BIOETHICS EDUCATION : LIFESTYLE, FERTILITY AND THE ASSISTED REPRODUCTIVE

TECHNOLOGIES

Irina Pollard, Dept Biological Sciences, Macquarie University, Sydney, NSW 2109, Australia

e-mail ipollard@rna.bio.mq.edu.au

PART I - THE INFERTILITY PUZZLE

(from ‘Information Brochure’, North Shore Fertility Pty. Ltd.)

LIFESTYLE AND FERTILITY

OVERALL FITNESS AND THE CAPABILITYTO BEAR HEALTHY CHILDREN DEPENDS ON:

1. OUR GENES

2. THE CONDITIONS UNDER WHICH WE LIVE

3. THE WAYS IN WHICH WE BEHAVE

INFERTILITY – THE INABILITY TO ACHIEVE PREGNANCY

1. MEDICALa) After 12 months of unprotected sexual intercourse or

b) Due to a diagnosed physical abnormality of the reproductive system; e.g., blocked fallopian tubes

2. SOCIAL Non-engagement in a heterosexual relationship

3. THE INABILITY TO CARRY A PREGNANCY TO LIVE BIRTH

MEDICAL INFERTILITY

Affects 10-15% of couples attempting pregnancy

DISTRIBUTION OF CAUSE

FEMALE INFERTILITY

(from Ian Pike’sguest lecture)

MALE INFERTILITY

FERTILITY DECLINES WITH AGE

Female infertility increases from 30 years of age to the menopause

Genetic anomalies in men also increases with age (from Ian Pike’sguest lecture)

MANY CONCEPTUSES DO NOT SURVIVE

Human fecundity rate; i.e., the probability of achieving a clinical recognized pregnancy within any given menstrual cycle, is about 25% and high levels of fertilization failures or early developmental death, are the norm at conception

Spontaneous abortion is one of Nature’s ways to counter negative genetic and environmental factors

MAXIMIZING FERTILITY AND REPRODUCTIVE OUTCOME: GENERAL HEALTH ISSUES

THERE ARE SEVERAL THINGS POTENTIAL PARENTS CAN DO TO SIGNIFICANTLY IMPROVE THEIR REPRODUCTIVE HEALTH AND REDUCETHE CHANCE FOR ASSISTED REPRODUCTIVE TECHNOLOGY TREATMENT

i) NUTRITION AND REPRODUCTION

All essential nutrients in diet - women who are significantly overweight or underweight can have difficulty getting pregnant

ii) EXERCISE AND REPRODUCTION

Regular aerobic exercises but excessive can affectovulation and sperm count

iii) SUBSTANCE ABUSE AND REPRODUCTION

Alcohol, nicotine, illicit drugs and some medicationsadversely affect the embryo, fetus and newborn

iv) FOLIC ACID AND NEURAL TUBE DEFECTS

Is recommended as daily food supplement prior to conception

Beans and green leafy vegetables are a rich source of folic acid (from E. Hyams ‘Plants in the Service of Man’.

Dent & Sons, 1971)

MAXIMIZING FERTILITY AND REPRODUCTIVE OUTCOME: GENERAL HEALTH ISSUES CONTINUED

v) TEMPERATURE EFFECTS AND SPERM QUALITY

Optimum spermatogenesis 4-7˚ C below body temperature

vi) PHYSICAL AND PSYCHOLOGICAL STRESS

A relationship between emotion and fertility exists

vii) REGULARITY OF INTERCOURSE

2-3 times per week, particularly around the time of ovulation

viii) SCREENING TESTS

Both partners have blood tests taken for HIV antibodies, hepatitis B&C, and females for immunity to Rubella (German Measles) – the virus known to cause major abnormalities in the fetus if contracted during early pregnancy

‘The Stairs of Age’ by Winter Carl Hansson (1777-1805)

POVERTY, POPULATION AND DEVELOPMENT

Today in industrialized countries the prospects for pregnant women and their fetuses is very good. In the US, for example, 80% of all established pregnancies culminate in the delivery of a live child; and once a child is born it has 99.3% chance for surviving infancy

However, certain social/ethnic minority groups are significantly disadvantaged compared with the general population. Indigenous people in Australia and the United States, for example, experience various forms of difficulties simultaneously

“Good health is a basic human right, especially among poor people afflicted with disease who are isolated, forgotten, ignored, and often without hope. Just to know that someone cares about them can not only ease their physical pain but also remove an element of alienation and anger that can lead to hatred and violence.” Former U.S. President Jimmy Carterhttp://www.cartercenter.org/healthprograms

