Ethical concerns in the provision of in vitro fertilization treatment in Ghana: A qualitative study.

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David Appiah, John K Ganle This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4693060/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Oct, 2024 Read the published version in BMC Medical Ethics → Version 1 posted 10 You are reading this latest preprint version Abstract Background Infertility presents both medical and public health challenges, with in vitro fertilization (IVF) emerging as a prominent solution, particularly when other alternatives are exhausted. However, IVF treatment raises significant ethical questions that have been under explored in the Ghanaian context. This study aimed to explore ethical concerns regarding the provision of in vitro fertilization (IVF) treatment in Ghana. Methods A phenomenological descriptive qualitative design was employed. Purposive sampling techniques were used to recruit 12 participants from three in vitro fertilization (IVF) centres. In-depth face-to-face interviews guided by an open-ended interview guide were conducted. Thematic analysis of the interviews was performed to identify major themes. Results Providing IVF in Ghana raises several ethical issues, including inequitable access due to high costs and limited availability, which favour wealthier individuals and leave marginalized populations with fewer options. There are significant ethical considerations in balancing the potential benefits of successful IVF outcomes against the health risks and emotional tolls on patients. Decisions about the fate of surplus embryos present moral dilemmas, including whether to preserve, donate, or discard them. Differing personal beliefs about the moral status of the embryo further complicate the ethical landscape. Ensuring informed consent is challenging due to the complex medical, ethical, and emotional implications of IVF, potentially leading to compromised consent. Additionally, there are ongoing risks of breaches in confidentiality, given the sensitive nature of reproductive health data and the importance of protecting patient privacy. Conclusion This study revealed that several ethical dilemmas confront both healthcare providers and couples in the process of IVF. There is an urgent need for the development of clear and uniform regulations to govern the practice of IVF treatment in Ghana, with further attention given to mitigating financial barriers and enhancing support systems for couples considering IVF. Assisted reproductive technologies Commercialization of embryos Informed consent In vitro fertilization treatment Reproductive ethics Background Infertility is a significant public health concern because it can have psychological effects on couples, particularly women. An estimated 10–15% of couples worldwide experience infertility, with geographical differences; in sub-Saharan Africa, the frequency is particularly high, frequently reaching up to 30% in specific places. The incidence of infertility in Ghana is between 11 and 15 percent, highlighting the need for readily available, reasonably priced fertility treatments and assistance given the anticipated future drop in fertility [ 1 , 2 ]. Women experiencing infertility reported feelings of loneliness, anxiety, depression, reduced concentration, worry, and diminished sexual satisfaction [ 1 ]. Infertile women in Ghana face severe social stigma because they are often shunned and forsaken by those who should support them, including their husbands and extended family [ 2 ]. In the Ghanaian cultural context, motherhood is frequently viewed as a status of achievement [ 3 ]. Consequently, women or couples often put forth a great deal of effort to conceive. For instance, those who opt to treat infertility spend considerable time and money, and these expenses are often paid out of pocket, unleashing financial strain and potentially bankruptcy [ 4 ]. Generally, assisted reproductive technology (ART) and the increasing development of in vitro fertilization (IVF) treatment methods provide options for treating infertility [ 5 ]. IVF is a type of ART but is extensively used interchangeably. This complex procedure involves extracting the ovum for sperm fertilization outside the human body and transferring it back into the uterus. The introduction of IVF halts the emotional trauma that childlessness brings to people [ 6 ]. IVF is often the last resort utilized to achieve pregnancy since it has the potential to overcome various undiagnosed biological issues of fertility [ 7 ]. Nevertheless, it is a costly and invasive procedure that may result in complications [ 8 ]. Many countries in the Western world such as Spain, Portugal, Estonia, the USA, Greece, North Cyprus, and Ukraine, provide IVF treatment. Similarly, 21 out of the 54 countries in Africa provide IVF treatment [ 9 ]. Although IVF treatment is not so popular in Ghana as in the Western world, 14 fertility clinics that provide this service can be found, especially in Greater Accra, Takoradi, and Kumasi [ 10 ]. Although IVF is a revolutionary procedure, it is confronted with ethical issues, including equity of IVF service, compromised informed consent, funding of IVF treatment, and the effect of religious beliefs on IVF policy-making [ 11 ]. Moreover, valid informed consent is often compromised: the psychological state of people seeking IVF treatment has been found to exhibit extreme hopefulness and desperation to have a child [ 12 ]. Again, the information provided on IVF consent forms is often not precise [ 13 ]. In Ghana, these challenges are compounded by high costs, inequalities, lack of legal frameworks, and inconsistencies in adherence to international standards [ 14 ]. The lack of laws and guidelines for medical assisted reproduction (MAR) in countries such as Ghana further exacerbates these issues as countries with only “guidelines” have been shown to be inadequate to address the social, ethical, and legal aspects of this crucial field of medicine [ 15 , 16 ]. At the same time, studies on informed consent, fairness in accessing IVF treatment, and ownership of embryos in different situations in Ghana are limited. Studies focused on the ethical implications of in vitro fertilization in Ghana are very scant. Therefore, this study aimed to explore the ethical concerns that exist regarding in vitro fertilization treatment in Ghana. Methods Study Design A descriptive phenomenological qualitative research was conducted to explore the ethical issues in the provision of in vitro fertilization treatment in Ghana, and findings were reported using the consolidated criteria for reporting qualitative research as a guide (COREQ) [ 17 , 18 ]. Providers of IVF services shared their views and experiences in relation to the ethical issues inherent in the provision of in vitro fertilization treatment. Additionally, opinions were sought from bioethicists and a lawyer. After the views and lived experiences were shared, the findings were described and analysed in relation to the prevalent ideas related to the research questions. Study Setting The study was conducted at three fertility clinics in the Accra, Ghana's capital city, which has the highest number of fertility centres. The ethics committee mandated the anonymization of the names and locations of fertility centres where data were collected due to the sensitive nature of the subject matter. Thus, these centres will be referred to as IVF Centre 1, IVF Centre 2, and IVF Centre 3 within the study to maintain confidentiality and protect the privacy of the parties involved. These three were selected following an initial visit to a total of 14 fertility centres in Accra. However, only the three facilities agreed to allow their staff take part in the study. Participants and Recruitment A total of twelve participants (9 healthcare professionals, 2 bioethicists, and one lawyer) constituted the participants. The study initially anticipated a sample size of 13 participants. However, data saturation was reached for all major themes after 12th participant was interviewed. Participants were carefully chosen using a purposive sampling technique, which prioritized maximum diversity. Participants were contacted via phone calls after an initial request was made to their respective facilities/institutions to participate in the study. The researchers conducted informal meetings with participants to establish rapport and re-screen them for inclusion before sending them a formal invitation for the study. Data collection In-depth interviews were conducted using an open-ended topic guide containing open-ended questions The interview guide was pretested among four (4) non-participants to help clarify the content of the interview guide before the actual interview was performed. The interviews were conducted in person (face-to-face) by the first author at a convenient location within the workplace of each participant. Each interview session lasted 45 to 60 minutes. All interviews were conducted in English, and participants were informed in advance that the sessions would be recorded and transcribed. Healthcare providers were asked about their perspectives on factors influencing patients' choices of IVF treatment, ethical challenges encountered in IVF treatment, and issues related to equitable access to IVF treatment in Ghana. Bioethicists shared their opinions on ethical concerns in IVF treatment as well as affordability and equity issues within the IVF industry. The lawyer provided insights into the legal and regulatory provisions governing IVF treatment in Ghana. Field notes were made during and after each interview, and subsequently written up and included in the analysis. Analysis Braun and Clarke's guidelines for thematic analysis of the data were followed [ 19 ]. These steps included becoming familiar with the data, generating initial codes, searching for themes, reviewing, refining, and summarizing the findings. Initially, the first author and another independent transcriber transcribed all the audio recordings of the interviews. Then, the transcripts were cleaned to pseudonymize participants’ identifiers. Each transcript was read multiple times, with one randomly selected from each group: a bioethicist, two healthcare professionals, and the lawyer. We used descriptive-focused coding to identify concepts aligned with the study objectives, creating an initial codebook. Data coding and theme organization and alignment were performed with the aid of NVivo QRS version 14 software. This codebook guided the coding of the remaining transcripts, with new codes added as they emerged. Codes were later grouped into clusters and relevant themes. Themes were continuously refined until they accurately represented the findings. To address potential researcher bias in the coding and themes identification, the second author compared and validated the emerging themes from the first author and independent transcriber. The final themes were discussed to reach a consensus. Results Characteristics of the participants Among the 12 participants, one was a gynaecologist specialist, two were gynaecologist consultants, four fertility midwives, two clinical embryologists, two were bioethicists, and one was a lawyer. Educational qualifications varied among the participants, with all the gynaecologists, clinical embryologists, and bioethicists holding postgraduate qualifications, while the midwives and the lawyer possessed graduate-level qualifications. Each participant was assigned an identifier from P1 to P12 for reference throughout the study. Through a comprehensive thematic analysis aligned with the study objectives, six overarching ethical issues emerged to form the main themes. These included (1) Inequitable access, (2) Balancing risks and rewards, (3) Fate of surplus embryos, (4) Status of the embryo, (5) Compromises in informed consent, and (6) Potential risk of breach in confidentiality. Theme 1: Inequitable access The participants highlighted the presence of barriers, the role of government funding and income-based pricing, the significance of insurance coverage, and the need for flexible payment plans to ensure fairness and equity in accessing fertility treatments. Participants