POGO SURVIVORS CONFERENCE - PDF Free Download

POGO SURVIVORS CONFERENCE Dr. Karen Glass MD, FRCS(C), FACOG Director Fertility Preservation Program, CReATe Fertility Centre Assistant Professor, University of Toronto

I HAVE NO CONFLICT OF INTEREST.

FERTILITY PRESERVATION OPTIONS BEFORE AND AFTER CANCER TREATMENT Before Cancer treatment After Cancer treatment

FERTILITY PRESERVATION OPTIONS BEFORE CANCER TREATMENT Do Nothing: Figure it all out later Do IVF: Freeze eggs or embryos Freeze sperm Do ovarian/testicular tissue freezing (requires a laparoscopic surgery for females) Protect ovaries/testes (nothing fantastic available yet)

FP OPTIONS AFTER CANCER TREATMENT Do Nothing: Figure it out later Do IVF: Freeze eggs or embryos must wait a minimum of 6 mos. Freeze sperm must wait a minimum of 6 mos. Do ovarian/testicular tissue freezing (requires a laparoscopic surgery for females)

DO NOTHING: FIGURE IT OUT LATER Could monitor ovarian reserve with AMH blood test Could do semen analysis

IVF: IN VITRO FERTILIZATION Recently one cycle of funded IVF added to budget in ON Oncology patients included Medications not included ($2000-4000). Compassionate donations. Starts Dec 1, 2015 (possibly) 12-14 day process to stimulate ovaries to produce eggs and then remove the eggs in an office based procedure Can remain frozen in liquid nitrogen indefinitely

IVF

EGGS EMBRYOS

FERTILIZATION

FAMILY BUILDING OPTIONS IF YOU ARE IN PREMATURE OVARIAN/TESTICULAR FAILURE Adoption Egg Donation Sperm Donation Embryo Donation Gestational Surrogacy

A D O P T I O N I N O N T A R I O

EGG/SPERM DONATION: KNOWN OR ANONYMOUS Known Donor work up: Full medical history and physical Infectious disease screening Genetic disease screening (Counsyl test, CF, Sickle cell, thalassemia) Pelvic ultrasound for egg donors Ovarian reserve testing or semen analysis Counselling of donor and her/his partner Known Egg donors should have had a child already (some exceptions) Known Sperm donors will have sperm quarantined for 6 months Legal contracts

ANONYMOUS EGG DONORS Assistance via agencies to locate donor appropriate for each patient: American Canadian Cycles can be Exclusive or Shared Work up done by agency but blood and AMH will need to be updated for egg donors. Takes 1-2 mos once matched to start actual IVF Costs $15,000-30,000 (CDN $ issues) OHIP likely will cover the costs of one donor stimulation & retrieval now

ANONYMOUS & KNOWN EGG DONORS Once all donor blood work and counselling complete, then cycle coordination starts Both donor and recipient start birth control pills to coordinate cycles Donor then starts stimulation medications when her period comes Recipients start Estrogen patches or pills to get lining of uterus ready for embryo On day of retrieval: Intended father will come in to produce sperm sample Intended mother will start progesterone injections or suppositories Embryo transfer on 5 days post egg retrieval

ANONYMOUS SPERM DONATION Counselling for intended parents General infertility work up for intended parents Sperm donors have completed the quarantine for 6 months Very simple, just order sperm from any CDN compliant sperm bank Costs: approx. $1000 per sample Female partner will have cycle monitoring to know when to inseminate sperm

EMBRYO DONATION Long waiting list Less expensive than egg donation plus sperm donation Minimal ability to choose details of characteristics of donor egg and sperm.

SURROGACY Can be known or anonymous (i.e. introduced via an agency) Will have full medical work up similar to egg donor Surrogate and partner will have counselling Intended parents have infertility work up and counselling New OHIP funding will likely cover the cost of the work up and embryo transfer for the surrogate Legal fees and expenses for surrogate not covered

CONCLUSIONS Every case is different Earlier FP consultation will leave more options Lots of options to build families post treatment New Ontario funding will help oncofertility pts!!

POT OF GOLD AT THE END OF THE RAINBOW

Third Party Reproduction and the Law in Canada Life After Childhood Cancer Managing Your Fertility: Current Options, Practical Strategies Saturday, October 17, 2015

Sara R. Cohen, LL.B. Fertility Law Canada TM at D2Law LLP sara@fertilitylawcanada.com (416)907-2189 www.fertilitylawcanada.com @fertilitylaw

The Team Medical Legal Psychosocial

Source of Law AHRA Legal Parentage 3 rd party reproduction law

What is third party reproduction? Third Party Reproduction Surrogacy Donor Gametes Donor Embryos

6 A: Surrogacy Gestational Surrogacy Surrogacy Traditional Surrogacy

7 Relevant Legislation Section 6 of Assisted Human Reproduction Act (AHRA) 6. (1) No person shall pay consideration to a female person to be a surrogate mother, offer to pay such consideration or advertise that it will be paid. (2) No person shall accept consideration for arranging for the services of a surrogate mother, offer to make such an arrangement for consideration or advertise the arranging of such services. (3) No person shall pay consideration to another person to arrange for the services of a surrogate mother, offer to pay such consideration or advertise the payment of it. (4) No person shall counsel or induce a female person to become a surrogate mother, or perform any medical procedure to assist a female person to become a surrogate mother, knowing or having reason to believe that the female person is under 21 years of age.

