Reproductive Technology

1. Reproductive Technology

2. Assisted Reproduction When a couple is sub-fertile or infertile they may need Assisted Reproduction to become pregnant: • Replace source of gametes • Sperm, oocyte or zygote donors • Aid in the fertilization process • Replace the uterus • Surrogate mothers • Treat cause of infertility

3. Top 7 Ways to Make a BabyUsing Assisted Reproductive Technology • Artificial insemination -- of mother with father's sperm • Artificial insemination -- of mother with donor sperm • In vitro fertilization (IVF) -- using egg and sperm of parents • IVF -- with Intra-Cytoplasmic Sperm Injection (ICSI) • IVF -- with frozen embryos • GIFT – Gamete Intrafallopian transfer • ZIFT – Eggs combined with sperm and placed in fallopian tubes

4. Artificial Insemination • Artificial insemination: Introducing semen into the uterus or oviduct by other than natural means.

5. In Vitro Fertilization • In vitro fertilization: Taking eggs from a woman, fertilizing them in the laboratory with a man's sperm, and returning the resulting embryos to her uterus several days later.

6. Intra-cytoplasmic sperm injection - is a lab procedure to help infertile couples undergo in vitro fertilization due to male factor infertility. Intra-Cytoplasmic Sperm Injection

7. Eggs are combined with partner’s sperm in a dish and then taken to a lab They are surgically injected into your fallopian tubes using a laparoscope Fertilization then occurs inside your body and the embryo implants naturally. Gamete Intrafallopian Transfer(GIFT)

8. Zygote Inrafallopian Transfer(ZIFT) • The eggs are mixed with partner’s sperm, and then they are surgically place in your fallopian tubes. • But then your doctor will wait until fertilization occurs to place the embryos inside you.

9. Frozen embryos: Specialists may freeze additional embryos from a woman's cycle for later use. They may also freeze embryos of a donor in order to have them ready to place in a surrogate mother's uterus at the appropriate moment in the surrogate's natural or hormone-replaced cycle. Frozen Embryos

10. ART Procedures

11. Infertility • Clinically defined as inability to conceive after more than one year of intercourse without contraception • World Health Organization • Defines sub-fertility as diminished ability to conceive • Infertility as complete inability to ever conceive • Personally • Means changing your entire life plan

12. Infertility Statistics • Affects about 1 in 6 couples in USA • Cause can be identified in about 85% of cases • Can be treated successfully in about 85 – 90 % of couples • Problem in female – 50% • Problem in male – 30% • Problem in both partners – 20%

13. Male Infertility Problems: • Oligospermia – low sperm count • Caused by: hormones, environment, physical • Poor sperm quality • Motility – sperm can’t swim • Abnormality – sperm are abnormally shaped • Antibodies against own sperm • Autoimmune disorder

14. Genetics of Male Infertility • Oligospermia – low sperm count • Genes: hormones, Y chromosome abnormalities, testicular/prostrate development • Environment: drugs, toxins, heat (kills) • Poor sperm quality • Genes: hormones, enzymes to harness energy • Environment: drugs, toxins, heat (mutates) • Antibodies against own sperm • Genes: Immune system malfunctioning

15. Treatment of Male Infertility • Primary – change environment • Avoid heat, drugs, toxins • Timing intercourse • Secondary – correct hormone levels, surgery corrects physical problems, immune suppressants • Final – Assisted Reproduction Technologies

16. Female Infertility Problems: • Irregular/malfunctioning ovulation • Hormone imbalance, malfunctioning or absent ovaries or tubes • Physical blockage • Fibroids or Endometriosis • Blocked/abnormal Fallopian tubes • Vaginal secretions • Hormones or certain diseases

17. Genetics of Female Infertility • Irregular/malfunctioning ovulation • Genes: Hormones, thyroid, pituitary problems • Environment: Birth control, stress • Physical blockage • Genes: Cancer, developmental defect • Environment: Cancer or infections • Vaginal secretions • Genes: Hormones, mucus disorders, immune