particularly identified financial constraints as a barrier that hinders equitable access to IVF treatment. As participant 1 mentioned, In our part of the world, IVF is fully fee paying. So, those who have the money will have access to the procedure (P1, gynaecologist consultant, IVF centre 2). Today, if you are not a high-income earner, I doubt you can go through IVF treatment. You may abandon it on the way (P9, clinical embryologist, IVF centre 3). However, a participant provided justification for access barriers to the general population by citing the need to prioritize more critical healthcare issues within limited resources: So, we should give more to life threatening medical situations or clinical situations. So, if you compare putting an infectious disease treatment on the NHIS (National Health Insurance Scheme) compared to this [IVF treatment], the ethical arguments may lead you to favour the infectious disease … so the ethics of rationing becomes very important … if you are not able to have a child, you can live your full life (P10, bioethicist). Despite access challenges, a participant mentioned that exceptions should be made for certain individuals who lack mental soundness to parent children: If they[patients] are not, you know, mentally sound … they cannot be responsible parents, so they should not be given a chance at IVF. These are the few exceptions I may think of (P1, gynaecologist consultant, IVF centre 2). Another aspect of equity highlighted in the study relates to who should be entitled to access IVF treatment. Some of the participants emphasized that the type of relationship between couples should not be a factor restricting IVF treatment. They extended recognition to diverse family structures, including single parents by choice. However, same-sex couples were not explicitly considered for IVF treatment: Well, the truth is that people who come here, they come as partners. We do not know whether they are legally married or not … There are women who do not have the eggs, and they may ask the centre to assist them to get female egg donors so they can carry pregnancy with them. There are a few women too who come, they do not have any male partners and they do not have anybody in mind to donate the sperm for them. We have not had anybody, especially, let's say, two males who come, they want a female to be a surrogate for them neither have we had two women come in and say they are a couple (P1, gynaecologist consultant, IVF centre 2). To address the inequities in access to IVF treatment, some participants reported a need for government intervention and funding to make fertility treatments more accessible to a broader population. Income-based pricing models were proposed by one of the participants to ensure fairness. She argued that sliding-scale fees based on income could make treatments more affordable for lower-income individuals or couples: You may have a couple who would be able to pay outright, probably charge based on people's ability to pay so that they can reduce the cost for those who do not have to pay. So those who have should pay more and then those who do not have, should be subsidized (P11, bioethicist). The absence of insurance coverage for fertility treatment was identified as a major barrier to equitable access. Participants thus called for insurance policies to include fertility treatment coverage to reduce the financial strain on patients. As participants 8 and 10 mentioned, Possibly if insurance could come and cover some aspects of the treatment, it will help (P8, Clinical embryologist, IVF Centre 2). Whatever the private facilities in particular who would not forfeit their profit margins can do is to probably collaborate with some insurance system (P10, bioethicist). While payment plans were seen as a potential solution to address affordability concerns, some participants noted that challenges with payment plans, such as unstable instalment rates and inflexible terms, could create additional financial burdens: We do payment plans for our facilities … We have as low as five hundred … Unfortunately, because it is not well afforded, some people start payment in bit which may go beyond a year, then our prices are reviewed, and they come back to meet a higher price. Unfortunately, there is nothing they can do about it due to unstable foreign exchange (P2, gynaecologist specialist, IVF centre 1). Theme 2: Balancing risks and rewards The findings revealed that individuals and couples often engage in delicate balancing when considering IVF treatments. The desire for multiple births, coupled with the associated risks, presents a complex ethical decision-making dilemma. Additionally, the emotional toll resulting from treatment failure adds another layer of complexity to treatment. The clients expect the possibility of multiple foetuses. So mostly they are happy to get twins or triplets and want us to manage them to term and that is what we do (P7, fertility midwife, IVF centre 3). Participants however reported the challenges associated with multiple gestations (such as twins or triplets) resulting from IVF treatments: Our main concern is cervical insufficiency, the risk of abortions and all that … We have had one. She had uterine atone. The uterus just become too relaxed that it cannot even contract. So, they end up bleeding more. So even before we enter the theatre, you must secure blood and all that. So, in the absence of it, the client's life is at risk, because they have carried more than one, so the uterus is over overstretched (P6, fertility midwife, IVF centre 2). Additionally, providers often make recommendations based on medical considerations, aiming to balance the desire for a successful pregnancy with the potential complications of multiple births: Whenever we are doing embryo transfer, we are tight in the corner as in, when we do put only one, and it does not work I mean, we have wasted the patient time and money. So, if we put two, in case one does not work, one will stand … So, for the healthy young ladies[lady], she can carry more than one foetus, she can carry two. So, in that sense, when we start antenatal, we keep on monitoring (P5, fertility midwife, IVF centre 1). One gynaecologist consultant at IVF centre 3 further raised concerns about some adverse effects of treatment associated with IVF treatment and the difficulty of navigating such adverse effects: When it comes to assessing the risk and benefit of IVF treatment, the risk of hyper ovarian stimulation and the benefit of retrieving adequate eggs, then it becomes problematic … if we compare the adverse effect, it gives some people (P3, Gynaecologist Consultant, IVF centre 3). Moreover, one of the participants shared couples’ experiences dealing with the emotional and psychological impact of treatment failure, including the fact that the fear of not achieving a successful pregnancy often heavily affects individuals and couples undergoing fertility treatments: You can understand how they[couples] feel when it does not succeed, the depression, the disappointments, the economic loss, and all that (P1, gynaecologist consultant, IVF centre 2). Theme 3: Fate of surplus embryos Embryo storage and disposal emerged as challenging ethical dilemma. The participants responded to questions related to the moral status of the embryos, the responsibility of the parents in decision-making, and the impact of choosing to discard or donate unused embryos: So, I believe it [embryos] can be donated. I believe there should be a charity that also would be into donation of these embryos. So, if that avenue is there, that could be explored instead of just destroying them (P11, bioethicist). Some participants believe that embryo storage should depend on the consenting couple: When you do the egg collection, then you need to affirm it to them [couples] that maybe the number of eggs you have got, is it more likely some will be left. You talk to them [couples] to start preparing towards freezing. Some people readily accept, others too may not want to; they say, well, you just put in what you have to put in, the rest they are not willing to store. Others may ask you to preserve it for people who want it. Others may tell you to destroy it because they do not want it (P1, gynaecologist consultant, IVF centre 2). The commercialization of embryos particularly raised ethical concerns among participants. They deliberated over the implications of commodifying human reproductive materials and the potential exploitation of vulnerable individuals. Ethical considerations spanned issues of affordability, consent, and the role of profit-driven entities in fertility treatment: I think this [commercialization of embryo] is something that we have to look into, you know, there should be a system in place where people are adequately informed (P11, bioethicist). So, if you work around it in such a way that you adequately compensate for this without excessive profiteering, that for me, would be a good point or balance point to work things out with (P10, bioethicist). Some participants believe that commercializing embryos should be completely avoided, while others argue that they could be subject to reasonable negotiation: Selling of embryos should not be encouraged. It feels like you are selling something that does not have to be sold, I think we should not. We can give some appreciation to the one who is giving out the embryo or the gamete, but not like prescribing a fee. We should not prescribe an amount (P7, fertility midwife, IVF centre 3). Selling any part of the human body has some legal consequences. But a person can receive compensation for giving out an embryo, if there is that agreement between parties (P12, legal practitioner). Theme 4: Status of the embryo Participants debated about when personhood begins and whether embryos created during IVF should be considered as having moral or legal standing. Some participants stressed that in the decision-making process regarding the existence of a child, the child does not play an active role, and they do not inherently possess rights. Instead, the primary decision-making authority lies with the parents: Do you have a right before you exist? So, if the child is unborn, has the child an identity, has the child a right? What is the role of the child in coming into existence? Is it not the decision of the two parties[parents]? The child has no part to play in that. So, then where lies the right of the unborn child in doing that? It is just the decision of these two (P10, bioethicist). The unborn child has no legal status. Only the parents have. So, if that unborn child becomes a human, then they can exercise their rights (P12, legal practitioner). Nevertheless, some participants acknowledged the significance of making decisions that prioritize the well-being and potential rights of the unborn child: You have to weigh with the quality of life … with the disadvantage of being born. If the risk is way beyond the minor acceptable risk, then I do not think it is reasonable to give birth to that child to come and suffer. If the risk is too much and that has to do with the quality of life for that child that is going to be born, then, to me, you have to consider the outcome (P11, bioethicist). Theme 5: Compromises in informed consent Participants stressed the importance of offering comprehensive and comprehensible information about the proposed treatments to couples who seek IVF treatment. They believe that couples should fully grasp the potential risks, benefits, and alternatives to make informed choices about their fertility care. As participants expressed, We have materials to aid them understand and seek their feedback from the understanding they got. Our terms and condition of payment, the risk and benefits of the treatment, the success rate and possibility of failure (P3, gynaecologist consultant, IVF centre 3). However, it was noted that the acceptance of informed consent may be influenced by the specific situations and circumstances in which couples find themselves. Several factors influence the acceptance of informed consent among couples undergoing fertility treatments, such as in vitro fertilization (IVF). Psychological distress, common in this context, may hinder their ability to