controversies in in-vitro fertilization

Controversies in

D r . H e n r y O s a z u w a

C o n s u l t a n tO b s t e t r i c i a n / G y n e c o l o g i s t

I n - V i t r o F e r t i l i z a t i o n

Introduction

Societies are b u i l t & r e n e w e d b y c h i l d b i r t h – Challenges the very structure of society.

Private sector driven, at a p a c e f a s t e r t h a n l e g a l , e t h i c a l & r e l i g i o u s changes.

10 - 15 % of couples are infertile.

Nigeria – m a y b e u p 2 5 % (post-infection causes are significant)

IVF (+ ET) is a subset of ART treatment (It will be used inter-changeable) .

A y o u n g a n d ra p i d l y e v o l v i n gbranch of medicine.

Pioneered by Patrick S te p to e and Ro b e r t Ed w a r d s , with the birth Louis

Brown in 1978 England

Ev i d e n c e for interventions are

e m p i r i c a l to some extent.

More than 5 m i l l i o n I V F ( A C T ) B i r t h s .

5 m i l l i o n I V F ( A C T ) B i r t h s .

M o r e t h a n t h e p o p u l a t i o n o f

L iber ia .

A t i m e l y to p i c – i s s u e a re ge a r i n g t o b o i l o ve r !

1. Genetic engineering.

2. Therapeutic cloning.

3. Stem cell research

Massive test for our C h r i s t i a n b e l i e f s , e t h i c s and s c i e n t i f i c m o r a l s .

“ T h e c a t a m o n g t h e

p i ge o n s ”

Po o r i n N i ge r i a .

Re g u l a t i o n o f A s s i s te d Re p r o d u c t i v e te c h n o l o g i e s

“ Re g u l a t o r y f ra m e wo r k fo r fe r t i l i t y t re a t m e n t i n t h e c o u n t r y h a d c o n t i n u a l l y p u t

c o u p l e s i n n e e d o f I V F o n t h e

v u l n e r a b l e e d g e ” .

The defunct Fertility Society of Nigeria has been replaced by the newly registered

Association of Fertility and Reproduction of Nigeria (AFRN).

P r o f . G i w a - O s a g i e

Most guidelines are based on regulatory bodies in E u r o p eand A m e r i c a .

Re g u l a t i o n o f A s s i s te d Re p r o d u c t i v e te c h n o l o g i e s

Overview of ACT procedures

I n d i c a t i o n s

Traditionally for tubal disease

Unexplained Infertility

Male factor infertility

Failed Ovulation induction

PGD/PGS – Sickle cell disease; Down’s syndrome

Sex selection

Assisted Reproductive Technologies

Involves all fertility treatments in which there is m a n i p u l a t i o n o f B OT H e g g s a n d s p e r m

I V F + E T, I C S I , Z I F T, G I F T (Excludes Intra-uterine Insemination -

IUI).

Typical IVF cycle

Pituitary suppression (GnRH agonist/antagonist) – P r e v e nt s L H S U R G E .

LH surge - Final follicular maturation; Ovulation and Luteinization of the Graaffian follicular.

Controlled Ovarian Hyper-stimulation P i t u i ta r y s u p p r e s s i o n

G o n a d o t r o p i n s

Oocyte Retrieval

Embryo Transfer

C o n t ro l l e d O va r i a n H y p e r - s t i m u l a t i o n

Oocyte retrieval

Suction D e v i c e

Trans-Vaginal Ultrasound

G u i d a n c e

I n s e m i n a t i o n - F e r t i l i z a t i o n

IVF/ ICS/PGD/PGS

Embryos – C l e ava g e s ta g e Embryos – B l a s to c y s t

Embryo transfer

Embryos loaded in a P i p e tte Tra n s fe r r e d

Cryo-preservation – liquid Nitrogen; - (minus) 196 oC

S u s p e n d i n g l i f e ! Increases the c u m u l a t i v e p r e g n a n c y ra te .

Eliminates the need for r e p e a te d s t i m u l a t i o n a n d e g g r e t r i e va l .

Makes it more c o s t e f fe c t i v e for the couple

N o d e t r i m e nta l e f fe c t s on embryo or negative

peri-natal outcome or infant morbidity.

The longer they preserved the more the problems –

D i v o rc e , d e a t h a n d l a b o ra to r y e r r o r s .

ComplicationsO C R – Bleeding or pelvic Infection.

Anaesthetic complications.

Tr e a t m e nt o u tc o m e – Multiple pregnancy.

H o r m o n a l m e d i c a t i o n – Mood swings, Headache, weight gain, Breast tenderness, Abdominal pain, Diarrhoea, Nausea

O va r i a n H y p e r - S t i m u l a t i o n Sy n d r o m e ( O H S S ) - Rare (0.1 – 0.2%).

A Template for addressing CONTROVERSIES

M e d i c a l .

