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Assisted Reproductive Technology by Jerri Rowe, MS Overview Setting the Stage: Questions to Think About Assisted Reproductive Technology (ART) is the technology that can be used to help men and women have children. There have been many scientific advances affecting ART in recent years. These new advances have also added to the ethical dilemmas associated with Assiated Reproductive Technology. Are the increased medical risks to women undergoing ART therapies worth it? Once an embryo is created, does it have moral status as a human being or is it just someone's property? What happens to an embryo if the "parents" divorce or one of them dies? Is there an age when men and women are simply too old to become parents? Introduction Assisted Reproductive Technology (ART) is the technology developed to aid in the conception of children. Women or men who are unable to have children due to some physical limitation (infertility) can be helped with one of the several methods of ART. Infertility is defined as the inability to conceive for a one-year or greater period or a period of 6 months if a woman is over 35. Also included in the definition is the inability to carry the baby to term or having had 2 or more miscarriages in the past. Recent statistics show that infertility has been diagnosed in approximately 17% of all couples. The reasons for infertility vary and can be seen in both males and females. The most common causes of infertility in males are low sperm count, immobile sperm, previous STDs (sexually transmitted diseases), prostate infection or testicular injury. For women, causes of infertility are various and include problems with ovulation, blocked fallopian tubes, previous STDs, polyps or fibroids, endometriosis, previous IUD (intrauterine device used for contraception), infections and age (over 35). There is also 5 - 10% rate of unexplained infertility. There are several different approaches to ART depending upon the physical needs and/or difficulties assessed. Artificial insemination is the procedure that positions sperm that has been previously treated either into the cervical canal, the uterus, the fallopian tubes or the ovarian follicle by mechanical means such as the use of a syringe. The most common form of artificial insemination is intrauterine insemination (IUI). IUI is usually done in the office setting and takes just a few minutes. A catheter is inserted through the vagina and into the uterine cavity where the sperm are injected. Unlike in vitro fertilization the physician cannot immediately tell if fertilization has taken place and the woman is pregnant. In vitro fertilization (IVF) is the process of combining an egg with sperm in a petri dish where fertilization takes place. (The success ate is approximately 20% to 25%). This process results in an embryo. The embryo is then implanted into the woman's uterus via a non-surgical vaginal approach. All forms of in vitro fertilization require preparation of the woman and sometimes the sperm and eggs. To prepare for IVF the woman is first stimulated into ovulation through the use of hormones. Then the eggs are retrieved either vaginally or through laparoscopic surgery. Fertilization then takes place in the lab (Petri dish). After fertilization the embryo is transferred into the uterus. Another form of IVF is gamete intrafallopian transfer (GIFT). As in IVF the woman is given fertility medication to stimulate egg production after which the eggs are retrieved. The sperm is also collected from the man as in IVF. Then sperm and egg are surgically placed into the fallopian tube of the woman where hopefully fertilization will occur. Zygote intrafallopian transfer (ZIFT) occurs much like IVF and GIFT in the preparatory phases. However, the difference is that with ZIFT a zygote, which is a fertilized egg at the 2-cell stage, is transferred into fallopian tubes. Intracytoplasmic sperm injection (ICSI) is used when there is severe male infertility. This procedure uses microscopic instrumentation to fertilize a specially prepared egg with one sperm. The fertilized embryo is then transferred into the uterus of the woman as in IVF. There are several more variations of assisted reproduction. However, the purpose here is only to inform the discussion. The rapid rate of new scientific technology brings with it new ethical dilemmas. Ethical questions that affect ART are the subject of this module. A few scenarios that will be shared that will engage you in critical thinking regarding a subject that most, at some point in their life, will encounter, either personally or anecdotally. There have been several studies that have presented information on increased medical risks to women undergoing ART therapies and pregnancies as well as increased risk of low birth weight and disease for infants. The question can be asked whether it is morally acceptable to subject families to this increased risk of harm with insufficient scientific data on reproductive technologies available? One can also ask if patients are not fully aware of all risks can a truly informed consent be made. On the other hand, nearly 20% of couples currently feel the anguish, shame, and frustration of not being able to get pregnant. With the technology available since 1978 is it cruel not to grant access to those who need ART to further their quest for biological children of their own? The list of ethical concerns grows when donors are used in ART. With young women being paid $5,000 - $10,000 per ovulation cycle sale of human eggs is becoming a booming business. Some additional questions to ask are: • Will this lead to exploitation of young, low-income women? • What are the long-term effects of multiple cycles of hormonal treatment and egg retrieval? • Once embryos are made do they have moral status or do they become property? • What are the legal implications of divorce or death on embryos in storage? Whose rights take precedence husband or wife? Women who are past the physical childbearing age can now use ART to become impregnated. Recently women in their 60s have delivered babies and begun their roles as parents. To date, the oldest woman to give birth is 66 years old. In these cases opinions greatly differ on questions such as: • Is 60 too old for a woman to give birth? • Is it too old for a man to become a father? • Is this a chance of a lifetime for a woman who has been unable to give birth until now? • Will the current trend of postponing childbearing and thereby increasing age gap affect society as a whole? If so, how? If not, why not? These concerns and many more have come up as there are now over 3 million ART babies since the birth of the first test-tube baby, Louise Brown, in 1978. Answers are coming slowly, mostly on a case-by-case basis as these issues arrive in the legal system. Some see regulation as an answer to some of the current ethical dilemmas; fertility centers are currently not regulated in the U.S. Most centers only undergo self-monitoring on guidelines given by organizations such as ASRM (The American Society for Reproductive Medicine). There are also those who feel that government interference will only hold back the practice of medicine and scientific progress in the area of ART. As current high school students you soon will likely aid in the process of defining or redefining the ethics of ART.