comprehend and accept the details, raising concerns about the validity of their consent. The couples' fertility journeys and history, shaped by past experiences, impact their trust and understanding during the informed consent process. Some people may seem to have understood. But maybe they did not because of the desperate nature of the situation. They are willing to go through anything so long as it will guarantee them pregnancy and baby … those who are quite well educated understand some of the processes and all that. For those who are not educated … giving them instructions sometimes may not go down too well for them (P1, gynaecologist consultant, IVF centre 2). The complexity of medical procedures and associated risks involved in IVF treatment could also influence patient perception and acceptance, particularly for those facing greater medical complexities or potential health risks. Cultural and religious beliefs contribute significantly to perspectives on assisted reproductive technologies, affecting the acceptance or rejection of certain aspects of IVF. Educational background and varying levels of understanding among couples may affect the quality of informed consent. Theme 6 Difficulties in maintaining Confidentiality Participants highlighted a need to maintain the strictest confidentiality regarding patients' personal and medical information. However, IVF treatment is performed by a multidisciplinary team of healthcare professionals, making it sometimes difficult to maintain strict confidentiality. IVF is more privacy protected because of the whole stigma from society. So, we as healthcare providers are tasked to ensure that the information of the patient is unknown to providers who are not directly caring for our clients because some providers can have big mouths (P7, fertility midwife, IVF centre 3). Discussion This study aimed to explore ethical concerns in the provision of in vitro fertilization (IVF) treatment in Ghana. The major themes presented demonstrated that many ethical issues confront the human reproductive technology industry in Ghana. Evidence from this study indicated that financial constraints were a major barrier to accessing IVF treatment. Other studies have emphasized that the cost of IVF treatment can be prohibitively expensive for many individuals, potentially preventing them from pursuing such treatment [ 20 , 21 ]. The high cost of IVF treatment is a well-documented factor and seems to be particularly impactful in the context of Ghana. The relatively lower income levels of most Ghanaians contribute to the perception that IVF treatment is a privilege rather than a readily accessible option. Economic disparities may disproportionately affect access to IVF, creating barriers for those with limited financial means. There is a need for financial support mechanisms and affordable pricing models to address inequities in access to IVF treatment. The study revealed that while some consider IVF a luxury for the wealthy, others say that the cost is justified given the intrinsic importance of having a child. This finding is consistent with previous research, which indicates that despite the initial perception of high IVF costs, the intrinsic value of having a child tends to outweigh financial expenditures [ 22 , 23 ]. Regardless, the cost of treatment should not be prohibitively expensive but rather represent the economic disparities in the country where it is administered. This study stresses the importance of government action and funding to increase access to fertility treatments; nevertheless, in low- and middle-income countries such as Ghana, government funding may be perceived as insufficient allocative justice [ 24 ]. This calls for the government to strike a balance between healthcare objectives and IVF therapy. An additional finding from the study indicated that individuals with mental health issues should not have access to IVF treatment. Although this finding is not directly stated in most of the literature, the nature of IVF treatment may exacerbate psychological issues and may not be favourable for people with mental health conditions prior to treatment. This claim is evident in the literature, implying that a negative pregnancy test is associated with an increased risk for depression in women undergoing IVF [2527]. It is also perceived that individuals with mental health conditions may be incapable of bearing the responsibility of parenting [ 28 , 29 ] and thus should not be given the chance at IVF treatment in pursuit of a child. However, this could raise ethical concerns about fairness in IVF services. Intense emotional investment in the process, coupled with potential disappointments such as failed attempts, may indeed impact the mental well-being of individuals with preexisting mental health conditions. Mental health assessments and support should be integrated into the IVF process to ensure the well-being of patients throughout their fertility journey. It was noted in the findings of this study that couples are usually desperate to have their own children and may override thoughtful decision-making during the informed consent process. This finding is consistent with previous studies, including those by Frank, Mohammadzadeh, and Van-Den Akker [ 30 – 32 ], which have all indicated that the intense desire for a biological child can complicate ethical decision-making and lead individuals to overlook potential risks associated with IVF treatment. The intense longing for a biological child creates an emotional state that may overshadow rational decision-making. This emotional intensity could stem from societal expectations, personal desires for parenthood, or cultural influences. When individuals or couples are deeply invested in the outcome of fertility treatments, they may prioritize the goal of having a child over careful consideration of the potential risks and alternatives associated with IVF. The emotional aspect might cloud the ability to fully comprehend the implications and make informed choices during the consent process. Healthcare professionals need to be adept at recognizing signs of desperation in couples undergoing IVF. The finding also showed that the desire for multiple births, coupled with the associated risks, presents a complex ethical decision-making dilemma for healthcare providers. Striking a balance between respecting patient autonomy and preventing harm poses challenges in the practice of IVF [ 33 – 35 ]. Addressing these ethical dilemmas is essential for providing responsible and patient-focused infertility treatment. There were also ethical concerns surrounding embryo storage and disposal of unused embryos. The findings of this study suggested that there are multiple opinions related to the moral status of embryos, the responsibility of parents in decision-making, and the impact of choosing to discard or donate unused embryos. Many studies suggest that the responsibility of parents in decision-making varies among clinics, with some requiring a couple's participation in disposal, some allowing but not requiring it, and some discouraging or disallowing it [ 36 – 39 ]. The diverse opinions and practices regarding embryo disposal can be attributed to the complex and emotive nature of the matter. Philosophical viewpoints on the moral status of embryos likely contribute to these differences, as well as cultural, religious, and individual beliefs. Clinics may adopt varying approaches based on their ethical frameworks, legal considerations, and perhaps the absence of standardized guidelines in this sensitive area. The varying opinions on embryo storage and disposal also highlight the need for clear guidelines and open communication between patients and providers. Clinics should have policies that respect the preferences of patients while adhering to ethical standards. The findings also revealed a diversity of opinions on the commercialization of embryos, with some advocating total avoidance, while others suggesting that it may be acceptable with appropriate compromise. The literature highlights arguments against embryo commercialization, citing moral, scientific, and human rights concerns, as well as potential conflicts of interest and prioritization of financial gain in IVF involving profit-driven entities [ 40 – 42 ]. These sources, likely representing a broader body of literature, emphasize ethical, moral, and human rights issues associated with the commercialization of embryos. The concerns about conflicts of interest and the role of profit-driven entities in IVF align with prior discussions in the field. This finding reflects the ongoing debate within the scientific and ethics communities regarding the commercialization of embryos. The opposition to embryo commercialization is likely rooted in moral and ethical considerations, such as the sanctity of human life, potential exploitation, and concerns about the commodification of embryos. Additionally, the apprehension about profit-driven entities in IVF reflects worries about the potential compromise of medical decision-making for financial gains. These findings underscore a need for careful regulation of embryo commercialization. The concerns raised, including conflicts of interest and prioritization of financial gain, highlight potential risks associated with uncontrolled commercialization. Advocating for adequate, worldwide, and tolerant control of embryo commercialization has become crucial for addressing these ethical, moral, and financial considerations [ 43 ]. Implementing robust laws and regulations can help strike a balance between technological advancement and safeguarding against potential ethical lapses in the realm of assisted reproductive technologies. The findings of this study should be interpreted with certain limitations in mind. The sample size was relatively small (12 participants). While qualitative research often involves smaller samples, the findings may not be generalizable to a broader population. Additionally, the participants were healthcare professionals involved in IVF, which may limit the diversity of perspectives, as patients or individuals from diverse backgrounds may have provided a more comprehensive view of the subject. Finally, the use of descriptive-focused coding for thematic analysis may have limited the depth of the analysis. It may also not have captured more nuanced or abstract themes that could emerge from the data. Conclusion This study highlights the many ignored facets of in vitro fertilization treatment in low-income setting settings. The findings contribute to the existing body of knowledge on reproductive ethics and as well provide practical insights and recommendations that can guide policy and practice in Ghana. Moving forward, there is urgent need for all stakeholders to come together to develop clear and uniform regulations to govern the practice of IVF treatment in Ghana, with further attention given to mitigating financial barriers and enhancing support systems for couples considering IVF. Abbreviations IVF In vitro fertilization ART Assisted reproductive technology Declarations Ethics approval and consent to participate The Noguchi Memorial Institute for Medical Research–Institutional Review Board (NMIMR-IRB) gave ethical approval for this study (approval # CPN 014/23-24, valid from 2 nd August to 1 st August 2024). The study procedures adhered to the ethical principles of the Declaration of Helsinki. Written informed consent was obtained from all participants. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare no competing interests. Funding The research did not receive funding. Authors’ contributions DA was fully responsible for conceptualization, data analysis, and writing of the initial draft. JKG was responsible for reviewing, editing, and managing the research project. Acknowledgements The author wishes to acknowledge Regina Appiah, a scrub nurse at the Obstetrics/Gynaecology Theatre at the University of Ghana Medical Centre, for her valuable suggestions and unwavering support. Author details 1 Graduate Student, Department of Population Family and Reproductive Health, University of Ghana. 