S o c i o - E c o n o m i c

Et h i c a l

L e ga l

Re l i g i o u s / C u l t u ra l

I s s u e s a r e c o m p l e x & I n t e r - r e l a t e d .

Medical issuesR i s k fo r O va r i a n C a n c e r .

Pregnancy BreastfeedingOCPEarly menopause

Use of G n R H A g o n i s t o r A nta g o n i s t .

Increased risk of problems in A R T PREGNANCIES – Singleton.

Associated with reduced risk for ovarian malignancy Frequent ovulation and ovarian stimulation can potentially Increase the risk for ovarian malignancy.

The evidence base is weak

I V F & M y o m e c to my ( F i b r o i d s u r g e r y ) ; Tu b a l s u r g e r y ; which comes first.

I n - v i t r o M a t u ra t i o n – Poor responders.

L u te a l p h a s e s u p p o r t – Progestogen; prednisolone; Low dose Aspirin.

Social/Economic issues

Can the IVF be available to all?

Economic impact of Multiple IVF births

Embryonic research affects the way society looks at children and future of cloning.

Ethical issuesBlend with Religious fears!

Couples living with Retroviral infection (HIV)

Treatment of Unmarried couples – Fate of the child when there is breakup of the

union with no conclusive agreement

Sex selection

The premium placed on a particular gender is high.

Family balancing.

Single women; same sex couples.

Legal issues

The legal s ta t u s o f t h e c h i l d r e n – Donor gametes

Rights of the parents – D o n a t e d g a m e t e s ; S u r r o g a c y .

Rights of unc la imed embryos .

M i xe d legal system

English common law

Islamic law

Traditional law

Religion and IVF

“The way in which people negotiate their prosperity in relation to the POWERS that bear

down upon and sustain them”

Religion

F a m i l y f o r m a t i o n is central to this religious project (Infertility can be seen

as a r e l i g i o u s c r i s i s ).

IVF (ART) can be seen generally as p r o m o t i n g f a m i l y f o r m a t i o n and relief of infertility.

Surrogacy arrangements introduce a t h i r d p a r t y t o t h e r e l a t i o n s h i p as well as t h e c h i l d i n t o a c o m m o d i t y .

M u t u a l i t y and E x c l u s i v i t y of MARRIAGE is an image of the True God.

Medical intervention in procreation defaces this image when f e r t i l i z a t i o n r o u t i n e l y t a k e s p l a c e i n t h e a b s e n c e o f t h e c o u p l e ( Severing of the connection between conjugate act and procreation) .

Donated gametes and embryos introduce a t h i r d p a r t y t o t h e r e l a t i o n s h i p ( donor other than the husband/wife – removing reproduction from the marital context) . Some allow IVF games are not donated.

Destruction of embryos

M i g r a t i o n o f c o n s c i o u s n e s s

E n s o u l m e n t

C r y o p r e s e r v a t i o n – F r e e z i n g / T h a w i n g i n c r e a s e s r i s k o f e m b r y o d e m i s e .

D e s t r u c t i o n o f u n u s e d e m b r y o s –T a n t a m o u n t t o M U R D E R .

S e x s e l e c t i o n

P r e - i m p l a n t a t i o n G e n e t i c

D i a g n o s i s

S t e m c e l l r e s e a r c h

I n v o l v e s t h e k i l l i n g o f a n

i n n o c e n t p e r s o n s

“Generationist” Doctrine

M i g r a t i o n o f c o n s c i o u s n e s s

E n s o u l m e n t S e e s P E R S O N H O O D a s s o m e t h i n g t h a t

develops more gradual ly ,

a l l o w i n g f o r l e g i t i m a t e d e s t r u c t i o n o f

e m b r y o s f o r I N F E R T I L I T Y t r e a t m e n t o f

r e s e a r c h .

A f t e r ; 1 4 d a y s ; 2 0 w e e k s ; 2 8 w e e k s & t e r m ( 3 7 w e e k s ) .

Conclusion

Infertility is a significant problem

ART is a credible treatment option

Inter vent ions i s at the heart of human or ig in and creat ion of fami l ies

Controversies are huge and will persist for a long time

Omega 3 debate

I n t h e s c i e n t i f i c c o m m u n i t y,

e v e r y t h i n g i s right , u n t i l

t h e y a r e n o l o n g e r right .

The catholic church

H u m a n s e x u a l i t y h a s t w o c o m p o n e n t s , t h e

u n i t i v e a n d p r o c r e a t i v e ; I V F

s e p a r a t e s t h e s e c o m p o n e n t s a n d m a k e s t h e p r o c r e a t i v e i t s o n l y g o a l .

“ i n s e p a r a b l e c o n n e c t i o n , w i l l e d b y G o d ,

a n d u n a b l e t o b e b r o k e n b y m a n o n h i s o w n

i n i t i a t i v e , b e t w e e n t h e t w o

m e a n i n g s o f t h e c o n j u g a l a c t . . .”

P o p e P i u s I V

www.cmda .org

References