Reproductive technologies have enabled millions of couples and individuals to build or expand their families. These medical procedures are generally ethically acceptable, but as technological capabilities expand, so does the need to address ethical considerations. The basic principles of beneficence, nonmaleficence, autonomy, and justice serve as a framework when considering the ethics of most clinical procedures. This chapter discusses considerations for the number of embryos to transfer, the use of donor gametes, how to proceed when treatment seemed futile, aneuploidy testing of embryos, as well as a discussion of the ethical cautions in newer techniques such as gene-editing. The aforementioned core principles can serve as guidance when ascertaining the ethical status of current and future reproductive technologies. In discussing the ethics of informed consent in childbearing, the chapter highlights the need to address the systematic inequalities and injustices that prevent women and birthing people from exercising true autonomy in reproductive decision making. The focus on relational care and increasing awareness of inequalities and of the rights of birthing people would help to change the landscape and move our systems away from dehumanization and medicalization and toward true informed decision making.

This document is designed to provide a framework for assisted reproductive technology (ART) programs that meet or exceed the requirements suggested by the Centers for Disease Control and Prevention for certification of ART laboratories. This document replaces the document "Revised Minimum Standards for Practices Offering Assisted Reproductive Technologies: A Committee Opinion'' published in 2019. ((C) 2021 by American Society for Reproductive Medicine.)

A patient request to transfer embryos into her body in a location or at a time when pregnancy is highly unlikely to occur is deemed a request for "compassionate transfer'' and often reflects the patient's deeply personal, strongly held preferences and values. It is ethically permissive for physicians to honor or decline such requests if they do so in a nondiscriminatory manner. ((C) 2019 by American Society for Reproductive Medicine.)

This document provides guidance, background, and tips on how to recognize quality trials and focuses on evaluating the validity, importance, and relevance of clinical trial results. This document replaces the document of the same name, last published in 2008 (Fertil Steril (R) 2008;90:S114-20). ((C)2019 by American Society for Reproductive Medicine.)

This document is designed to assist in vitro fertility clinics in the management of cryopreserved reproductive tissues stored in cryogenic storage (cryostorage) tanks, based upon scientific principles and laboratory experience related to best practice for safe and reliable storage of cryopreserved reproductive tissue. Embryology and andrology laboratories provide storage of often irreplaceable reproductive tissues such as oocytes, embryos, sperm, and ovarian and testicular tissues, including tissues from cancer patients. All of these reproductive tissues must be maintained under stringent conditions. (C) 2020 by American Society for Reproductive Medicine.

This document reviews gonadotropin treatment for ovulation induction in anovulatory women and outlines the recommended pretreatment evaluation, indications, treatment regimens, and complications of gonadotropin treatment. It replaces the document with a similar name, last published in 2008 (Fertil Steril 2008;90:S7-12). ((C) 2019 by American Society for Reproductive Medicine.)

The Ethics Committee recommends that in vitro fertilization (IVF) centers develop patient-centered policies regarding requests for futile treatment. In most cases, clear communication can avoid a direct conflict, but clinicians ethically may refuse to provide treatment believed to be futile or to carry a very poor prognosis. In certain instances, clinicians may provide limited treatment which they judge likely to be futile, but must be vigilant in their presentation of risks, benefits, and alternatives. This version replaces the previous published draft of this name (Fertil Steril 2012; 98: e6-9). ((C) 2019 by American Society for Reproductive Medicine.)

Postoperative adhesions are a natural consequence of surgical tissue trauma and healing and may result in infertility, pain, and bowel obstruction. Adherence to microsurgical principles and minimally invasive surgery may help to decrease postoperative adhesions. Some surgical barriers have been demonstrated to be effective for reducing postoperative adhesions, but there is no substantial evidence that their use improves fertility, decreases pain, or reduces the incidence of postoperative bowel obstruction. This document replaces the document, "Pathogenesis, consequences, and control of peritoneal adhesions in gynecologic surgery: a committee opinion,'' last published in 2013. ((C) 2019 by American Society for Reproductive Medicine.)