2 Associate Professor, Department of Population Family and Reproductive Health, University of Ghana. References Donkor ES, Naab F, Kussiwaah DY. “I am anxious and desperate”: psychological experiences of women with infertility in The Greater Accra Region, Ghana. Fertil Res and Pract[Internet]. 2017 Mar 16[cited 2023 Mar 1]; 3(1): 6. https://doi.org/10.1186/s40738-017-0033-1 Ofosu-Budu D, Hanninen V. Living as an infertile woman: the case of southern and northern Ghana.Reprod Health. 2020 May 20; 17(1): 69. Alhassan A, Ziblim AR, Muntaka S. 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Upsala Journal of Medical Sciences[Internet]. 2020 Apr 2[cited 2023 Feb 10]; 125(2): 192–9. https://doi.org/10.1080/03009734.2019.1684405 Kuivasaari-Pirinen P, Koivumaa-Honkanen H, Hippeläinen M, Raatikainen K ,Heinonen S. Outcome of Assisted Reproductive Technology(ART) and Subsequent Self-Reported Life Satisfaction. PLOS ONE[Internet]. 2014 Nov 13[cited 2023 Feb 23]; 9(11): e112540. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0112540 Bazzaco AA, Valelongo PO, Miziara ID, Barbosa CP. Understanding about free consent in assisted reproduction techniques. Revista Bioética. 2014; 22: 134-44. Dieke AC, Zhang Y, Kissin DM, Barfield WD, Boulet SL. Disparities in Assisted Reproductive Technology Utilization by Race and Ethnicity, United States, 2014: A Commentary. Journal of Women’s Health[Internet]. 2017 Jun[cited 2023 Mar 3]; 26(6): 605–8. https://www.liebertpub.com/doi/full/10.1089/jwh.2017.6467 Hiadzi RA, Woodward B, Akrong GB. Ethical issues surrounding the use of assisted reproductive technologies in Ghana: An analysis of the experiences of clients and service providers. Heliyon[Internet]. 2023 Feb[cited 2023 Feb 23]; 9(2): e13767. https://linkinghub.elsevier.com/retrieve/pii/S240584402300974X Busardò FP, Gulino M, Napoletano S, Zaami S, Frati P. The Evolution of Legislation in the Field of Medically Assisted Reproduction and Embryo Stem Cell Research in European Union Members. Zollner U,editor. BioMed Research International[Internet]. 2014 Jul 24; 2014: 307160. https://doi.org/10.1155/2014/307160 Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research(COREQ):a 32-item checklist for interviews and focus groups. International journal for quality in health care. 2007 Dec 1; 19(6): 349-57. Neubauer BE, Witkop CT, Varpio L. How phenomenology can help us learn from the experiences of others. Perspectives on medical education. 2019 Apr; 8: 90-7. Braun V, Clarke V. Reflecting on reflexive thematic analysis. Qualitative research in sport, exercise and health. 2019 Aug 8; 11(4): 589-97. Maeda E, Jwa SC, Kumazawa Y, Saito K, Iba A, Yanagisawa‑Sugita A, Kuwahara A, Saito H, Terada Y, Fukuda T, Ishihara O. Out-of-pocket payment and patients’ treatment choice for assisted reproductive technology by household income: a conjoint analysis using an online social research panel in Japan. BMC Health Services Research. 2022 Aug 27; 22(1): 1093. https://doi.org/10.1186/s12913-022-08474-5 Barbagallo F, Cannarella R, Crafa A, La Vignera S, Condorelli RA,Manna C, Calogero AE. The impact of a very short abstinence period on assisted reproductive technique outcomes: A systematic review and meta-analysis. Antioxidants. 2023 Mar 20; 12(3): 752. https://doi.org/10.3390/antiox12030752 Nachtigall RD, MacDougall K,Davis AC, Beyene Y. Expensive but worth it: older parents’ attitudes and opinions about the costs and insurance coverage for in vitro fertilization. Fertility and sterility. 2012 Jan 1; 97(1): 82-7. https://doi.org/10.1016/j.fertnstert.2011.10.019 Connolly M, Gallo F, Hoorens S, Ledger W. Assessing long-run economic benefits attributed to an IVF-conceived singleton based on projected lifetime net tax contributions in the UK. Human Reproduction. 2009 Mar 1; 24(3): 626-32. https://doi.org/10.1093/humrep/den435 Margalit Y. Scarce medical resources–parenthood at every age, in every case and subsidized by the State? [Internet]. 2014. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2449979 Accessed on 14 April 2023. Volgsten H, Svanberg AS, Ekselius L, Lundkvist Ö, Poromaa IS. Risk factors for psychiatric disorders in infertile women and men undergoing in vitro fertilization treatment.Fertility and Sterility. 2010 Mar 1; 93(4): 1088-96. https://doi.org/10.1016/j.fertnstert.2008.11.008 Yli-Kuha AN, Gissler M, Klemetti R, Luoto R, Koivisto E, Hemminki E. Psychiatric disorders leading to hospitalization before and after infertility treatments. Human Reproduction.2010 Aug 1; 25(8): 2018-23. https://doi.org/10.1093/humrep/deq164 Holley SR,Pasch LA,Bleil ME,Gregorich S,Katz PK,Adler NE.Prevalence and predictors of major depressive disorder for fertility treatment patients and their partners.Fertility and sterility.2015 May 1;103(5):1332-9. https://doi.org/10.1016/j.fertnstert.2015.02.018 Fudge E,Falkov A,Kowalenko N,Robinson P.Parenting is a mental health issue.Australasian Psychiatry.2004 Jun;12(2):166-71. https://doi.org/10.1080/j.1039-8562.2004.02091.x Reupert A, Maybery D, Nicholson J, Göpfert M, Seeman MV,editors. Parental psychiatric disorder: Distressed parents and their families.Cambridge University Press; 2015 Jul 9. Frank C. ‘I Want a Child!’Concerning Problems of Informed Consent in Fertility Treatment.Psychoanalytic Psychotherapy. 2007 Jun 1; 21(2): 150-67. Mohammadzadeh E. P151: Emotional Disorders and Anxiety During IVF-Treatment. The Neuroscience Journal of Shefaye Khatam. 2014 Sep 10; 2(3): 175. van den Akker O. Emotional and psychosocial risk associated with fertility treatment. Reducing risk in fertility treatment. 2015: 79-96. https://doi.org/10.1007/978-1-4471-5257-6_5 Emery M.Which issues concerning multiple pregnancies should be addressed during psychosocial counselling?. Reproductive BioMedicine Online. 2007 Jan 1;15: 18-21. Kaur N, Ricciardelli R. Negotiating risk and choice in multifetal pregnancies.Social Science&Medicine. 2020 May 1; 252: 112926. Ryan GL, Zhang SH, Dokras A, Syrop CH, Van Voorhis BJ. The desire of infertile patients for multiple births. Obstetrical & gynecological survey. 2004 Aug 1; 59(8): 592. https://doi.org/10.1016/j.fertnstert.2003.05.035 Gurmankin AD, Sisti D, Caplan AL. Embryo disposal practices in IVF clinics in the United States. Politics and the Life Sciences. 2003 Sep; 22(2): 4-8. https://doi.org/10.1017/S0730938400006614 Frith L, Blyth E, Paul MS, Berger R. Conditional embryo relinquishment: choosing to relinquish embryos for family-building through a Christian embryo‘adoption’programme. Human Reproduction. 2011 Dec 1;26(12): 3327-38. https://doi.org/10.1093/humrep/der313 Corley SO,Berg JW.Embryo Donation:Ethical Issues.Third-Party Reproduction:A Comprehensive Guide.2014:121-9. https://doi.org/10.1007/978-1-4614-7169-1_12 Goedeke S, Daniels K, Thorpe M, Du Preez E. The fate of unused embryos: discourses, action possibilities, and subject positions. Qualitative Health Research.2017 Aug; 27(10): 1529-40. https://doi.org/10.1177/1049732316686759 Balakrishnan P, Balu N. Commercialisation of human embryos and Stem Cells. International journal of health sciences. 2022 Apr 14; 4703–16. https://doi.org/10.53730/ijhs.v6nS1.5896 Legge M, Fitzgerald R. Valuing embryos as both commodities and singularities. The New Zealand Medical Journal(Online). 2016 Mar 11; 129(1431): 80. Fox D. Paying for particulars in people-to-be: commercialisation, commodification and commensurability in human reproduction.Journal of Medical Ethics. 2008 Mar 1; 34(3): 162-6. Anton R. On the future advances in engineering and in-vitro culture of human embryos[Internet]. 2016 https://mpra.ub.uni-muenchen.de/id/eprint/71450 Accessed 13 March 2023. Additional Declarations No competing interests reported. Supplementary Files interviewguideforparticipantsgroup.pdf Additional files File name - Additional file 1.pdf Title of data- Interview guide for participant groups Description of data - interview guides used for data collection Cite Share Download PDF Status: Published Journal Publication published 17 Oct, 2024 Read the published version in BMC Medical Ethics → Version 1 posted Editorial decision: Revision requested 12 Aug, 2024 Reviews received at journal 09 Aug, 2024 Reviews received at journal 03 Aug, 2024 Reviewers agreed at journal 26 Jul, 2024 Reviewers agreed at journal 11 Jul, 2024 Reviewers invited by journal 11 Jul, 2024 Editor invited by journal 11 Jul, 2024 Editor assigned by journal 11 Jul, 2024 Submission checks completed at journal 11 Jul, 2024 First submitted to journal 05 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4693060","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":335662294,"identity":"1f8e3695-bb2f-4bdb-bfea-10508d1324ab","order_by":0,"name":"David Appiah","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+0lEQVRIiWNgGAWjYDCCA0DEA+N8qAASzMwNRGmRAGljnHEGpIWRsBYGmBZmzjaQEAEtfMfPGB5422ZXZ8/e+/gz47zaaP52oJYfFdtwapE8k2NwcG5bsgQPz3Ez6cJtx3NnHGZsYOw5cxunFoMDaQmHebcxS/BIpLExz9x2LLcBqIWZsQ2PlvPPQFrqJXjknzF/5p1zLHc+QS03kg8AtRwG2sLGIM3bUJO7gZAWyRuPDxyc+++4ZM+ZNDbJGccO5G4EajmIzy985xObP7w5U83P3n6M+cOHmrrceecPH3zwowK3FnRwGEweIFo9ENSRongUjIJRMApGCAAAK3lgQZEd5qEAAAAASUVORK5CYII=","orcid":"","institution":"University of Ghana","correspondingAuthor":true,"prefix":"","firstName":"David","middleName":"","lastName":"Appiah","suffix":""},{"id":335662295,"identity":"b86becdb-e281-42b3-838c-1636a368684f","order_by":1,"name":"John K Ganle","email":"","orcid":"","institution":"University of Ghana","correspondingAuthor":false,"prefix":"","firstName":"John","middleName":"K","lastName":"Ganle","suffix":""}],"badges":[],"createdAt":"2024-07-05 14:58:55","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4693060/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4693060/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12910-024-01113-0","type":"published","date":"2024-10-17T15:57:45+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":67148982,"identity":"6390add2-a292-422f-bd46-6ba26b9b6394","added_by":"auto","created_at":"2024-10-21 16:10:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":463712,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4693060/v1/bcdf9360-5b13-469f-9151-4804a51fcf22.pdf"},{"id":61745726,"identity":"e0e4cb31-64c4-4a85-99f0-c6802a76a171","added_by":"auto","created_at":"2024-08-05 06:31:10","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":112571,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAdditional files\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFile name - Additional file 1.pdf\u003c/p\u003e\n\u003cp\u003eTitle of data- Interview guide for participant groups\u003c/p\u003e\n\u003cp\u003eDescription of data - interview guides used for data collection\u003c/p\u003e","description":"","filename":"interviewguideforparticipantsgroup.