8 Section 12 - Reimbursements Reimbursement of expenditures 12. (1) No person shall, except in accordance with the regulations, (a) reimburse a donor for an expenditure incurred in the course of donating sperm or an ovum; (c) reimburse a surrogate mother for an expenditure incurred by her in relation to her surrogacy. (2) No person shall reimburse an expenditure referred to in subsection (1) unless a receipt is provided to that person for the expenditure. (3) No person shall reimburse a surrogate mother for a loss of workrelated income incurred during her pregnancy, unless (a) a qualified medical practitioner certifies, in writing, that continuing to work may pose a risk to her health or that of the embryo or foetus; and (b) the reimbursement is made in accordance with the regulations.

9 Reimbursements (cont d) What is acceptable where no regulations or caselaw? Maternity clothing? Travel? Childcare? Rent? Heating? Differs lawyer to lawyer My rule: but-for test If the expense would have been incurred otherwise, cannot be said to be incurred as a result of the surrogacy

10 Sections 60 & 61 AHRA 60. A person who contravenes any of sections 5 to 7 and 9 is guilty of an offence and (a) is liable, on conviction on indictment, to a fine not exceeding $500,000 or to imprisonment for a term not exceeding ten years, or to both; or (b) is liable, on summary conviction, to a fine not exceeding $250,000 or to imprisonment for a term not exceeding four years, or to both. 61. A person who contravenes any provision of this Act other than any of sections 5 to 7 and 9 or of the regulations or an order made under subsection 44(1) is guilty of an offence and (a) is liable, on conviction on indictment, to a fine not exceeding $250,000 or to imprisonment for a term not exceeding five years, or to both; or (b) is liable, on summary conviction, to a fine not exceeding $100,000 or to imprisonment for a term not exceeding two years, or to both.

11 Legal Parentage re Surrogacy While woman is pregnant Once baby is born 3+ parent families Cy and Ruby s Act (Parental Recognition), 2015 (not yet tabled)

What is the legal process? #1 surrogacy agreement Intended parents Independent legal advice Must be in place prior to transfer Ideally prior to commencing medication #2 legal parentage

13 B: Gamete Donation Gamete donation Sperm donation Egg donation (ova) Legislation is the same Practice quite different

14 Types of donors Known Family member, friend, acquaintance Open identity (open i.d.) When 18 or 19 (depending on sperm bank), access to identifying information including name, last known contact information, etc. Anonymous

15 Relevant Legislation (AHRA) 7. (1) No person shall purchase, offer to purchase or advertise for the purchase of sperm or ova from a donor or a person acting on behalf of a donor. (4) In this section, purchase or sell includes to acquire or dispose of in exchange for property or services. NB: unlike s. 6, no prohibition on arranging the services of a donor for consideration

16 AHRA cont d 9. No person shall obtain any sperm or ovum from a donor under 18 years of age, or use any sperm or ovum so obtained, except for the purpose of preserving the sperm or ovum or for the purpose of creating a human being that the person reasonably believes will be raised by the donor.

17 Section 12 - Reimbursements Reimbursement of expenditures 12. (1) No person shall, except in accordance with the regulations, (a) reimburse a donor for an expenditure incurred in the course of donating sperm or an ovum; (c) reimburse a surrogate mother for an expenditure incurred by her in relation to her surrogacy. (2) No person shall reimburse an expenditure referred to in subsection (1) unless a receipt is provided to that person for the expenditure. (3) No person shall reimburse a surrogate mother for a loss of workrelated income incurred during her pregnancy, unless (a) a qualified medical practitioner certifies, in writing, that continuing to work may pose a risk to her health or that of the embryo or foetus; and (b) the reimbursement is made in accordance with the regulations.

18 Sections 60 & 61 AHRA 60. A person who contravenes any of sections 5 to 7 and 9 is guilty of an offence and (a) is liable, on conviction on indictment, to a fine not exceeding $500,000 or to imprisonment for a term not exceeding ten years, or to both; or (b) is liable, on summary conviction, to a fine not exceeding $250,000 or to imprisonment for a term not exceeding four years, or to both. 61. A person who contravenes any provision of this Act other than any of sections 5 to 7 and 9 or of the regulations or an order made under subsection 44(1) is guilty of an offence and (a) is liable, on conviction on indictment, to a fine not exceeding $250,000 or to imprisonment for a term not exceeding five years, or to both; or (b) is liable, on summary conviction, to a fine not exceeding $100,000 or to imprisonment for a term not exceeding two years, or to both.

Legal Parentage re Gamete/Embryo Donation Varies province to province BC and Alberta specific legislation Ontario no specific legislation 3+ parent families Cy and Ruby s Act (Parental Recognition), 2015 (not yet tabled)

What is the legal process? #1 donor agreement Intended parents Independent legal advice Must be in place prior to retrieval Ideally prior to commencing medication #2 legal parentage Rarely done if mom carrying own baby for heterosexual couple Currently issue for single people, gay men or lesbian women

C: Embryo Donation What is it? Other options Far less common than use of donor gametes Anonymous or known Who is doing it? Studies Why?

Relevant Legislation Assisted Human Reproduction Act: 7. (2) No person shall (a) purchase, offer to purchase or advertise for the purchase of an in vitro embryo; or (b) sell, offer for sale or advertise for sale an in vitro embryo. 12. (1) No person shall, except in accordance with the regulations, (b) reimburse any person for an expenditure incurred in the maintenance or transport of an in vitro embryo;

What Embryo Donation in Canada is NOT Embryo donation Embryo adoption Status of embryo adoption = change in legal status of child

Thank you! Follow up questions may be sent to Sara at sara@fertilitylawcanada.com