18. Treatment of Female Infertility • Primary – change environment • Timing intercourse - checking for ovulation • Decrease stress, diet, exercise, etc • Secondary – correct hormone levels, surgery to correct physical problems • Final – Assisted Reproduction Technologies • More often necessary for female infertility

19. Infertility Testing • Couple seek testing after trying for more than one year • Tests: • Semen Analysis (male) • Hormone levels checked (female) • Physical exams (both) • Hysterosalpingogram (HSG; female) • Endometrial Biopsy (female) • Post coital exam (done on female)

20. Assisted Reproductive Technologies (ART) • Donating gametes • Surrogate mothers • Helping bring gametes together (fertilization) • Putting zygote in correct place • Preimplantation screening

21. Donating gametes • Sperm donation: • For Lesbian couple or male infertility • Sperm can be inseminated into uterus or cervix (artificial insemination) • Or sperm can be mixed with oocyte and zygote implanted • Oocyte donation: • Mixed with sperm and implanted as zygote • More costly and harder to come by than semen

22. Surrogate Mothers • Defined as “donating uterus” • What else? • Also time, energy, effort, hormones, blood, diet, health care • Surrogate mothers: • Inseminated with father’s semen, using her own oocytes • Or may be implanted with a zygote from couple’s gametes • Legal rights of surrogate mothers vary by state and country

23. Arguments for and against surrogacy

24. Contractarian Argument for Commercial Surrogacy • People have the right to procreation and to have a family. • Gestation can be regard as a service akin to baby sitting or rearing a child for some else. No buying or selling baby is involved. • Anyone with a sound mind should be allowed, with his/her informed consent, to enter freely into a contractual agreement.

25. Family-based Argument for Non-commercial Surrogacy • If the baby has no genetic ties with the commissioning parents, why not adoption? • Gestation is the defining criteria of mother-child relationship. The woman who gives birth to a baby is its mother even in the absence of genetic ties. This can protect the best interests of the child. Some feminist maintains that the pregnant woman is the first person who has an intimate relation with the child and so she deserves to have the baby. • Commercial surrogacy involves the buying and selling of baby. It should therefore be prohibited.

26. Family-based Argument With due respect to the parental right of the surrogate mother, contracts of surrogacy, commercial or non-commercial, should be unenforceable. The commissioning parents should follow a procedure similar to the adoption of baby. The surrogate mother should be given a grace period for changing her mind. Surrogacy should be permissible only if the baby has genetic ties with both commissioning parents and they are married.The result is better than adoption.

27. Best-interests Argument Against Surrogacy The arrangement based on the family argument does not serve to protect the interests of all the parties involved, including the baby, because the arrangement is unenforceable. What will happen if the commissioning parents change their minds after the baby is conceived? The surrogate mother is the true mother and has the responsibility to rear the baby even if she does not want to. Won’t the commissioning parents be very upset if the surrogate mother change her mind during the grace period.

28. Best-interests Argument Against Surrogacy What will happen if neither the surrogate mother nor the commissioning parents wants to keep the baby? The surrogate mother may have developed an emotional tie with the baby during pregnancy. Should she be allowed to visit the baby? Will it undermine the integrity of the new family if she does that?

29. Helping Fertilization • IVF – in vitro fertilization • Sperm and oocyte are mixed in Petri dish • Embryo at 8 or 16 cell stage implanted into uterus • ICSI – intracytoplasmic sperm injection • Sperm actually microinjected into oocyte • Then embryo implanted into uterus • Important when father has low sperm count or large number of abnormal sperm

30. in vitro Fertilization (IVF) • Problem is that egg and sperm can’t meet: • Blocked tubes or abnormal structures • Not enough healthy sperm • Put sperm and egg together in dish and then implant early embryo into uterus • Costs $5,000 to 15,000 each try • Success rate ~ 30% • Children have ~ twice rate of birth defects

31. ICSI • IVF where sperm is injected into oocyte

32. Improving IVF’s chances: • Use ICSI • Implanting more than one embryo • What is the problem there? • Implant embryos at later stage in development (blastocysts) • Culturing zygote with “helper” cells that normally surround embryo • Screening embryos for chromosomal abnormalities

