S244 Invited presentations and presentations by organisations and societies / International Journal of Gynecology & Obstetrics 119S3 (2012) S161S260
CROSS BORDER REPRODUCTIVE CARE (CBRC): ETHICAL ISSUES
The term CBRC refers to patients or other collaborators (such as
gametes donors or potential surrogates) who cross national borders
in order to obtain fertility treatment. The reasons vary, from law
avoidance to access limitations and long waiting lists nationally, to
seeking better quality or cheaper treatment abroad.
CBRC enhances patients choice and autonomy, but also raises
concerns of potential harmful outcomes for them, the collaborators
and the future child(ren).
There may be complications, sometimes born by the home
country, where the patient may return with hyperstimulation or
a multiple pregnancy. Others are born by the receiving country,
especially if there is diversion of scarce local physician skills. Also,
economic incentives for egg donors or surrogates may lead to the
commodification of vulnerable women.
Access to evidence based reproductive care locally in a fair and
equitable manner should be encouraged, without discrimination.
Furthermore good clinical practice should be promoted across
borders as well as nationally, so that all patients and participants get
safe and evidence based care wherever they go. Ethical standards,
including the welfare of the future child, should be respected.
Finally CBRC implies the exchange of full information about care of
patients and collaborators.
FIGO Ethics committee report, Cross-border reproductive services (2010)
Int J of Gyn and Obs111:190191.
Pennings, G., de Wert, G., Shenfield, F., Cohen, J., Tarlatzis, B. and Devroey,
P. (2008). ESHRE task force on ethics and law 15: cross-border
reproductive care. Hum Reprod. 23: 21822184.
FROM EVIDENCE TO ACTION: NEPALS PROGRESS IN
M. Sherpa. Nepal
Mt Everest and the Himalayas are the pride of Nepal but
contributor to maternal mortality by limiting access to health
services including safe delivery. In 2001, 11% of women delivered
with skilled assistance, and PPH causing 47% of maternal
deaths (FHD/1998). Nepal then launched several initiatives:
increasing facility deliveries; training skilled birth attendants
(SBAs); upgrading facilities and scaling up PPH prevention at home
Overarching idea was to promote AMSTL in facilities and use of
Misoprostol at home births. An important finding in the pilot
was that health facility deliveries increased increasing overall
utertonic coverage. The USAID-funded Nepal Family Health Program
(NFHP) and Jhpiego supported the Family Health Division to pilot
community-based misoprostol distribution in Banke district in
2005. It was designed to be closely monitored to facilitate learning
lessons and a refined approach for greater impact and ease of
implementation. It was done as part of birth preparedness package
using FCHVs. To avoid misuse of the drug, it was packaged and
branded as Mother Safety Pills.
After the successful pilot, scaling up was planned. There was some
resistance, partly due to a lack of WHO global recommendations
misoprostol for PPH prevention. The MoHP approved community-
based distribution of misoprostol for PPH prevention for nationwide
expansion. 21 of 75 districts now implementing. Misoprostol is
also included in national Essential Drugs List and government
will procure misoprostol. Commitment and ownership by the
government and strong partnership is considered the most
important factor in Nepals success.
L. Shrikhande. India
Commercial surrogacy has been legal in India since 2002. Recently
there has been a sharp increase in the frequency of commercial
surrogacy arrangement in India. Considering the growing number
of Surrogacy cases in India and the challenges that the Surrogacy
would face in the future, the Government of India decided to come
up with a law which would govern the Surrogacy and ART in India.
Some of the features of the proposed bill are:
Constitution of an authority at National level and State level to
register and regulate the IVF clinics and ART centers.
Creation of a forum to file complaints for grievances against
clinics and ART centers.
Imposing duties and responsibilities on the clinics and ART
Regulations for sourcing, storage, handling, record keeping of
Gametes, Embryos and other human reproductive materials.
Placing rights and duties on Surrogate and IPs.
Imposing stringent penalties for breach of the duties and
regulations under the Act.
The above features are dynamic in nature and will go a long way
in making the entire surrogacy procedure transparent and fair. The
chances of any exploitation of the Intended Parents and Surrogate
will be eliminated all together.
Even though, there is no law or legislation to regulate surrogacy in
India at present, the entire surrogacy process is carried out in ethical
and transparent manner keeping in mind National Guidelines for
accreditation, supervision and regulation of ART clinics in India by
Indian Council of Medical research and the proposed new law.
RADIATION THERAPY FOR GYNECOLOGICAL CANCERS IN
RESOURCE POOR COUNTRIES
S.K. Shrivastava, U. Mahantshetty, R. Engineer, S. Chopra.
Department of Radiation Oncology, Tata Memorial Hospital, Mumbai,
The radiation therapy is the mainstay of treatment for
Gynaecological malignancies consisting of combination of external-
beam pelvic irradiation followed by intracavitary irradiation. The
aim is to deliver a dose equivalent of 80Gy. Under fluoroscopy
guidance, bony landmarks are used to mark the radiation portals.
Brachytherapy plays extremely important role. A good intracavitary
insertion delivers radiation dose to target without exceeding the
radiation tolerance doses to the rectum and bladder. Also the
phase III trials have shown an absolute benefit in overall and
progression free survival with chemo-radiotherapy.
There is shortage of equipments and personnel in resource poor
countries. Several countries have only telecobalt machines or low
energy linear Accelerators without multileaf collimators. It has
been noticed that even with basic machines execution of treatment
with proper planning for radiotherapy can give acceptable results.
The low resource countries/institutions should be trained to use
available equipments optimally to deliver radiation to save normal
tissues as much as possible.
In the past few years, there has been a rapid progress in radiation
delivery techniques. Newer external radiation techniques like IMRT,
IGRT, PET-CT Guided Radiation etc. have also been explored in
cervical cancers. However, these need further validation and since
there is no convincing evidence. Over the last two decades, various
imaging modalities like Ultrasound, CT, MRI and PET have been
explored in radiotherapy. The potential of USG as an alternate
imaging modality in cervical cancer is also being explored.