Patients preparing to undergo gonadotoxic medical therapy, radiation therapy, or gonadectomy should be provided with prompt counseling regarding available options for fertility preservation for iatrogenic infertility. Fertility preservation can best be provided by comprehensive programs designed and equipped to confront the unique challenges facing these patients. This document replaces the document with a similar name, last published in 2013. (C) 2019 by American Society for Reproductive Medicine.

This Ethics Committee report outlines the interests, obligations, and rights of all parties involved in gamete and embryo donation: both males and females who choose to provide gametes or embryos for use by others, recipients of donated gametes and embryos, individuals born as a result of gamete or embryo donation, and the programs that provide donated gametes and embryos to patients. This document replaces the document "Interests, obligations, and rights of the donor in gamete donation,'' last published in 2014. ((C) 2019 by American Society for Reproductive Medicine.)

Although there is currently no definitive evidence linking West Nile virus (WNV) transmission with reproductive cells, it is recommended that practitioners defer gamete donors who have confirmed or suspected WNV infections. This document replaces the previously published document of the same name, last published in 2016 (Fertil Steril 2016;105:e9-10).

Mild-stimulation protocols with in vitro fertilization (IVF) generally aim to use less medication than conventional IVF. This guideline evaluates pregnancy and live-birth rates in patients expected to be poor responders using mild ovarian stimulation and natural-cycle protocols vs conventional IVF. (C) 2018 by American Society for Reproductive Medicine.

Preimplantation genetic testing for monogenic diseases for adult-onset conditions is ethically permissible for a range of conditions including when the condition is serious and no safe, effective interventions arc available. The Committee strongly recommends that a genetic counselor experienced with PGT-M counsel patients considering such procedures. This document replaces the document titled "Use of preimplantation genetic diagnosis for serious adult-onset conditions: a committee opinion," last published in Fertil Steril 2013;100;54-7. (C) 2018 by American Society for Reproductive Medicine.