Assisted Reproductive Technology

by Jerri Rowe, MS

Overview

Setting the Stage: Questions to Think About

Assisted Reproductive Technology (ART) is the technology that can be used to help men and women have children. There have been many scientific advances affecting ART in recent years. These new advances have also added to the ethical dilemmas associated with Assiated Reproductive Technology.

Are the increased medical risks to women undergoing ART therapies worth it?

Once an embryo is created, does it have moral status as a human being or is it just someone's property?

What happens to an embryo if the "parents" divorce or one of them dies?

Is there an age when men and women are simply too old to become parents?

Introduction

Assisted Reproductive Technology (ART) is the technology developed to aid in the conception of children. Women or men who are unable to have children due to some physical limitation (infertility) can be helped with one of the several methods of ART. Infertility is defined as the inability to conceive for a one-year or greater period or a period of 6 months if a woman is over 35. Also included in the definition is the inability to carry the baby to term or having had 2 or more miscarriages in the past. Recent statistics show that infertility has been diagnosed in approximately 17% of all couples.

The reasons for infertility vary and can be seen in both males and females. The most common causes of infertility in males are low sperm count, immobile sperm, previous STDs (sexually transmitted diseases), prostate infection or testicular injury. For women, causes of infertility are various and include problems with ovulation, blocked fallopian tubes, previous STDs, polyps or fibroids, endometriosis, previous IUD (intrauterine device used for contraception), infections and age (over 35). There is also 5 - 10% rate of unexplained infertility.

There are several different approaches to ART depending upon the physical needs and/or difficulties assessed. Artificial insemination is the procedure that positions sperm that has been previously treated either into the cervical canal, the uterus, the fallopian tubes or the ovarian follicle by mechanical means such as the use of a syringe. The most common form of artificial insemination is intrauterine insemination (IUI). IUI is usually done in the office setting and takes just a few minutes. A catheter is inserted through the vagina and into the uterine cavity where the sperm are injected. Unlike in vitro fertilization the physician cannot immediately tell if fertilization has taken place and the woman is pregnant.

In vitro fertilization (IVF) is the process of combining an egg with sperm in a petri dish where fertilization takes place. (The success ate is approximately 20% to 25%). This process results in an embryo. The embryo is then implanted into the woman's uterus via a non-surgical vaginal approach. All forms of in vitro fertilization require preparation of the woman and sometimes the sperm and eggs. To prepare for IVF the woman is first stimulated into ovulation through the use of hormones. Then the eggs are retrieved either vaginally or through laparoscopic surgery. Fertilization then takes place in the lab (Petri dish). After fertilization the embryo is transferred into the uterus.

Another form of IVF is gamete intrafallopian transfer (GIFT). As in IVF the woman is given fertility medication to stimulate egg production after which the eggs are retrieved. The sperm is also collected from the man as in IVF. Then sperm and egg are
surgically placed into the fallopian tube of the woman where hopefully fertilization will occur. Zygote intrafallopian transfer (ZIFT) occurs much like IVF and GIFT in the preparatory phases. However, the difference is that with ZIFT a zygote, which is a fertilized egg at the 2-cell stage, is transferred into fallopian tubes.
Intracytoplasmic sperm injection (ICSI) is used when there is severe male infertility. This procedure uses microscopic instrumentation to fertilize a specially prepared egg with one sperm. The fertilized embryo is then transferred into the uterus of the woman as in IVF. There are several more variations of assisted reproduction. However, the purpose here is only to inform the discussion.

The rapid rate of new scientific technology brings with it new ethical dilemmas. Ethical questions that affect ART are the subject of this module. A few scenarios that will be shared that will engage you in critical thinking regarding a subject that most, at some point in their life, will encounter, either personally or anecdotally.

There have been several studies that have presented information on increased medical risks to women undergoing ART therapies and pregnancies as well as increased risk of low birth weight and disease for infants. The question can be asked whether it is morally acceptable to subject families to this increased risk of harm with insufficient scientific data on reproductive technologies available? One can also ask if patients are not fully aware of all risks can a truly informed consent be made. On the other hand, nearly 20% of couples currently feel the anguish, shame, and frustration of not being able to get pregnant. With the technology available since 1978 is it cruel not to grant access to those who need ART to further their quest for biological children of their own?

The list of ethical concerns grows when donors are used in ART. With young women being paid $5,000 - $10,000 per ovulation cycle sale of human eggs is becoming a booming business. Some additional questions to ask are:

• Will this lead to exploitation of young, low-income women?
• What are the long-term effects of multiple cycles of hormonal treatment and egg retrieval?
• Once embryos are made do they have moral status or do they become property?
• What are the legal implications of divorce or death on embryos in storage? Whose rights take precedence husband or wife?

Women who are past the physical childbearing age can now use ART to become impregnated. Recently women in their 60s have delivered babies and begun their roles as parents. To date, the oldest woman to give birth is 66 years old. In these cases opinions greatly differ on questions such as:

• Is 60 too old for a woman to give birth?
• Is it too old for a man to become a father?
• Is this a chance of a lifetime for a woman who has been unable to give birth until now?
• Will the current trend of postponing childbearing and thereby increasing age gap affect society as a whole? If so, how? If not, why not?

These concerns and many more have come up as there are now over 3 million ART babies since the birth of the first test-tube baby, Louise Brown, in 1978. Answers are coming slowly, mostly on a case-by-case basis as these issues arrive in the legal system. Some see regulation as an answer to some of the current ethical dilemmas; fertility centers are currently not regulated in the U.S. Most centers only undergo self-monitoring on guidelines given by organizations such as ASRM (The American Society for Reproductive Medicine). There are also those who feel that government interference will only hold back the practice of medicine and scientific progress in the area of ART. As current high school students you soon will likely aid in the process of defining or redefining the ethics of ART.