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4693060/v1/d22454e0073397d2d903210b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Ethical concerns in the provision of in vitro fertilization treatment in Ghana: A qualitative study.","fulltext":[{"header":"Background","content":"\u003cp\u003eInfertility is a significant public health concern because it can have psychological effects on couples, particularly women. An estimated 10\u0026ndash;15% of couples worldwide experience infertility, with geographical differences; in sub-Saharan Africa, the frequency is particularly high, frequently reaching up to 30% in specific places. The incidence of infertility in Ghana is between 11 and 15 percent, highlighting the need for readily available, reasonably priced fertility treatments and assistance given the anticipated future drop in fertility [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Women experiencing infertility reported feelings of loneliness, anxiety, depression, reduced concentration, worry, and diminished sexual satisfaction [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Infertile women in Ghana face severe social stigma because they are often shunned and forsaken by those who should support them, including their husbands and extended family [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In the Ghanaian cultural context, motherhood is frequently viewed as a status of achievement [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Consequently, women or couples often put forth a great deal of effort to conceive. For instance, those who opt to treat infertility spend considerable time and money, and these expenses are often paid out of pocket, unleashing financial strain and potentially bankruptcy [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGenerally, assisted reproductive technology (ART) and the increasing development of in vitro fertilization (IVF) treatment methods provide options for treating infertility [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. IVF is a type of ART but is extensively used interchangeably. This complex procedure involves extracting the ovum for sperm fertilization outside the human body and transferring it back into the uterus. The introduction of IVF halts the emotional trauma that childlessness brings to people [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. IVF is often the last resort utilized to achieve pregnancy since it has the potential to overcome various undiagnosed biological issues of fertility [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Nevertheless, it is a costly and invasive procedure that may result in complications [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMany countries in the Western world such as Spain, Portugal, Estonia, the USA, Greece, North Cyprus, and Ukraine, provide IVF treatment. Similarly, 21 out of the 54 countries in Africa provide IVF treatment [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Although IVF treatment is not so popular in Ghana as in the Western world, 14 fertility clinics that provide this service can be found, especially in Greater Accra, Takoradi, and Kumasi [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough IVF is a revolutionary procedure, it is confronted with ethical issues, including equity of IVF service, compromised informed consent, funding of IVF treatment, and the effect of religious beliefs on IVF policy-making [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Moreover, valid informed consent is often compromised: the psychological state of people seeking IVF treatment has been found to exhibit extreme hopefulness and desperation to have a child [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Again, the information provided on IVF consent forms is often not precise [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In Ghana, these challenges are compounded by high costs, inequalities, lack of legal frameworks, and inconsistencies in adherence to international standards [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The lack of laws and guidelines for medical assisted reproduction (MAR) in countries such as Ghana further exacerbates these issues as countries with only \u0026ldquo;guidelines\u0026rdquo; have been shown to be inadequate to address the social, ethical, and legal aspects of this crucial field of medicine [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. At the same time, studies on informed consent, fairness in accessing IVF treatment, and ownership of embryos in different situations in Ghana are limited. Studies focused on the ethical implications of in vitro fertilization in Ghana are very scant. Therefore, this study aimed to explore the ethical concerns that exist regarding in vitro fertilization treatment in Ghana.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eA descriptive phenomenological qualitative research was conducted to explore the ethical issues in the provision of in vitro fertilization treatment in Ghana, and findings were reported using the consolidated criteria for reporting qualitative research as a guide (COREQ) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Providers of IVF services shared their views and experiences in relation to the ethical issues inherent in the provision of in vitro fertilization treatment. Additionally, opinions were sought from bioethicists and a lawyer. After the views and lived experiences were shared, the findings were described and analysed in relation to the prevalent ideas related to the research questions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy Setting\u003c/h2\u003e \u003cp\u003eThe study was conducted at three fertility clinics in the Accra, Ghana's capital city, which has the highest number of fertility centres. The ethics committee mandated the anonymization of the names and locations of fertility centres where data were collected due to the sensitive nature of the subject matter. Thus, these centres will be referred to as IVF Centre 1, IVF Centre 2, and IVF Centre 3 within the study to maintain confidentiality and protect the privacy of the parties involved. These three were selected following an initial visit to a total of 14 fertility centres in Accra. However, only the three facilities agreed to allow their staff take part in the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eParticipants and Recruitment\u003c/h2\u003e \u003cp\u003eA total of twelve participants (9 healthcare professionals, 2 bioethicists, and one lawyer) constituted the participants. The study initially anticipated a sample size of 13 participants. However, data saturation was reached for all major themes after 12th participant was interviewed.\u003c/p\u003e \u003cp\u003eParticipants were carefully chosen using a purposive sampling technique, which prioritized maximum diversity. Participants were contacted via phone calls after an initial request was made to their respective facilities/institutions to participate in the study. The researchers conducted informal meetings with participants to establish rapport and re-screen them for inclusion before sending them a formal invitation for the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eIn-depth interviews were conducted using an open-ended topic guide containing open-ended questions The interview guide was pretested among four (4) non-participants to help clarify the content of the interview guide before the actual interview was performed.\u003c/p\u003e \u003cp\u003eThe interviews were conducted in person (face-to-face) by the first author at a convenient location within the workplace of each participant. Each interview session lasted 45 to 60 minutes. All interviews were conducted in English, and participants were informed in advance that the sessions would be recorded and transcribed.\u003c/p\u003e \u003cp\u003eHealthcare providers were asked about their perspectives on factors influencing patients' choices of IVF treatment, ethical challenges encountered in IVF treatment, and issues related to equitable access to IVF treatment in Ghana. Bioethicists shared their opinions on ethical concerns in IVF treatment as well as affordability and equity issues within the IVF industry. The lawyer provided insights into the legal and regulatory provisions governing IVF treatment in Ghana. Field notes were made during and after each interview, and subsequently written up and included in the analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eAnalysis\u003c/h2\u003e \u003cp\u003eBraun and Clarke's guidelines for thematic analysis of the data were followed [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. These steps included becoming familiar with the data, generating initial codes, searching for themes, reviewing, refining, and summarizing the findings. Initially, the first author and another independent transcriber transcribed all the audio recordings of the interviews. Then, the transcripts were cleaned to pseudonymize participants\u0026rsquo; identifiers. Each transcript was read multiple times, with one randomly selected from each group: a bioethicist, two healthcare professionals, and the lawyer. We used descriptive-focused coding to identify concepts aligned with the study objectives, creating an initial codebook. Data coding and theme organization and alignment were performed with the aid of NVivo QRS version 14 software. This codebook guided the coding of the remaining transcripts, with new codes added as they emerged. Codes were later grouped into clusters and relevant themes. Themes were continuously refined until they accurately represented the findings. To address potential researcher bias in the coding and themes identification, the second author compared and validated the emerging themes from the first author and independent transcriber. The final themes were discussed to reach a consensus.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of the participants\u003c/h2\u003e \u003cp\u003eAmong the 12 participants, one was a gynaecologist specialist, two were gynaecologist consultants, four fertility midwives, two clinical embryologists, two were bioethicists, and one was a lawyer. Educational qualifications varied among the participants, with all the gynaecologists, clinical embryologists, and bioethicists holding postgraduate qualifications, while the midwives and the lawyer possessed graduate-level qualifications. Each participant was assigned an identifier from P1 to P12 for reference throughout the study.\u003c/p\u003e \u003cp\u003eThrough a comprehensive thematic analysis aligned with the study objectives, six overarching ethical issues emerged to form the main themes. These included (1) Inequitable access, (2) Balancing risks and rewards, (3) Fate of surplus embryos, (4) Status of the embryo, (5) Compromises in informed consent, and (6) Potential risk of breach in confidentiality.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: Inequitable access\u003c/h2\u003e \u003cp\u003eThe participants highlighted the presence of barriers, the role of government funding and income-based pricing, the significance of insurance coverage, and the need for flexible payment plans to ensure fairness and equity in accessing fertility treatments. Participants particularly identified financial constraints as a barrier that hinders equitable access to IVF treatment. As participant 1 mentioned,\u003c/p\u003e \u003cp\u003e \u003cem\u003eIn our part of the world, IVF is fully fee paying. So, those who have the money will have access to the procedure\u003c/em\u003e (P1, gynaecologist consultant, IVF centre 2).\u003c/p\u003e \u003cp\u003e \u003cem\u003eToday, if you are not a high-income earner, I doubt you can go through IVF treatment. You may abandon it on the way\u003c/em\u003e (P9, clinical embryologist, IVF centre 3).\u003c/p\u003e \u003cp\u003eHowever, a participant provided justification for access barriers to the general population by citing the need to prioritize more critical healthcare issues within limited resources:\u003c/p\u003e \u003cp\u003e \u003cem\u003eSo, we should give more to life threatening medical situations or clinical situations. So, if you compare putting an infectious disease treatment on the NHIS (National Health Insurance Scheme) compared to this [IVF treatment], the ethical arguments may lead you to favour the infectious disease\u003c/em\u003e\u0026hellip;\u003cem\u003eso the ethics of rationing becomes very important\u003c/em\u003e\u0026hellip;\u003cem\u003eif you are not able to have a child, you can live your full life\u003c/em\u003e (P10, bioethicist).\u003c/p\u003e \u003cp\u003e Despite access challenges, a participant mentioned that exceptions should be made for certain individuals who lack mental soundness to parent children:\u003c/p\u003e \u003cp\u003e\u003cem\u003eIf they[patients] are not, you know, mentally sound\u003c/em\u003e\u0026hellip;\u003cem\u003ethey cannot be responsible parents, so they should not be given a chance at IVF. These are the few exceptions I may think of\u003c/em\u003e (P1, gynaecologist consultant, IVF centre 2).\u003c/p\u003e \u003cp\u003eAnother aspect of equity highlighted in the study relates to who should be entitled to access IVF treatment. Some of the participants emphasized that the type of relationship between couples should not be a factor restricting IVF treatment. They extended recognition to diverse family structures, including single parents by choice. However, same-sex couples were not explicitly considered for IVF treatment:\u003c/p\u003e \u003cp\u003e \u003cem\u003eWell, the truth is that people who come here, they come as partners. We do not know whether they are legally married or not\u003c/em\u003e\u0026hellip;\u003cem\u003eThere are women who do not have the eggs, and they may ask the centre to assist them to get female egg donors so they can carry pregnancy with them. There are a few women too who come, they do not have any male partners and they do not have anybody in mind to donate the sperm for them. We have not had anybody, especially, let's say, two males who come, they want a female to be a surrogate for them neither have we had two women come in and say they are a couple\u003c/em\u003e (P1, gynaecologist consultant, IVF centre 2).