A set of guidelines addressing post-mortem sperm retrieval (PMSR) requests was developed by a panel of experts, including a psychologist (L. D. A.), a legal expert, an institutional representative, a medical ethicist (J. J. F.), a reproductive technology expert (Z. R.) and a male infertility expert (P. N. S.) in 1995 at New York Hospital. The guidelines included four general considerations: (1) issues of consent (2) medical contraindications (3) resource availability and (4) a one-year specimen waiting period for bereavement and recipient evaluation (Table 1).

Issues of Consent
Evidence of intended paternity. Sperm retrieval after brain death can be ethical, provided there is explicit prior or reasonably inferred consent. Post-mortem consent clearly cannot be provided directly by the deceased man. Pre-mortem consideration of post-mortem conception is rarely anticipated, and prospective authorization is not likely to occur. A reasonable expectation that the recently deceased would consent to having his sperm used for procreation would best be determined by his actions and discussions prior to death with respect to intended pregnancy. Therefore, only men undergoing fertility treatment, actively attempting conception, or who had specifically expressed their plans to attempt conception in the immediate future would be suitable candidates for retrieval. The premorbid wishes of the incompetent sperm donor should be weighed significantly in making decisions as to whether to retrieve that individual's sperm for use in artificial conception.

Next-of-kin/Legal consent. The wife is the individual who is best capable of determining the deceased man's intentions for conception and is best able to give procedural consent. As such, she should be the primary individual responsible for providing information on the man's intent. As next of kin, the wife should have responsibility for giving permission for sperm retrieval and should maintain responsibility for storage and subsequent disposition of sperm. Next of kin are typically empowered to provide consent for other anatomic gifts, consistent with the presumed intent of the deceased. The wife should be the only individual for whom these sperm could be considered for conception. Verbal and written consent for the procedure, as with any anatomical gift or transplant, should be provided by the wife (next-of-kin). Any detectable conflict among interested parties should be a contraindication to PMSR.

In a landmark case in the United Kingdom involving Mrs. Diane Blood (Regina v. Human Fertilisation and Embryology Authority, exp. Blood, 1997), controversy developed over the fact that her husband's sperm was surgically retrieved prior to his death while in a coma. Because the effective consent, which must be in written form, was not in place before the taking and freezing of gametes, the retrieval procedure was considered to have been illegal. The Appeals Court and the High Court did not allow Mrs. Blood access to her husband's sperm given these circumstances. The case was remitted to the Human Fertilisation and Embryology Authority who ultimately allowed for the sperm to be released to Mrs. Blood in Belgium.

Because unwanted paternity is something to be avoided, third party designation of specimens for use by an individual who is not the wife is to be discouraged. Members of the deceased's family may have an interest in using the sperm to maintain the family lineage. However, that interest would represent only part of the interests of the couple prior to the man's death. Since sperm retrieval should be attempted only when there is a reasonable opportunity to use these gametes for attempts at reproduction, the wife must be the individual to provide consent, not the deceased man's family, as the wife is the individual with whom the deceased intended to procreate.

Although some benefit to the family may exist from the knowledge that some of part of the deceased man has been preserved, the potential legal and ethical conflicts of using sperm other than for procreation by the wife is ethically unacceptable. One goal of psychological evaluation prior to PMSR should be to assess potential coercion of the wife from family members or other interested parties. While consent for sperm retrieval should not be construed as consent for use of sperm for procreation, the wife must understand that assisted reproduction would be required to use these specimens.

If the wife should decide not to proceed with an attempt at conception, as is expected to occur in most cases, then this decision would invalidate any intended paternity provided by the couple together. Therefore, control over the retrieved sperm should reside solely in the hands of the wife, the woman with whom the man had intended to have children.

Medical Contraindications
In order to retrieve viable sperm for cryopreservation, the man's death should have been sudden (permitting retrieval < 24 hrs. post mortem) and not due to any disease known to affect spermatogenesis or effect transmission of disease. The subject of sperm retrieval should have a known medical history, or be undergoing post-mortem examination (autopsy evaluation). HIV testing results should be available. No history of genetic diseases should be present. Medical conditions that affect sperm production may further reduce sperm viability and make retrieval of viable sperm unlikely. Hepatitis testing is unreliable post-mortem. Testing of semen samples for HIV or other infectious diseases is otherwise possible, if requested by the recipient and if she has legal authority to consent to testing, in accordance with applicable law.

Resource Availability
Sperm maintain nearly normal motility and at least in vitro function for the first three hours post-mortem. After that time, sperm motility declines. Sperm viability tends to progressively decline as well. Although sperm viability is preserved relative to that of the tissues of other organs of the body, recovery of viable sperm appears relatively uncommon after 24 hours post-mortem unless the body has been cooled. Sperm cryopreservation will cause further deterioration in viability. However, current application of IVF with intracytoplasmic sperm injection (ICSI) will provide a high chance of fertilization, even with immotile sperm, as long as they are viable.

Given that most requests are primarily being made of men who died of trauma, it is likely that a urologist in a hospital setting would be the most accessible choice to present a request for PMSR. Ideally, a male infertility specialist comfortable with retrieval techniques should be available to harvest the semen.

