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Background Professional guidelines have addressed ethical dilemmas posed by a few types of nontraditional procreative arrangements (e.g., gamete donations between family members), but many questions arise regarding how providers view and make decisions about these and other such arrangements. Methods Thirty-seven ART providers and 10 patients were interviewed in-depth for approximately 1 h each. Interviews were systematically analyzed. Results Providers faced a range of challenges and ethical dilemmas concerning both the content and the process of decisions about requests for unconventional interfamilial and other reproductive combinations. Providers vary in how they respond — what they decide, who exactly decides (e.g., an ethics committee or not), and how — often undergoing complex decision-making processes. These combinations can involve creating or raising the child, and can shift over time — from initial ART treatment through to the child’s birth. Patients’ requests can vary from fully established to mere possibilities. Arrangements may also be unstable, fluid, or unexpected, posing challenges. Difficulties emerge concerning not only familial but social, combinations (e.g., between friends). These arrangements can involve blurry and confusing roles, questions about the welfare of the unborn child, and unanticipated and unfamiliar questions about how to weigh competing moral and scientific concerns — e.g., the autonomy of the individuals involved, and the potential risks and benefits. Clinicians may feel that these requests do not “smell right”; and at first respond with feelings of “yuck,” and only later, carefully and explicitly consider the ethical principles involved. Proposed arrangements may, for instance, initially be felt to involve consanguineous individuals, but not in fact do so. Obtaining and verifying full and appropriate informed consent can be difficult, given implicit familial and/or cultural expectations and senses of duty. Social attitudes are changing, yet patients’ views of these issues may also vary, based on their cultural backgrounds. Conclusions These data, the first to examine how clinicians make decisions about unconventional reproductive arrangements, highlight several critical ethical questions and ambiguities, and variations in clinicians’ responses. While several professional guidelines exist, the current data highlight additional challenges, and have vital implications for improving future guidelines, practice, education and research. Trial registration Not applicable.

Objective To study how IVF providers view and make decisions concerning age cutoffs and futility (e.g., whether they establish clear cutoffs, and if so, where). Design In-depth interviews of approximately 1 hour. Setting Not applicable. Patient(s) Interviewees: 27 ART providers (17 physicians, 10 other providers) and 10 patients. Intervention(s) Not applicable. Main Outcome Measure(s) Attitudes and decisions concerning age cutoffs were assessed. Result(s) Providers face several challenges and dilemmas concerning both the content and the process of decision-making about age cutoffs—what age cutoff to use for potential parents (women both using and not using their own eggs) and potential fathers (whether to consider the father's age, and if so, separately or only with the mother's age); what criteria to use in these decisions (how much to consider and weigh the mother's autonomy vs. the future child's well-being); how to make these decisions (e.g., "gut feelings" or perceptions of public opinion); who makes these decisions (e.g., physicians on their own vs. a formal ethics or Quality Assurance committee); and how to present/frame these issues to patients (e.g., how much to discourage older women). Patients' responses to age limitations vary (e.g., minimizing or feeling exceptions to the risks; or lying about their age). Conclusion(s) These data, the first to explore how providers make decisions about age cutoffs for patients, raise several critical issues. Although the American Society for Reproductive Medicine has addressed several concerns, the present data suggest additional questions and challenges, including inherent uncertainties and ethical conflicts, and have important implications for practice, policy, research, and education.

At the beginning of this decade, a civil court case in the United States (Davis v. Davis, 1989 & 1990) raised some interesting questions about the moral underpinnings of judgments on issues resulting from the application of new reproductive technologies, specifically in vitro fertilization. In this monograph I shall examine from a moral point of view some of the issues, themselves both moral and legal, raised in this case. The moral issues concern the possibility of a complicated set of rights conflicts between a prospective mother, a prospective father and a prospective child. While the initial judgment handed down seems reasonable, questions can be raised about the reasoning provided by the judge. In fact, the rationale, and possibly therefore the laws upon which it was based, manifest, in my view, a remarkably rigid and pre-historic set of moral values. Hence the first part of my title. The legal issues to be addressed arise out of a proposal by Anthony John Cuva (1991) for legislative change in the area of in vitro fertilization. While many of Cuva's presuppositions about the case seem right, I shall argue that his proposals are morally inconsistent, and as such provide little comfort to prospective parents contemplating the use of reproductive technologies. Hence the remainder of my title. This paper was originally published as a chapbook by the Vancouver Island University Institute of Practical Philosophy. Black, J. (1996). Frozen embryos, ice-age ethics and cold comfort: A case study in the ethics of reproductive technologies. Nanaimo, B.C: VIU Institute of Practical Philosophy. More information about the Institute of Practical Philosophy can be found at: https://socialsciences.viu.ca/institute-practical-philosophy, and this paper can be accessed at: https://ba.viu.ca/sites/default/files/frozen-embryos.pdf. https://viurrspace.ca/bitstream/handle/10613/6587/BlackJ.1996.pdf?sequence=3

Despite the risks associated with twin and higher-order multiple births, and calls in many countries for single-embryo transfer as the standard of care for good-prognosis patients, providers frequently transfer additional embryos, raising critical questions as to why this is the case and what can be done about it. In-depth interviews of approximately 1 h each were conducted with 27 IVF providers (17 physicians and 10 other healthcare providers) and 10 patients. Professional guidelines often contain flexibility and ambiguities or are unenforced. Thus, both providers and patients frequently wrestle with several dilemmas. Decisions about the number of embryos to transfer emerge as dyadic, dynamic and affected by several factors (e.g., providers’ type of institution, and personal and professional experiences and perceptions of the data), leading to differences in whether, how and with what effectiveness clinicians address these issues with patients. Many clinicians feel that the evidence concerning the apparent increased risk associated with a twin birth is not ‘compelling’, and patients frequently minimize the hazards. These data, the first to explore several critical aspects of how providers and patients view and make decisions about the number of embryos to transfer, thus highlight tensions, uncertainties and challenges that providers and patients confront, and have key implications for future practice, research, policy and education.