33. Helping Fertilization • ZIFT – zygote intrafallopian transfer • Same as IVF only implanted into fallopian tube rather than uterus • Less successful than IVF (~23%) • GIFT – gamete intrafallopian transfer • Deposit the sperm directly into fallopian tubes • Or deposit sperm and oocytes (mother’s or donor’s) into fallopian tubes • Like IVF that happens internally (~26%)

34. Preimplantation Screening Screening for genetic disorders BEFORE pregnancy begins: • One cell of 8 cell embryo is removed • Single cell is karyotyped and probed with FISH for specific genetic disorders • Preimplantation Genetic Diagnosis (PGD) • Only genetically “healthy” embryo is implanted (IVF) • ~ 29% success rate

35. PGD • Screen for: • Large chromosomal abnormalities • Rare Mendelian Disorders • Boys with X-linked disorders • PGD often done on IVF embryos to screen for chromosomal abnormalities commonly associated with IVF procedure • Weigh risk of disease vs. IVF not working • Who could help make this decision?

36. “Spares” • Every time IVF is done more embryos are made than are used • ~ 500,000 embryos are currently in deep freeze in USA today from IVF • Choices: • Research – example: stem cells • Donation to infertile couple • Discard them • Who should make this choice?

37. Adoption • Domestic Adoptions: • $5,000 to $40,000 • Must pass stringent screening process: Salary, housing, marital situation, criminal records • International Adoptions: • $7,000 to $30,000 • Different screening processes • Foster Care Adoptions: • Free or subsidized – older and abused children

38. Ethics of ART 1. A young, married couple is infertile. They have basically no insurance because he works as a free lance consultant and she works two part time jobs. Although they own a home and can afford to raise a child they can not afford to undergo the testing or treatments for their infertility. Neither can they afford adoption.

39. Ethics of ART 2. A lesbian couple has one child. The mother was inseminated from a sperm donor and carried the baby produced from her own oocyte. They happily raise the child together for 6 years, until the mother suddenly finds religion and decides that homosexuality is wrong. When they break up the mother wants the child but so does her ex.

40. Ethics of ART 3. An infertile couple has insurance that covers IVF but they don’t believe in using ART because of their religion. They would rather adopt, but their insurance doesn’t cover adoption (most don’t) and they can’t afford it.

41. Ethics of ART 4. An infertile couple uses Clomid (a drug that stimulates ovulation) to become pregnant. Suddenly they find themselves pregnant with 6 embryos. They don’t believe in selective reduction so they are going to try to carry all 6 babies to term. Their doctor knows that the babies won’t be healthy. The father concurrently loses his job, so now they have no insurance.

42. Ethics of ART 5. A couple wants to use PGD to make sure they have a girl. What would you think if: • They have 5 boys and want a girl • They live in China and can only have one child • They know the mother carries an X linked disease

43. Regulation • 1979 Government ban on federally funded embryo research • 1992 Fertility Clinic Success Rate and Certification Act • 1995 Law enacted that requires clinics to maintain standardized records of all procedures • Seven states have mandated insurance coverage • Many states regulate surrogate contracts

44. Proposed Regulations • Mandate insurance coverage • Restrict the use of reproductive technologies to married couples • Restrict the use of reproductive technologies to infertile couples • Require couples to sign a form that declares them the legal parents upon birth

45. Proposed Regulations • Legislate procedures for disposal of discarded embryos • Sperm banks would be required to keep records linking donors and recipients, and to screen donors for infectious diseases • Prohibit egg donations to women over 50

46. Social Issues • Medicalization • Parentage • Regulation of Clinics • Insurance coverage • Disposal of frozen embryos • Eugenics • Cloning • Unregulated industry

47. Issues • Clinics Disclosure Donor/patient selection Informed Consent Record Keeping • Legal rights/obligations of participants

48. Issues • Eugenics • Multiple births Selective reduction of embryos • Disposition of frozen unused embryos • Child’s right to know about genetic parents