\u003c/p\u003e \u003cp\u003eTo address the inequities in access to IVF treatment, some participants reported a need for government intervention and funding to make fertility treatments more accessible to a broader population. Income-based pricing models were proposed by one of the participants to ensure fairness. She argued that sliding-scale fees based on income could make treatments more affordable for lower-income individuals or couples:\u003c/p\u003e \u003cp\u003e \u003cem\u003eYou may have a couple who would be able to pay outright, probably charge based on people's ability to pay so that they can reduce the cost for those who do not have to pay. So those who have should pay more and then those who do not have, should be subsidized\u003c/em\u003e (P11, bioethicist).\u003c/p\u003e \u003cp\u003eThe absence of insurance coverage for fertility treatment was identified as a major barrier to equitable access. Participants thus called for insurance policies to include fertility treatment coverage to reduce the financial strain on patients. As participants 8 and 10 mentioned,\u003c/p\u003e \u003cp\u003e \u003cem\u003ePossibly if insurance could come and cover some aspects of the treatment, it will help\u003c/em\u003e (P8, Clinical embryologist, IVF Centre 2).\u003c/p\u003e \u003cp\u003e \u003cem\u003eWhatever the private facilities in particular who would not forfeit their profit margins can do is to probably collaborate with some insurance system\u003c/em\u003e (P10, bioethicist).\u003c/p\u003e \u003cp\u003eWhile payment plans were seen as a potential solution to address affordability concerns, some participants noted that challenges with payment plans, such as unstable instalment rates and inflexible terms, could create additional financial burdens:\u003c/p\u003e \u003cp\u003e \u003cem\u003eWe do payment plans for our facilities\u003c/em\u003e\u0026hellip;\u003cem\u003eWe have as low as five hundred\u003c/em\u003e\u0026hellip;\u003cem\u003eUnfortunately, because it is not well afforded, some people start payment in bit which may go beyond a year, then our prices are reviewed, and they come back to meet a higher price. Unfortunately, there is nothing they can do about it due to unstable foreign exchange\u003c/em\u003e (P2, gynaecologist specialist, IVF centre 1).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: Balancing risks and rewards\u003c/h2\u003e \u003cp\u003eThe findings revealed that individuals and couples often engage in delicate balancing when considering IVF treatments. The desire for multiple births, coupled with the associated risks, presents a complex ethical decision-making dilemma. Additionally, the emotional toll resulting from treatment failure adds another layer of complexity to treatment.\u003c/p\u003e \u003cp\u003e \u003cem\u003eThe clients expect the possibility of multiple foetuses. So mostly they are happy to get twins or triplets and want us to manage them to term and that is what we do\u003c/em\u003e (P7, fertility midwife, IVF centre 3).\u003c/p\u003e \u003cp\u003eParticipants however reported the challenges associated with multiple gestations (such as twins or triplets) resulting from IVF treatments:\u003c/p\u003e \u003cp\u003e \u003cem\u003eOur main concern is cervical insufficiency, the risk of abortions and all that\u003c/em\u003e\u0026hellip;\u003cem\u003eWe have had one. She had uterine atone. The uterus just become too relaxed that it cannot even contract. So, they end up bleeding more. So even before we enter the theatre, you must secure blood and all that. So, in the absence of it, the client's life is at risk, because they have carried more than one, so the uterus is over overstretched\u003c/em\u003e (P6, fertility midwife, IVF centre 2).\u003c/p\u003e \u003cp\u003eAdditionally, providers often make recommendations based on medical considerations, aiming to balance the desire for a successful pregnancy with the potential complications of multiple births:\u003c/p\u003e \u003cp\u003e \u003cem\u003eWhenever we are doing embryo transfer, we are tight in the corner as in, when we do put only one, and it does not work I mean, we have wasted the patient time and money. So, if we put two, in case one does not work, one will stand\u003c/em\u003e\u0026hellip;\u003cem\u003eSo, for the healthy young ladies[lady], she can carry more than one foetus, she can carry two. So, in that sense, when we start antenatal, we keep on monitoring\u003c/em\u003e (P5, fertility midwife, IVF centre 1).\u003c/p\u003e \u003cp\u003eOne gynaecologist consultant at IVF centre 3 further raised concerns about some adverse effects of treatment associated with IVF treatment and the difficulty of navigating such adverse effects:\u003c/p\u003e \u003cp\u003e \u003cem\u003eWhen it comes to assessing the risk and benefit of IVF treatment, the risk of hyper ovarian stimulation and the benefit of retrieving adequate eggs, then it becomes problematic\u003c/em\u003e\u0026hellip;\u003cem\u003eif we compare the adverse effect, it gives some people\u003c/em\u003e (P3, Gynaecologist Consultant, IVF centre 3).\u003c/p\u003e \u003cp\u003eMoreover, one of the participants shared couples\u0026rsquo; experiences dealing with the emotional and psychological impact of treatment failure, including the fact that the fear of not achieving a successful pregnancy often heavily affects individuals and couples undergoing fertility treatments:\u003c/p\u003e \u003cp\u003e \u003cem\u003eYou can understand how they[couples] feel when it does not succeed, the depression, the disappointments, the economic loss, and all that\u003c/em\u003e (P1, gynaecologist consultant, IVF centre 2).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eTheme 3: Fate of surplus embryos\u003c/h2\u003e \u003cp\u003eEmbryo storage and disposal emerged as challenging ethical dilemma. The participants responded to questions related to the moral status of the embryos, the responsibility of the parents in decision-making, and the impact of choosing to discard or donate unused embryos:\u003c/p\u003e \u003cp\u003e \u003cem\u003eSo, I believe it [embryos] can be donated. I believe there should be a charity that also would be into donation of these embryos. So, if that avenue is there, that could be explored instead of just destroying them\u003c/em\u003e (P11, bioethicist).\u003c/p\u003e \u003cp\u003eSome participants believe that embryo storage should depend on the consenting couple:\u003c/p\u003e \u003cp\u003e \u003cem\u003eWhen you do the egg collection, then you need to affirm it to them [couples] that maybe the number of eggs you have got, is it more likely some will be left. You talk to them [couples] to start preparing towards freezing. Some people readily accept, others too may not want to; they say, well, you just put in what you have to put in, the rest they are not willing to store. Others may ask you to preserve it for people who want it. Others may tell you to destroy it because they do not want it\u003c/em\u003e (P1, gynaecologist consultant, IVF centre 2).\u003c/p\u003e \u003cp\u003eThe commercialization of embryos particularly raised ethical concerns among participants. They deliberated over the implications of commodifying human reproductive materials and the potential exploitation of vulnerable individuals. Ethical considerations spanned issues of affordability, consent, and the role of profit-driven entities in fertility treatment:\u003c/p\u003e \u003cp\u003e \u003cem\u003eI think this [commercialization of embryo] is something that we have to look into, you know, there should be a system in place where people are adequately informed\u003c/em\u003e (P11, bioethicist).\u003c/p\u003e \u003cp\u003e \u003cem\u003eSo, if you work around it in such a way that you adequately compensate for this without excessive profiteering, that for me, would be a good point or balance point to work things out with\u003c/em\u003e (P10, bioethicist).\u003c/p\u003e \u003cp\u003eSome participants believe that commercializing embryos should be completely avoided, while others argue that they could be subject to reasonable negotiation:\u003c/p\u003e \u003cp\u003e \u003cem\u003eSelling of embryos should not be encouraged. It feels like you are selling something that does not have to be sold, I think we should not. We can give some appreciation to the one who is giving out the embryo or the gamete, but not like prescribing a fee. We should not prescribe an amount\u003c/em\u003e (P7, fertility midwife, IVF centre 3).\u003c/p\u003e \u003cp\u003e \u003cem\u003eSelling any part of the human body has some legal consequences. But a person can receive compensation for giving out an embryo, if there is that agreement between parties\u003c/em\u003e (P12, legal practitioner).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eTheme 4: Status of the embryo\u003c/h2\u003e \u003cp\u003eParticipants debated about when personhood begins and whether embryos created during IVF should be considered as having moral or legal standing. Some participants stressed that in the decision-making process regarding the existence of a child, the child does not play an active role, and they do not inherently possess rights. Instead, the primary decision-making authority lies with the parents:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eDo you have a right before you exist? So, if the child is unborn, has the child an identity, has the child a right? What is the role of the child in coming into existence? Is it not the decision of the two parties[parents]? The child has no part to play in that. So, then where lies the right of the unborn child in doing that? It is just the decision of these two\u003c/em\u003e (P10, bioethicist).\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe unborn child has no legal status. Only the parents have. So, if that unborn child becomes a human, then they can exercise their rights\u003c/em\u003e (P12, legal practitioner).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eNevertheless, some participants acknowledged the significance of making decisions that prioritize the well-being and potential rights of the unborn child:\u003c/p\u003e \u003cp\u003e \u003cem\u003eYou have to weigh with the quality of life\u003c/em\u003e\u0026hellip;\u003cem\u003ewith the disadvantage of being born. If the risk is way beyond the minor acceptable risk, then I do not think it is reasonable to give birth to that child to come and suffer. If the risk is too much and that has to do with the quality of life for that child that is going to be born, then, to me, you have to consider the outcome\u003c/em\u003e (P11, bioethicist).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eTheme 5: Compromises in informed consent\u003c/h2\u003e \u003cp\u003eParticipants stressed the importance of offering comprehensive and comprehensible information about the proposed treatments to couples who seek IVF treatment. They believe that couples should fully grasp the potential risks, benefits, and alternatives to make informed choices about their fertility care. As participants expressed,\u003c/p\u003e \u003cp\u003e \u003cem\u003eWe have materials to aid them understand and seek their feedback from the understanding they got. Our terms and condition of payment, the risk and benefits of the treatment, the success rate and possibility of failure\u003c/em\u003e (P3, gynaecologist consultant, IVF centre 3).\u003c/p\u003e \u003cp\u003eHowever, it was noted that the acceptance of informed consent may be influenced by the specific situations and circumstances in which couples find themselves. Several factors influence the acceptance of informed consent among couples undergoing fertility treatments, such as in vitro fertilization (IVF). Psychological distress, common in this context, may hinder their ability to comprehend and accept the details, raising concerns about the validity of their consent. The couples' fertility journeys and history, shaped by past experiences, impact their trust and understanding during the informed consent process.