Ethics in Reproductive Medicine

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Ethics inReproductive Medicine

• Georges El-Kehdy, MD
• Saint-Georges University Medical Center
• University of Balamand

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Artificial Insemination

• Artificial Insemination with Donor (AID), usually
  intravaginal or intracervical.
• In the West, sperm banks.
• Donor is anonymous and tested for STDs
• Used when the man is irremediably azoospermic
• At the time of ovulation the whole semen is put
  intravaginally or intracervically
• Parents and donor do not know each other

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Artificial Insemination

• Artificial Insemination with Husband (AIH)
• Intra-couple procedure
• Usually when husband is mildly oligospermic (gt5
  million spz/ml) or if woman has cervical problem
  or if couple has unexplained infertility. Rarely
  used with coital or anatomic defects
• At the time of ovulation (spontaneous or induced)
  intrauterine deposistion of washed spems (IUI)

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In-Vitro Fertilization

• First successful case 1978 Louise Brown in Great
  Britain
• Originally, was devised for tubal infertility
• Later was expanded to male, unexplained, and
  other forms of infertility.
• Now also used by a small number of couples to
  avoid transmission of inherited genetic diseases
• The techniques are standardized and simplified

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In-Vitro Fertilization

• Techniques
• Induction of ovulation to recruit a great number
  of follicles which will yield a great number of
  oocytes
• Different protocoles of ovulation induction
• Monitoring cycles with serum estradiol and serial
  ultrasounds
• When follicles are mature triggering of
  ovulation with HCG

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In-Vitro Fertilization

• Techniques
• 34 hours later oocyte pick-up (OPU) by vaginal
  ultrasound or laparoscopy
• Aspiration of follicles. Oocytes are put in
  glassware dishes (In-Vitro)
• Manipulation of oocytes and their in-vitro
  maturation

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In-Vitro Fertilization

• Techniques
• Oocytes are put with sperms either directly
  (50.000 spz/oocyte) or by micro-injection called
  ICSI (1 spz/oocyte)
• If fertilization occurs an embryo will result
• 48 to 72 hours later this embryo who would have
  reached the 8-cell stage is replaced in the
  uterus of the woman

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Cloning

• Reproductive
• Therapeutic
• Totipotent cells (0-2 days)
• Pluripotent cells (5-10 days)
• Multipotent cells (10 days)
• Unipotent cells
• Specialized cells

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Medical Problems of IVFwith Ethical Implication

• AID STDs
• IVF (and to a lesser extent AIH)
• OHSS
• Ovarian Cancer (?) due to drugs
• Multifetal Pregnancies Prematurity, Preeclampsia
• Abortion preclinical and clinical

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Ethical Problems

• AID
• Possibility of one donor to have several children
  that might marry
• Problems of child rejection by the mothers
  husband (who in fact is the legal father)
• Child wanting to retrace his biological father
• Late appearance of a genetic disease in the donor
• Sperm manipulation Sex selection

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Ethical Problems of IVF

• Embryos
• Surnumerary freezing (dissociation of
  generations), disposal (posthumous)
• Manipulation Preimplantation genetic diagnosis
  (PGD)
• Research on embryo
• Sex Selection
• Fetal reduction in multifetal pregnancies

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Ethical Problems of IVF

• Parenthood
• As many as five persons have been parents to one
  child
• Posthumous (what if one parent dies)
• Separation of couple
• Oocyte donation
• Surrogacy

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Surrogacy

• Types
• Eggs, sperms or both may be donated
• Sperms from the intended father inseminates the
  surrogate mother who is the gestational and
  genetic one
• IVF-ET combines various modalities of surrogacy
  as many as 5 persons have been parents to one
  child
• Major arguments for and against
• For Reproductive freedom is a cherished right
  and some women may derive satisfaction from being
  surrogates and help others (altruistic)
• Against Harm to the child, mother, her family
  and the society

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Surrogacy

• Financial agreements and altruistic motives
• Payment
• For what is payment made?
• Not contingent on the delivery of an acceptable
  product
• Rather on time and efforts put on the entire
  process
• Why is payment offered or requested?
• Is payment likely to lead to the exploitation of
  surrogate?
• If too low exploitation by not providing
  adequate compensation
• If too high exploitation by being irresistible
  and coercive
• Access barrier where this is available only to
  affluent couples.

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Ethical Problems of IVF

• Surrogacy
• Financial incentives and altruistic motives
• Psychological aspects
• Interruption of mother-fetus bonds
• In non-financial agreements, changing of mind
• Legal situation
• Surrogate mother cannot break contract
• Fetus as a commodity
• Fetus as an (end)-product
• Hazards are for the surrogate mother

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Ethical Problems of IVF

• Oocyte Donation
• Sources during intervention (stimulated cycle or
  not), fetuses, cadavers.
• Types donation, selling, trade
• Confidentiality problems
• Psychological and legal problems when the source
  is aborted fetuses or cadavers

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Ethical Problems of IVF

• Embryo Freezing
• Several oocytes are produced that might result in
  several embryos. Three embryos are replaced. The
  rest frozen.
• Frozen embryos for replacement later on, for
  research or disposal of.
• Replacement 3 or 4. 1 or 2 for pregnancy. The
  others abortion. What if one or both parents die
  or separate
• Research on or Disposal of Embryos who has the
  decision.

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Sex Selection

• Indications
• Medical gender-related diseases
• Non-medical Family balancing
• Methods
• Pre-fertilization newest is flow cytometry
• Post-fertilization and Pre-transfer IVF and PGD
• Post-implantation Karyotyping by CVS and
  Amniocentesis

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Sex Selection

• Medical testing not expressly for the purpose of
  sex selection if sex is known, the information
  belongs legally and ethically to the patient, and
  she should be informed if she requests it.
• Medical testing expressly for the purpose of sex
  selection
• Position 1 Never participate in a sex selection
• Position 2 Participate in a sex selection for
  medical reasons
• Position 3 Participate in a sex selection
  whenever requested