Retrieving and freezing sperm within a 24-hour period requires suitable and available cryopreservation facilities within a close traveling distance. Such cryobanks should be available for immediate processing of the retrieved sperm. Post-mortem surgical retrieval without a likely use of the material could represent a mutilation of the dead that may represent a lack of respect.

Bereavement
Prior to sperm retrieval, the deceased man's wife should consent to a one year waiting period before use of the retrieved sperm. One year is generally considered the initial period of psychological adjustment and bereavement after loss of a loved one. During this time period, the wife must undergo medical and psychological consultations with discussion of the procedures necessary to achieve conception, including costs and medical interventions. Consultation should include a basic assessment of the psychological status of the wife, family stability, social and financial support systems, as well as a discussion of the implications of raising a child as a single parent without its genetic father. Issues of disclosure to the child of the method of conception should also be discussed.

At the time of a man's sudden death, intense bereavement may cause a woman to attempt to "hold on" to her deceased partner by requesting sperm retrieval. Denial, a normal process of self-deception that is part of the grief process following a tragic loss, may initially drive the wife to request the procedure. A pregnancy may be planned as an act of love or memorial in the face of death. Sperm preservation could provide the false impression that the man will live on through his retrieved sperm and its fertility potential.

As the process of mourning proceeds, decision-making can then be based on thoughtful considerations of outcomes, rather than being driven by a more transitory state of mind. Therefore, the distinction between a possible child and the deceased man will become more evident. In addition, as time passes after the man's unexpected death, the woman will be better able to differentiate between her previous married life and her subsequent life without the deceased. Many women have reconsidered their initial decision and decided to proceed with their life, possibly establishing a new relationship and proceeding to fulfill their plans to have children with a new partner.

DISCUSSION
Some may suggest that it would never be reasonable to consider PMSR. However, reports on the attitudes of the general public and of centers licensed for infertility treatment in the United Kingdom found that the majority of women in these centers support the idea of posthumous reproduction. Key points in that argument would suggest that PMSR is fundamentally different from organ donation because organ donation involves direct benefit to the transplant recipient. Because the benefit to society from sperm retrieval is less than that achieved from organ donation, the indications that the husband was interested in contributing to conception must be clear. To consider a post-mortem procedure, compelling evidence must exist that some good will result from the intervention.

There are specific limitations and biologic restrictions involved if someone plans to use these tissues to achieve conception. In all likelihood, the limited number of viable sperm available after posthumous harvesting and cryopreservation would require the use of ART for actual conception. IVF can be performed with ICSI when only a few viable sperm are present. However, such reproductive technology is complex, expensive, and has its own inherent risks, such as multiple pregnancies.

Some who disagree with the principles of PMSR argue that in most cases, sperm retrieval is not ultimately in the interest of survivors or children yet to be conceived. White states that it is not clear that an individual's autonomy after death is respected by guessing at what he would have wanted in life, that is, a time frame that he no longer clearly occupies. The effects on a child of being the product of posthumous reproduction are not completely known. The concern with PMSR is that bringing a child into a single-parent household would be harmful to the child. However, others argue that PMSR does not harm children more than if they were never created at all. Consideration for the welfare of the child to be born should be maintained in a balanced, pragmatic and sensible manner.

Whether gamete extraction is appropriate depends in part upon the likelihood of a healthy and happy life to come: an outcome that arises in virtually no medical circumstances other than reproductive technologies. The guidelines presented here facilitate decision-making surrounding PMSR, and dramatically reduced the number of post-mortem sperm retrievals performed at our institution. Practitioners at our institution have found these guidelines very helpful for managing PMSR requests. Even when retrieval has been performed, appropriately counseled women will rarely proceed with an attempt at pregnancy.

The exclusionary criteria that we propose and have applied are not intended to replace further consideration of this procedure by groups such as The Ethics Committee of the American Society of Reproductive Medicine. However, it would be inappropriate to present any procedure, especially an ethically significant procedure without discussion of contraindications. The minimally invasive procedure described in this manuscript appears to represent an optimal technique for PMSR. Deceased men are not obviously harmed by this practice, and some argue that the practice enlarges rather than diminishes the reproductive choices of the surviving partners.

We do not present our opinions regarding the ethics and morality of PMSR. No member of the panel takes responsibility, in whole or in part, for decisions made on the basis of these guidelines. These criteria should not necessarily be considered complete or sufficient. That is, additional criteria could be added if circumstances suggest the need to add exclusionary criteria. The physician retains the right to refrain from performing PMSR if there is belief that the procedure may result in significant adverse effects to involved individuals. Furthermore, fulfillment of these criteria does not compel a unit specializing in assisted reproduction to use the retrieved sperm in an attempt at fertility.

Table 1.
Guidelines for Post-Mortem Sperm Procurement
1) Issues of Consent

• a) Presumed consent of deceased
• b) Next-of-kin consent by wife only

• a) Death sudden
• b) Death not due to communicable disease or disease known to adversely affect spermatogenesis

• a) Retrieval procedure must be within 24 hours of death
• b) Sperm cryobanks must be available locally to accept specimens

• a) Quarantine of samples for one year allows appropriate bereavement/counseling for wife
• b) Specimens can be screened for communicable diseases in concordance with applicable law.