\u003c/p\u003e \u003cp\u003e \u003cem\u003eSome people may seem to have understood. But maybe they did not because of the desperate nature of the situation. They are willing to go through anything so long as it will guarantee them pregnancy and baby\u003c/em\u003e\u0026hellip;\u003cem\u003ethose who are quite well educated understand some of the processes and all that. For those who are not educated\u003c/em\u003e\u0026hellip;\u003cem\u003egiving them instructions sometimes may not go down too well for them\u003c/em\u003e (P1, gynaecologist consultant, IVF centre 2).\u003c/p\u003e \u003cp\u003eThe complexity of medical procedures and associated risks involved in IVF treatment could also influence patient perception and acceptance, particularly for those facing greater medical complexities or potential health risks. Cultural and religious beliefs contribute significantly to perspectives on assisted reproductive technologies, affecting the acceptance or rejection of certain aspects of IVF. Educational background and varying levels of understanding among couples may affect the quality of informed consent.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eTheme 6 Difficulties in maintaining Confidentiality\u003c/h2\u003e \u003cp\u003eParticipants highlighted a need to maintain the strictest confidentiality regarding patients' personal and medical information. However, IVF treatment is performed by a multidisciplinary team of healthcare professionals, making it sometimes difficult to maintain strict confidentiality.\u003c/p\u003e \u003cp\u003e \u003cem\u003eIVF is more privacy protected because of the whole stigma from society. So, we as healthcare providers are tasked to ensure that the information of the patient is unknown to providers who are not directly caring for our clients because some providers can have big mouths\u003c/em\u003e (P7, fertility midwife, IVF centre 3).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to explore ethical concerns in the provision of in vitro fertilization (IVF) treatment in Ghana. The major themes presented demonstrated that many ethical issues confront the human reproductive technology industry in Ghana. Evidence from this study indicated that financial constraints were a major barrier to accessing IVF treatment. Other studies have emphasized that the cost of IVF treatment can be prohibitively expensive for many individuals, potentially preventing them from pursuing such treatment [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The high cost of IVF treatment is a well-documented factor and seems to be particularly impactful in the context of Ghana. The relatively lower income levels of most Ghanaians contribute to the perception that IVF treatment is a privilege rather than a readily accessible option. Economic disparities may disproportionately affect access to IVF, creating barriers for those with limited financial means. There is a need for financial support mechanisms and affordable pricing models to address inequities in access to IVF treatment.\u003c/p\u003e \u003cp\u003eThe study revealed that while some consider IVF a luxury for the wealthy, others say that the cost is justified given the intrinsic importance of having a child. This finding is consistent with previous research, which indicates that despite the initial perception of high IVF costs, the intrinsic value of having a child tends to outweigh financial expenditures [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Regardless, the cost of treatment should not be prohibitively expensive but rather represent the economic disparities in the country where it is administered. This study stresses the importance of government action and funding to increase access to fertility treatments; nevertheless, in low- and middle-income countries such as Ghana, government funding may be perceived as insufficient allocative justice [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This calls for the government to strike a balance between healthcare objectives and IVF therapy.\u003c/p\u003e \u003cp\u003eAn additional finding from the study indicated that individuals with mental health issues should not have access to IVF treatment. Although this finding is not directly stated in most of the literature, the nature of IVF treatment may exacerbate psychological issues and may not be favourable for people with mental health conditions prior to treatment. This claim is evident in the literature, implying that a negative pregnancy test is associated with an increased risk for depression in women undergoing IVF [2527]. It is also perceived that individuals with mental health conditions may be incapable of bearing the responsibility of parenting [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] and thus should not be given the chance at IVF treatment in pursuit of a child. However, this could raise ethical concerns about fairness in IVF services. Intense emotional investment in the process, coupled with potential disappointments such as failed attempts, may indeed impact the mental well-being of individuals with preexisting mental health conditions. Mental health assessments and support should be integrated into the IVF process to ensure the well-being of patients throughout their fertility journey.\u003c/p\u003e \u003cp\u003e It was noted in the findings of this study that couples are usually desperate to have their own children and may override thoughtful decision-making during the informed consent process. This finding is consistent with previous studies, including those by Frank, Mohammadzadeh, and Van-Den Akker [\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], which have all indicated that the intense desire for a biological child can complicate ethical decision-making and lead individuals to overlook potential risks associated with IVF treatment. The intense longing for a biological child creates an emotional state that may overshadow rational decision-making. This emotional intensity could stem from societal expectations, personal desires for parenthood, or cultural influences. When individuals or couples are deeply invested in the outcome of fertility treatments, they may prioritize the goal of having a child over careful consideration of the potential risks and alternatives associated with IVF. The emotional aspect might cloud the ability to fully comprehend the implications and make informed choices during the consent process. Healthcare professionals need to be adept at recognizing signs of desperation in couples undergoing IVF.\u003c/p\u003e \u003cp\u003eThe finding also showed that the desire for multiple births, coupled with the associated risks, presents a complex ethical decision-making dilemma for healthcare providers. Striking a balance between respecting patient autonomy and preventing harm poses challenges in the practice of IVF [\u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Addressing these ethical dilemmas is essential for providing responsible and patient-focused infertility treatment.\u003c/p\u003e \u003cp\u003eThere were also ethical concerns surrounding embryo storage and disposal of unused embryos. The findings of this study suggested that there are multiple opinions related to the moral status of embryos, the responsibility of parents in decision-making, and the impact of choosing to discard or donate unused embryos. Many studies suggest that the responsibility of parents in decision-making varies among clinics, with some requiring a couple's participation in disposal, some allowing but not requiring it, and some discouraging or disallowing it [\u003cspan additionalcitationids=\"CR37 CR38\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. The diverse opinions and practices regarding embryo disposal can be attributed to the complex and emotive nature of the matter. Philosophical viewpoints on the moral status of embryos likely contribute to these differences, as well as cultural, religious, and individual beliefs. Clinics may adopt varying approaches based on their ethical frameworks, legal considerations, and perhaps the absence of standardized guidelines in this sensitive area. The varying opinions on embryo storage and disposal also highlight the need for clear guidelines and open communication between patients and providers. Clinics should have policies that respect the preferences of patients while adhering to ethical standards.\u003c/p\u003e \u003cp\u003eThe findings also revealed a diversity of opinions on the commercialization of embryos, with some advocating total avoidance, while others suggesting that it may be acceptable with appropriate compromise. The literature highlights arguments against embryo commercialization, citing moral, scientific, and human rights concerns, as well as potential conflicts of interest and prioritization of financial gain in IVF involving profit-driven entities [\u003cspan additionalcitationids=\"CR41\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. These sources, likely representing a broader body of literature, emphasize ethical, moral, and human rights issues associated with the commercialization of embryos. The concerns about conflicts of interest and the role of profit-driven entities in IVF align with prior discussions in the field. This finding reflects the ongoing debate within the scientific and ethics communities regarding the commercialization of embryos. The opposition to embryo commercialization is likely rooted in moral and ethical considerations, such as the sanctity of human life, potential exploitation, and concerns about the commodification of embryos. Additionally, the apprehension about profit-driven entities in IVF reflects worries about the potential compromise of medical decision-making for financial gains. These findings underscore a need for careful regulation of embryo commercialization. The concerns raised, including conflicts of interest and prioritization of financial gain, highlight potential risks associated with uncontrolled commercialization. Advocating for adequate, worldwide, and tolerant control of embryo commercialization has become crucial for addressing these ethical, moral, and financial considerations [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Implementing robust laws and regulations can help strike a balance between technological advancement and safeguarding against potential ethical lapses in the realm of assisted reproductive technologies.\u003c/p\u003e \u003cp\u003eThe findings of this study should be interpreted with certain limitations in mind. The sample size was relatively small (12 participants). While qualitative research often involves smaller samples, the findings may not be generalizable to a broader population. Additionally, the participants were healthcare professionals involved in IVF, which may limit the diversity of perspectives, as patients or individuals from diverse backgrounds may have provided a more comprehensive view of the subject. Finally, the use of descriptive-focused coding for thematic analysis may have limited the depth of the analysis. It may also not have captured more nuanced or abstract themes that could emerge from the data.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights the many ignored facets of in vitro fertilization treatment in low-income setting settings. The findings contribute to the existing body of knowledge on reproductive ethics and as well provide practical insights and recommendations that can guide policy and practice in Ghana. Moving forward, there is urgent need for all stakeholders to come together to develop clear and uniform regulations to govern the practice of IVF treatment in Ghana, with further attention given to mitigating financial barriers and enhancing support systems for couples considering IVF.