Encounters for infertility care are opportunities to assess and update immunization status. Women of reproductive age are often unaware of their need for immunization, their own immunization status, and the potentially serious consequences of preventable disease on pregnancy outcome. The purpose of this ASRM Practice Committee document is to summarize current recommendations regarding vaccinations for women of reproductive age. This document replaces the ASRM Practice Committee document titled, “Vaccination guidelines for female infertility patients,” last published in 2013 (Fertil Steril 2013;99:337–9). Encounters for infertility care are opportunities to assess and update immunization status. Women of reproductive age are often unaware of their need for immunization, their own immunization status, and the potentially serious consequences of preventable disease on pregnancy outcome. The purpose of this ASRM Practice Committee document is to summarize current recommendations regarding vaccinations for women of reproductive age. This document replaces the ASRM Practice Committee document titled, “Vaccination guidelines for female infertility patients,” last published in 2013 (Fertil Steril 2013;99:337–9). Discuss: You can discuss this article with its authors and other readers at https://www.fertstertdialog.com/users/16110-fertility-and-sterility/posts/34944-26574 Discuss: You can discuss this article with its authors and other readers at https://www.fertstertdialog.com/users/16110-fertility-and-sterility/posts/34944-26574 Encounters for infertility care are opportunities to assess and update immunization status. Women of reproductive age often are unaware of their need for immunization, their own immunization status, and the potentially serious consequences of preventable disease on pregnancy outcome. In one study, fewer than 60% of surveyed obstetrician-gynecologists routinely obtained any vaccination history, and only 10% offered vaccines currently recommended for adults (1Schrag S.J. Fiore A.E. Gonik B. Malik T. Reef S. Singleton J.A. et al.Vaccination and perinatal infection prevention practices among obstetrician-gynecologists.Obstet Gynecol. 2003; 101: 704-710Crossref PubMed Scopus (90) Google Scholar). National standards for vaccinations have been established and last updated in February 2016 by the Centers for Disease Control and Prevention (CDC) and are available for review on the CDC website (2Centers for Disease Control and PreventionRecommended adult immunization schedule—United States 2016.http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdfGoogle Scholar). The purpose of the present document is to summarize current recommendations regarding vaccinations for female infertility patients. Ideally, immunizations should be completed before conception because some recommended vaccinations cannot be administered during pregnancy (1Schrag S.J. Fiore A.E. Gonik B. Malik T. Reef S. Singleton J.A. et al.Vaccination and perinatal infection prevention practices among obstetrician-gynecologists.Obstet Gynecol. 2003; 101: 704-710Crossref PubMed Scopus (90) Google Scholar, 2Centers for Disease Control and PreventionRecommended adult immunization schedule—United States 2016.http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdfGoogle Scholar, 3R Monif G. Baker D.A. Infectious diseases in obstetrics and gynecology, United Kingdom.5th ed. Taylor and Francis, London2004Google Scholar, 4Munoz F.M. Englund J.A. Vaccines in pregnancy.Infect Dis Clin North Am. 2001; 15: 253-271Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar, 5Gonik B. Fasano N. Foster S. The obstetrician-gynecologist's role in adult immunization.Am J Obstet Gynecol. 2002; 187: 984-988Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar). Vaccinations before or during pregnancy protect women from potentially serious illnesses, prevent vertical transmission to the fetus, and confer passive immunity to the newborn. Transport of maternal immunoglobulin (IgG) antibodies to the fetus occurs throughout gestation and increases markedly during the last 4 to 6 weeks of gestation (3R Monif G. Baker D.A. Infectious diseases in obstetrics and gynecology, United Kingdom.5th ed. Taylor and Francis, London2004Google Scholar, 4Munoz F.M. Englund J.A. Vaccines in pregnancy.Infect Dis Clin North Am. 2001; 15: 253-271Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar, 5Gonik B. Fasano N. Foster S. The obstetrician-gynecologist's role in adult immunization.Am J Obstet Gynecol. 2002; 187: 984-988Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar). Many physicians are reluctant to immunize pregnant women because of concerns that an incidental congenital anomaly or spontaneous abortion might be attributed wrongly to a vaccination. This fear persists despite the fact that there are few vaccines that are contraindicated during pregnancy (2Centers for Disease Control and PreventionRecommended adult immunization schedule—United States 2016.http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdfGoogle Scholar). The contraindicated vaccines include measles, mumps, and rubella (MMR); varicella; and herpes zoster. All others are either fully recommended or recommended if some other risk factor is present. Vaccinations during pregnancy are indicated when benefits clearly outweigh risks. Special circumstances that may influence the indication for vaccination include military service, travel to high prevalence areas, hazardous occupations, immunocompromised patients, and chronic illness. Guidelines for vaccinations in individuals with such special indications are outlined in a committee opinion published by the CDC (2Centers for Disease Control and PreventionRecommended adult immunization schedule—United States 2016.http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdfGoogle Scholar). Immunizations generally recommended for women of reproductive age are listed in Table 1, which provides a condensed summary of the Recommended Adult Immunization