PART II : ASSISTED REPRODUCTIVE TECHNOLOGY (ART)

Since the first ‘test-tube’ baby Louise Brown was born in Britain in 1978,more than a million children have been born through assisted reproduction

Social Impacts of Assisted Reproductive Technology

MAJOR ASSISTED REPRODUCTIVE TECHNOLOGIES (ART)

_ Artificial insemination by donor or by husband (AID; AIH) _ In vitro fertilization and embryo transfer (IVF-ET)_ Direct intra-peritoneal insemination (DIPI)_ Gamete intra-fallopian transfer (GIFT)_ Zygote intra-fallopian transfer (ZIFT)_ Intracytoplasmic sperm injection (ICSI)_ Sperm collection by way of microsurgery _ Embryo and sperm cryopreservation and storage_ Cytoplasmic transfer_ Preimplantation genetic diagnosis (PGD)_ Karyotyping and genetic manipulation_Tissue banking_ Ovulation induction_ Laparoscopy and hysteroscopy _ Laser laparoscopy_ Hystero-sonography_ Ultrasound scanning_ Egg and embryo donation_ Posthumous gamete donation

MALE-FACTOR INFERTILITY:STANDARD SEMEN PARAMETERS

SPERM PARAMETER FERTILE RESULT

1. COUNT >20 MILLION/ML

2. MOTILITY >50% GOOD FORWARD PROGRESS

3. MORPHOLOGY >30% NORMAL

4. FERTILIZABILITYARTIFICIAL INSEMINATION BY HUSBAND OR BY DONOR

Donor insemination is more successful than partner insemination, does not carry an increased risk of spontaneous abortion or congenital anomalies, and has advantages over adoption in that the child is genetically related to the mother and the couple can experience conception, pregnancy and delivery

(from Ian Pike’s guest lecture)

Drawing by Barbara Duckworth

INTRACYTOPLASMIC SPERM INJECTION (ICSI)

ICSI, in conjunction with IVF technology, has givenhope to men with sever infertility problems

Even immature spermatids (sperm precursor cells)can be harvested and used to fertilize the egg

FEMALE-FACTOR INFERTILITY: IN VITRO FERTILIZATION (IVF) TECHNOLOGY

AIM OF TREATMENT

1. Menstrual Cycle Management

2. Control Ovaries by Drugs

a) Drug 1 – block usual control mechanism from brain X ovary

b) Drug 2 – Direct stimulation to the ovary

c) Develop a batch of eggs

IN VITRO FERTILIZATION (IVF) TECHNOLOGY CONTINUED

3. Prepare Eggs for Fertilization

4. Drug 3 – induce ovulation

5. Harvest eggs

6. In vitro fertilization

PROTOCOL - IVF TREATMENT CYCLE

KeyU/S Ultrasound Scan* FSH daily injections Blood hormone test (E = estradiol 17β)a GnRH analogue – daily injection

(from N.S. Fertility)

TECHNOLOGIES IN COMBINATION WITH IVF TECHNOLOGY

PREIMPLANTATION GENETIC DIAGNOSIS (PGD)

Alternative to ultrasound, amniocentesis or chorionic villus sampling

STORAGE FOR FROZEN EMBRYO TRANSFER

SPERM, EGG AND EMBRYO DONATION

1. Female Infertility

Premature MenopauseGenetic Disease Carrier Donor EggAge Factor & Chronic IVF Failure

Lack of / Unsuitable Uterus Surrogacy

2. Male Infertility

Abnormal Semen Donor Sperm

3. Couple Infertility

Chronic IVF Failure Donor Embryo

SEX SELECTION AND DESIGNER CHILDREN

ASSISTED REPRODUCTION : RISKS AND UNCERTAINTIES

Some researchers are questioning the safety of technologies such as ICSI and other invasive techniques, claiming that they may be linked to increased rates of birth defects and rare genetic imprinting disorders

Dolly the sheep – the world’s first cloned mammal was euthanized 14th February, 2003 (The Japan Times, February 16, 2003)

TECHNOLOGIES IN COMBINATION WITH IVF TECHNOLOGY CONTINUED

Research into cell and tissue differentiation using cultured embryonic stem cells from humans, and other species, may enable the control of differentiation and dedifferentiation in somatic cells. This could allow the production of tissues with enhanced stem cell components that may be used as universal donor cells for transplantation

(To-day’s Life Sciences, March/April 1999)

BALANCING RISKS AND UNCERTAINTIES