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIVF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIn vitro fertilization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eART\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAssisted reproductive technology\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Noguchi Memorial Institute for Medical Research–Institutional Review Board (NMIMR-IRB) gave ethical approval for this study (approval # CPN 014/23-24, valid from 2\u003csup\u003end\u003c/sup\u003e August to 1\u003csup\u003est\u003c/sup\u003e August 2024). The study procedures adhered to the ethical principles of\u0026nbsp;the\u0026nbsp;Declaration of Helsinki. Written informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author\u0026nbsp;upon\u0026nbsp;reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research did not receive funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDA\u0026nbsp;was\u0026nbsp;fully responsible for conceptualization,\u0026nbsp;data analysis,\u0026nbsp;and\u0026nbsp;writing\u0026nbsp;of\u0026nbsp;the initial draft.\u003c/p\u003e\n\u003cp\u003eJKG\u0026nbsp;was\u0026nbsp;responsible for reviewing, editing,\u0026nbsp;and managing the research project.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author wishes to acknowledge Regina Appiah, a\u0026nbsp;scrub nurse\u0026nbsp;at the Obstetrics/Gynaecology\u0026nbsp;Theatre\u0026nbsp;at\u0026nbsp;the\u0026nbsp;University of Ghana Medical Centre,\u0026nbsp;for her valuable suggestions and unwavering support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1 Graduate Student, Department of Population Family and Reproductive Health, University of Ghana.\u003c/p\u003e\n\u003cp\u003e2 Associate Professor, Department of Population Family and Reproductive Health, University of Ghana.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDonkor ES, Naab F, Kussiwaah DY. \u0026ldquo;I am anxious and desperate\u0026rdquo;: psychological experiences of women with infertility in The Greater Accra Region, Ghana. 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How phenomenology can help us learn from the experiences of others. Perspectives on medical education. 2019 Apr; 8: 90-7.\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Reflecting on reflexive thematic analysis. Qualitative research in sport, exercise and health. 2019 Aug 8; 11(4): 589-97.\u003c/li\u003e\n\u003cli\u003eMaeda E, Jwa SC, Kumazawa Y, Saito K, Iba A, Yanagisawa‑Sugita A, Kuwahara A, Saito H, Terada Y, Fukuda T, Ishihara O. Out-of-pocket payment and patients\u0026rsquo; treatment choice for assisted reproductive technology by household income: a conjoint analysis using an online social research panel in Japan. BMC Health Services Research. 2022 Aug 27; 22(1): 1093. https://doi.org/10.1186/s12913-022-08474-5 \u003c/li\u003e\n\u003cli\u003eBarbagallo F, Cannarella R, Crafa A, La Vignera S, Condorelli RA,Manna C, Calogero AE. The impact of a very short abstinence period on assisted reproductive technique outcomes: A systematic review and meta-analysis. Antioxidants. 2023 Mar 20; 12(3): 752. https://doi.org/10.3390/antiox12030752\u003c/li\u003e\n\u003cli\u003eNachtigall RD, MacDougall K,Davis AC, Beyene Y. Expensive but worth it: older parents\u0026rsquo; attitudes and opinions about the costs and insurance coverage for in vitro fertilization. Fertility and sterility. 2012 Jan 1; 97(1): 82-7. https://doi.org/10.1016/j.fertnstert.2011.10.019\u003c/li\u003e\n\u003cli\u003eConnolly M, Gallo F, Hoorens S, Ledger W. Assessing long-run economic benefits attributed to an IVF-conceived singleton based on projected lifetime net tax contributions in the UK. Human Reproduction. 2009 Mar 1; 24(3): 626-32. https://doi.org/10.1093/humrep/den435\u003c/li\u003e\n\u003cli\u003eMargalit Y. Scarce medical resources\u0026ndash;parenthood at every age, in every case and subsidized by the State? [Internet]. 2014. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2449979 Accessed on 14 April 2023.\u003c/li\u003e\n\u003cli\u003eVolgsten H, Svanberg AS, Ekselius L, Lundkvist \u0026Ouml;, Poromaa IS. Risk factors for psychiatric disorders in infertile women and men undergoing in vitro fertilization treatment.Fertility and Sterility. 2010 Mar 1; 93(4): 1088-96. https://doi.org/10.1016/j.fertnstert.2008.11.008\u003c/li\u003e\n\u003cli\u003eYli-Kuha AN, Gissler M, Klemetti R, Luoto R, Koivisto E, Hemminki E. Psychiatric disorders leading to hospitalization before and after infertility treatments. 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Parental psychiatric disorder: Distressed parents and their families.Cambridge University Press; 2015 Jul 9.\u003c/li\u003e\n\u003cli\u003eFrank C. \u0026lsquo;I Want a Child!\u0026rsquo;Concerning Problems of Informed Consent in Fertility Treatment.Psychoanalytic Psychotherapy. 2007 Jun 1; 21(2): 150-67.\u003c/li\u003e\n\u003cli\u003eMohammadzadeh E. P151: Emotional Disorders and Anxiety During IVF-Treatment. The Neuroscience Journal of Shefaye Khatam. 2014 Sep 10; 2(3): 175.\u003c/li\u003e\n\u003cli\u003evan den Akker O. Emotional and psychosocial risk associated with fertility treatment. Reducing risk in fertility treatment. 2015: 79-96. https://doi.org/10.1007/978-1-4471-5257-6_5 \u003c/li\u003e\n\u003cli\u003eEmery M.Which issues concerning multiple pregnancies should be addressed during psychosocial counselling?. Reproductive BioMedicine Online. 2007 Jan 1;15: 18-21.\u003c/li\u003e\n\u003cli\u003eKaur N, Ricciardelli R. Negotiating risk and choice in multifetal pregnancies.Social Science\u0026amp;Medicine. 2020 May 1; 252: 112926.\u003c/li\u003e\n\u003cli\u003eRyan GL, Zhang SH, Dokras A, Syrop CH, Van Voorhis BJ. The desire of infertile patients for multiple births. Obstetrical \u0026amp; gynecological survey. 2004 Aug 1; 59(8): 592. https://doi.org/10.1016/j.fertnstert.2003.05.035\u003c/li\u003e\n\u003cli\u003eGurmankin AD, Sisti D, Caplan AL. Embryo disposal practices in IVF clinics in the United States. Politics and the Life Sciences. 2003 Sep; 22(2): 4-8. https://doi.org/10.1017/S0730938400006614\u003c/li\u003e\n\u003cli\u003eFrith L, Blyth E, Paul MS, Berger R. Conditional embryo relinquishment: choosing to relinquish embryos for family-building through a Christian embryo\u0026lsquo;adoption\u0026rsquo;programme. Human Reproduction. 2011 Dec 1;26(12): 3327-38. https://doi.org/10.1093/humrep/der313\u003c/li\u003e\n\u003cli\u003eCorley SO,Berg JW.Embryo Donation:Ethical Issues.Third-Party Reproduction:A Comprehensive Guide.2014:121-9. https://doi.org/10.1007/978-1-4614-7169-1_12\u003c/li\u003e\n\u003cli\u003eGoedeke S, Daniels K, Thorpe M, Du Preez E. The fate of unused embryos: discourses, action possibilities, and subject positions. Qualitative Health Research.2017 Aug; 27(10): 1529-40. https://doi.org/10.1177/1049732316686759\u003c/li\u003e\n\u003cli\u003eBalakrishnan P, Balu N. Commercialisation of human embryos and Stem Cells. International journal of health sciences. 2022 Apr 14; 4703\u0026ndash;16. https://doi.org/10.53730/ijhs.v6nS1.5896\u003c/li\u003e\n\u003cli\u003eLegge M, Fitzgerald R. Valuing embryos as both commodities and singularities. The New Zealand Medical Journal(Online). 2016 Mar 11; 129(1431): 80.\u003c/li\u003e\n\u003cli\u003eFox D. Paying for particulars in people-to-be: commercialisation, commodification and commensurability in human reproduction.Journal of Medical Ethics. 2008 Mar 1; 34(3): 162-6.\u003c/li\u003e\n\u003cli\u003eAnton R. On the future advances in engineering and in-vitro culture of human embryos[Internet]. 2016 https://mpra.ub.uni-muenchen.de/id/eprint/71450 Accessed 13 March 2023.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-ethics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meth","sideBox":"Learn more about [BMC Medical Ethics](http://bmcmedethics.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meth/default.aspx","title":"BMC Medical Ethics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Assisted reproductive technologies, Commercialization of embryos, Informed consent, In vitro fertilization treatment, Reproductive ethics","lastPublishedDoi":"10.21203/rs.3.rs-4693060/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4693060/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eInfertility presents both medical and public health challenges, with in vitro fertilization (IVF) emerging as a prominent solution, particularly when other alternatives are exhausted. However, IVF treatment raises significant ethical questions that have been under explored in the Ghanaian context. This study aimed to explore ethical concerns regarding the provision of in vitro fertilization (IVF) treatment in Ghana.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA phenomenological descriptive qualitative design was employed. Purposive sampling techniques were used to recruit 12 participants from three in vitro fertilization (IVF) centres. In-depth face-to-face interviews guided by an open-ended interview guide were conducted. Thematic analysis of the interviews was performed to identify major themes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eProviding IVF in Ghana raises several ethical issues, including inequitable access due to high costs and limited availability, which favour wealthier individuals and leave marginalized populations with fewer options. There are significant ethical considerations in balancing the potential benefits of successful IVF outcomes against the health risks and emotional tolls on patients. Decisions about the fate of surplus embryos present moral dilemmas, including whether to preserve, donate, or discard them. Differing personal beliefs about the moral status of the embryo further complicate the ethical landscape. Ensuring informed consent is challenging due to the complex medical, ethical, and emotional implications of IVF, potentially leading to compromised consent. Additionally, there are ongoing risks of breaches in confidentiality, given the sensitive nature of reproductive health data and the importance of protecting patient privacy.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study revealed that several ethical dilemmas confront both healthcare providers and couples in the process of IVF. There is an urgent need for the development of clear and uniform regulations to govern the practice of IVF treatment in Ghana, with further attention given to mitigating financial barriers and enhancing support systems for couples considering IVF.\u003c/p\u003e","manuscriptTitle":"Ethical concerns in the provision of in vitro fertilization treatment in Ghana: A qualitative study.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-05 06:31:06","doi":"10.21203/rs.3.rs-4693060/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-12T05:42:16+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-09T15:36:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-04T03:52:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"317648063363079468239830758003357536277","date":"2024-07-26T20:04:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"24142800916258656009193565738984870000","date":"2024-07-11T11:05:30+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-11T10:41:11+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-07-11T06:27:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-11T06:22:30+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-11T06:22:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Ethics","date":"2024-07-05T14:57:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-ethics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meth","sideBox":"Learn more about [BMC Medical Ethics](http://bmcmedethics.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meth/default.aspx","title":"BMC Medical Ethics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c0e5375f-343d-477e-bdb6-5b055e26c9e0","owner":[],"postedDate":"August 5th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-21T16:02:34+00:00","versionOfRecord":{"articleIdentity":"rs-4693060","link":"https://doi.org/10.1186/s12910-024-01113-0","journal":{"identity":"bmc-medical-ethics","isVorOnly":false,"title":"BMC Medical Ethics"},"publishedOn":"2024-10-17 15:57:45","publishedOnDateReadable":"October 17th, 2024"},"versionCreatedAt":"2024-08-05 06:31:06","video":"","vorDoi":"10.1186/s12910-024-01113-0","vorDoiUrl":"https://doi.org/10.1186/s12910-024-01113-0","workflowStages":[]},"version":"v1","identity":"rs-4693060","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4693060","identity":"rs-4693060","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}