Schedule published by the CDC. Physicians are encouraged strongly to assess the history of immunizations in women before beginning treatment for infertility.Table 1Summary of the recommended adult immunization schedule outline by the Centers for Disease Control and Prevention 2Centers for Disease Control and PreventionRecommended adult immunization schedule—United States 2016.http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdfGoogle Scholar.VaccineAge group (y)19–2122–2627–4950–5960–64≥65InfluenzaaCovered by the Vaccine Injury Compensation Program.1 dose annuallybFor all persons in this category who meet the age requirements and who lack documentation of vaccination or have no evidence of previous infection.Tetanus, diphtheria, pertussis (Td/Tdap)aCovered by the Vaccine Injury Compensation Program.Substitute 1-time dose of Tdap for Td booster; then boost with Td every 10 yearsbFor all persons in this category who meet the age requirements and who lack documentation of vaccination or have no evidence of previous infection.Td/TdapdTdap recommended for ≥65 if contact with <12-month-old child. Either Td or Tdap can be used if no infant contactVaricellaeFor nonpregnant women.2 dosesbFor all persons in this category who meet the age requirements and who lack documentation of vaccination or have no evidence of previous infection.Human papilloma virus (HPV)aCovered by the Vaccine Injury Compensation Program. Female3 dosesbFor all persons in this category who meet the age requirements and who lack documentation of vaccination or have no evidence of previous infection.No recommendationHuman papilloma virus (HPV)aCovered by the Vaccine Injury Compensation Program. Male3 doses (19–21 ybFor all persons in this category who meet the age requirements and who lack documentation of vaccination or have no evidence of previous infection.; 22–26 ycRecommended if some other risk factor is present (e.g., based on medical, occupational, lifestyle, or other indications).)No recommendationMeasles, mumps, rubella (MMR)aCovered by the Vaccine Injury Compensation Program.,eFor nonpregnant women.1 or 2 dosesbFor all persons in this category who meet the age requirements and who lack documentation of vaccination or have no evidence of previous infection.No recommendationPneumococcal (polysaccharide)1 or 2 dosescRecommended if some other risk factor is present (e.g., based on medical, occupational, lifestyle, or other indications).1 dosebFor all persons in this category who meet the age requirements and who lack documentation of vaccination or have no evidence of previous infection.MeningococcalaCovered by the Vaccine Injury Compensation Program.1 or more dosescRecommended if some other risk factor is present (e.g., based on medical, occupational, lifestyle, or other indications).Hepatitis AaCovered by the Vaccine Injury Compensation Program.2–3 doses depending on vaccinecRecommended if some other risk factor is present (e.g., based on medical, occupational, lifestyle, or other indications).Hepatitis BaCovered by the Vaccine Injury Compensation Program.3 dosescRecommended if some other risk factor is present (e.g., based on medical, occupational, lifestyle, or other indications).a Covered by the Vaccine Injury Compensation Program.b For all persons in this category who meet the age requirements and who lack documentation of vaccination or have no evidence of previous infection.c Recommended if some other risk factor is present (e.g., based on medical, occupational, lifestyle, or other indications).d Tdap recommended for ≥65 if contact with <12-month-old child. Either Td or Tdap can be used if no infant contacte For nonpregnant women. Open table in a new tab Annual influenza vaccination is recommended for all individuals 6 months of age and older. Women who are pregnant or contemplating pregnancy should be immunized because influenza infection may increase the risk for medical complications, as heart rate, stroke volume, and oxygen consumption are increased and lung capacity is decreased during pregnancy. The optimal interval for immunization spans the months of October and November because the flu season occurs during January through March. Injectable influenza vaccines, inactivated influenza vaccine (IIV) quadrivalent and trivalent, contain inactivated virus and therefore may be administered at any time during pregnancy. In contrast, intranasal influenza vaccines contain live attenuated virus and should not be administered during pregnancy. Concerns had previously been raised about administering thimerosol-containing influenza vaccine to pregnant women. Thimerosol is a mercury-based preservative used in vaccines that was thought to be associated with adverse effects. However, no scientific evidence has correlated ill effects in the children born to women who have taken vaccines containing thimerosol (6Fiore A.E. Shay D.K. Broder K. Iskander J.K. Uyeki T.M. et al.Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009. Centers for Disease Control and Prevention.MMWR Recomm Rep. 2009; 201 (RR-8):1–52: 58Google Scholar). Therefore, IIVs can be given to pregnant women whether they contain thimerosol or not. A tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) was approved by the Advisory Committee on Immunization Practices (ACIP) in 2011 and was recommended for adults (19 to 64 years of age) who have or who anticipate having close contact with an infant less than 12 months of age (7Centers for Disease Control and Prevention (CDC). Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine from the Advisory Committee on Immunization Practices, 2010.MMWR Morb Mortal Wkly Rep. 2011; 60: 13-15PubMed Google Scholar). Due to the recent increase in pertussis outbreaks, health-care providers should vaccinate women who are pregnant or might become pregnant and have not previously received Tdap. If they are currently pregnant, Tdap preferably should be administered during the third trimester or late second trimester (i.e., after 20 weeks' gestation). If not given during pregnancy, it should be administered immediately postpartum to ensure pertussis immunity and to reduce transmission to the newborn. Varicella vaccine contains live attenuated virus. Prior to pregnancy, all adults without evidence of immunity should receive 2 doses of single-antigen varicella vaccine administered 1 month apart or a second dose if they have previously received only 1 dose. Pregnancy should be avoided for 1 month after vaccination. If exposed to varicella prior to pregnancy, the vaccine should be administered within 96 hours of exposure and pregnancy avoided. Pregnant women should be assessed for evidence of varicella immunity. Pregnant women who do not show signs of immunity should receive the first dose of varicella vaccine upon completion or termination of pregnancy and before discharge from the hospital. Cases of congenital varicella after immunization have been reported. Women through age 26 and men through age 21 should be vaccinated to prevent HPV infections and HPV-associated diseases, including cancers; the dosing schedule varies based on the age that vaccination started (2Centers for Disease Control and PreventionRecommended adult immunization schedule—United States 2016.http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdfGoogle Scholar). Originally, the HPV vaccine was a bivalent compound; however, the current vaccine is either quadrivalent or 9-valent (9v). Individuals who began with bivalent or quadrivalent compounds may complete the series with the 9v HPV compound. There is no ACIP recommendation regarding additional vaccination with 9v HPV for those individuals who completed immunization with bivalent or quadrivalent vaccines. While HPV vaccination is not recommended during pregnancy, there is no evidence that the vaccine is harmful, and no intervention is needed for women who inadvertently receive it while pregnant. Women who discover they are pregnant should delay remaining doses until after pregnancy. Pregnancy testing is not needed before vaccination (8Use of a 2-dose schedule for human papillomavirus vaccination — Updated recommendations of the Advisory Committee on Immunization Practices.MMWR Wkly. 2016; 65: 1405-1408Google Scholar). MMR vaccine is recommended for all women without confirmed immunity to rubella. MMR vaccine contains live attenuated virus. Vaccination therefore should be administered before pregnancy to avoid the possibility of intrauterine infection, and pregnancy should be avoided for 1 month after vaccination. However, there is no confirmed instance where MMR vaccine has been linked to congenital malformation or significant intrauterine infection (9Soares R.C. Siqueira M.M. Toscano C.M. Maia Mde L. Flannery B. Sato H.K. et al.Follow-up study of unknowingly pregnant women vaccinated against rubella in Brazil, 2001-2002.J Infect Dis. 2011; 204: S729-S736Crossref PubMed Scopus (23) Google Scholar). Consequently, inadvertent MMR administration during pregnancy is not an indication for pregnancy termination. The pneumococcal vaccine is recommended for any person at increased risk for pneumococcal infection. Individuals at high risk include those with asplenia, sickle-cell anemia, chronic cardiovascular/pulmonary disease, diabetes, or immunocompromise as may result from human immunodeficiency virus (HIV) infection, systemic illness, or malignancy. Ideally, high-risk women should be immunized before pregnancy. HA vaccine is recommended for any women at high risk, including those receiving clotting-factor concentrates, those with chronic liver disease, women working with HA virus or HA-infected laboratory animals, women traveling to countries with a high prevalence of HA infection, and intravenous drug users. The vaccine contains inactivated virus and poses no known risk to the fetus. HB vaccine is approved for any woman at high risk, including those receiving hemodialysis or clotting-factor concentrates, health-care workers exposed to blood and blood products, intravenous drug users, women having a sexually transmitted infection or multiple sexual partners, those traveling to countries with a high prevalence of hepatitis B infection, and women living in the same household with a known infected individual. The vaccine contains noninfectious DNA particles, can be administered during pregnancy if needed, and poses no known risk to the fetus. The meningococcal vaccine should be administered to any person who is at increased risk for meningococcal infection. For pregnant women, its use should be limited to those at high risk who have not been inoculated previously. Individuals at high risk include those who live in high endemic areas, such as sub-Saharan Africa, parts of the Middle East, and college dormitories. Preferably, such high-risk women should be vaccinated before pregnancy, because experience with the vaccine in pregnancy is limited. •Vaccination in women of reproductive age before or during pregnancy confers resistance to intrauterine infections and provides the newborn with passive immunity to neonatal infections.•Immunization schedules are best completed before beginning treatment for infertility, because some vaccinations should not be administered during pregnancy.•Rubella and varicella immunity should be documented prior to pregnancy. If nonimmune, the vaccine should be administered and pregnancy should be avoided for 4 weeks.•The influenza and Td immunizations should be completed before pregnancy but can be administered during pregnancy. The inactivated influenza vaccine can be given anytime during pregnancy. Tdap should be given preferably during the third trimester or late second trimester.•Varicella, pneumococcal, HPV, HA, HB, and meningococcal vaccinations are indicated in specific circumstances and are always administered best before pregnancy. •Prior to, during, or after pregnancy, it is important to be aware of a patient's immunization history and to update her vaccine status when appropriate.

