S244 Invited presentations and presentations by organisations and societies / International Journal of Gynecology & Obstetrics 119S3 (2012) S161–S260

I331

CROSS BORDER REPRODUCTIVE CARE (CBRC): ETHICAL ISSUES

F. Shenfield

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.

Reference(s)

FIGO Ethics committee report, Cross-border reproductive services (2010)

Int J of Gyn and Obs111:190–191.

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: 2182–2184.

I332

FROM EVIDENCE TO ACTION: NEPAL’S PROGRESS IN

ADDRESSING PPH

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

births.

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 Nepal’s success.

I333

SURROGACY

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

centers.

– Regulations for sourcing, storage, handling, record keeping of

Gametes, Embryos and other human reproductive materials.

– Placing rights and duties on Surrogate and IP’s.

– 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.

I334

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,

India

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.