obligation to give realistic information about success rates to potential
patients. If their success rates are widely different from the current norm they should
disclose this fact to patients. They also have an obligation to consider the reasons for
this as they might relate to poor practice, and if so, to correct their deficiencies.
MULTIPLE PREGNANCIES

1. Replacement of more than one embryo may raise the likelihood of at least one embryo
implanting. This is offset by the increased risk, especially of premature labour, in
multiple pregnancies. The risk of twin pregnancies, while higher than that of singleton
pregnancies, is considered acceptable by most people. Practitioners should follow pro-
fessional guidance on the maximum number of embryos to be transferred per treat-
ment cycle. If multiple pregnancies occur, selective termination might be considered
on medical grounds to increase the chances of the pregnancy proceeding to term
where this is compatible with the national law and code of ethics.
DONATION

1. Some patients are unable to produce usable gametes. They require ova or sperm from
donors. Donation should follow counselling and be carefully controlled to avoid
abuses, including coercion of potential donors. It is inappropriate to offer money or
benefits in kind (for example free or lower cost treatment cycles) to encourage dona-
tion but donors may be reimbursed for reasonable expenses.
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Handbook of WMA Policies
S-2006-01-2006 ⏐ World Medical Association
2. Where a child is born following donation, families should be encouraged to be open
with him/her about this, irrespective of whether domestic law entitles the child to
information about the donor. Keeping secrets within families is difficult and can be
harmful to children if information about donor conception is disclosed inadvertently
and without appropriate support.
PRE-IMPLANTATION GENETIC DIAGNOSIS (PGD)

1. Pre-implantation genetic diagnosis (PGD) may be performed on early embryos to
search for the presence of genetic or chromosomal abnormalities, especially those
associated with severe illness and very premature death and for other reasons, includ-
ing identifying those embryos most likely to implant successfully in women who have
had multiple spontaneous abortions. Embryos carrying the abnormality are discarded;
only embryos with apparently normal genetic and chromosomal complements are im-
planted.
2. Neither this powerful technique nor simpler means should be used for trivial reasons
such as sex selection for reasons of gender preference. The WMA holds that physi-
cians should only be involved with sex selection where it is used to avoid a serious
sex-chromosome related condition such as Duchenne’s Muscular Dystrophy.
3. PGD can also be combined with HLA matching to select embryos on the basis that
stem cells from the resulting child’s umbilical cord blood could be used to treat a
seriously ill sibling. Views on the acceptability of this practice vary and physicians
should follow national laws and local ethical and professional standards if confronted
with such requests.
USE OF SPARE GAMETES AND EMBRYOS
AND DISPOSAL OF UNUSED GAMETES AND EMBRYOS

1. In most cases, assisted conception results in the production of gametes and embryos
that will not be used to treat those from whom they are procured. Such so-called spare
gametes and embryos may be stored, cryo-preserved for future use, donated to other
patients or disposed of. One alternative to disposal, in countries that permit embryo
research, is donation to a research facility. The available options must be explained
clearly and precisely to individuals before donations are made or retrievals performed.
SURROGACY

1. Where a woman is unable, for medical reasons, to carry a child to term, surrogacy
may be used to overcome childlessness, unless prohibited by national law or the ethi-
cal rules of the National Medical Association or other relevant organization. Where
surrogacy is practised, great care must be taken to protect the interests of all parties
involved.
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RESEARCH

1. Physicians should promote the importance of research using tissues obtained during
assisted conception procedures. Because of the special status of the material being
used, research on human gametes and especially on human embryos is, in many juris-
dictions, specifically regulated. Physicians have an ethical duty to comply with such
regulation and to help inform public debate and understanding of the issues.
2. Due to the special nature of human embryos, research should be carefully controlled
and should be limited to areas in which the use of alternative materials will not pro-
vide an adequate alternative.
3. Views, and legislation, differ on whether embryos may be created specifically for, or
in the course of, research. Physicians should act in accordance with national legisla-
tion and local ethical advice.
CELL NUCLEAR REPLACEMENT

1. The WMA opposes the use of cell nuclear replacement with the aim of cloning human
beings.
2. Cell nuclear replacement may also be used to develop embryonic stem cells for
research and ultimately, it is hoped, for therapy for many serious diseases. Views on
the acceptability of such research differ and physicians wishing to participate in such
research should ensure that they are acting in accordance with national laws and local
ethical guidance.
RECOMMENDATIONS

1. Assisted reproductive technology is a dynamic, rapidly developing field of medical
practice. Developments should be subject to careful ethical consideration alongside
the scientific monitoring.
2. Human gametes and embryos are accorded a special status. Their use, including for
research, donation to others and disposal, should be carefully explained to potential
donors and subject to local regulation.
3. Embryo research should only be carried out if local law and ethical standards permit it
and should be limited to areas where the use of alternative materials or computer
modelling does not provide an adequate alternative.
4. Physicians should follow professional guidance on the maximum number of embryos
to transfer in any treatment cycle.
5. It is inappropriate to offer money or benefits in kind (for example free or lower cost
treatment cycles) to encourage donation but donors may be reimbursed for reasonable
expenses.
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Handbook of WMA Policies
S-2006-01-2006 ⏐ World Medical Association
6. Families using donated embryos or gametes should be encouraged and supported to
be open with the child about this.
7. Sex selection should only be carried out to avoid serious, including life threatening,
medical conditions.
8. Physicians have an important role in ensuring that public debate about the
possibilities of assisted conception, and the limits to be applied to its practice, is
informed.
9. Physicians should comply with national legislation and should demonstrate com-
pliance with high normative standards.
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