Adjuvant immunotherapy treatments in in vitro fertilization (IVF) aim to improve the outcome of assisted reproductive technology (ART) in both the general ART population as well as subgroups such as patients with recurrent miscarriage or implantation failure. The purpose of this guideline is to evaluate the role of immunomodulating therapy in ART. Unfortunately, many of the evaluated therapies lack robust evidence from well-designed adequately powered randomized controlled trials to support their use. Immunotherapies reviewed in the present document are either not associated with improved live-birth outcome in IVF or have been insufficiently studied to make definitive recommendations. (C) 2018 by American Society for Reproductive Medicine.

Professionals who discover misconduct or other undisclosed information that would be material to the participation of another party (such as a donor, gestational carrier, intended parent, or lawyer) in an assisted reproductive technology arrangement should encourage disclosure to that party. In some instances, it is ethically permissible for the physician either to disclose material information to the affected party or to decline to provide care. In all cases involving the legal status or rights of the parties, referral to legal professionals is advised. This document replaces the document of the same name, last published in 2014 (Fertil Steril 2014; 101: 38-42). (C) 2018 by American Society for Reproductive Medicine.

Planned oocyte cryopreservation ("planned OC'') is an emerging but ethically permissible procedure that may help women avoid future infertility. Because planned OC is new and evolving, it is essential that women who are considering using it be informed about the uncertainties regarding its efficacy and long-term effects. (C) 2018 by American Society for Reproductive Medicine.

This document discusses the ethical implications of informing offspring about their conception using gamete or embryo donation. It replaces the 2013 ASRM Ethics Committee document of the same name (Fertil Steril 2013;100:45-9).

Fertility programs may withhold services from prospective patients on the basis of well-grounded reasons that those patients will be unable to provide minimally adequate or safe care for offspring. This document was reviewed and updated; this version replaces the previous version of this document, last published July 2013 ((C) 2017 by American Society for Reproductive Medicine.)

Standardization improves performance and safety. A template for standardizing the embryo transfer procedure is presented here with 12 basic steps supported by published scientific literature and a survey of common practice of SART programs; it can be used by ART practices to model their own standard protocol.