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 Baby Using 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
All of these ART or Assisted Reproductive Technologies are medical interventions in the processes of reproduction, including ovulation, fertilization, and implantation of the fertilized eggs into the uterus.
Numerous Reproductive technologies have allowed infertile couples to have children, but it has raised ethical and legal questions regarding the involvement of third parties as donors or surrogates and the propriety of altering natural processes of procreation.
More than 40,000 infants were born in 2001 as a result of assisted – reproductive technology
According to the Centers for Disease Control and Prevention the highest success rates were reported in patients who used donor eggs and freshly fertilized embryos. There was a 56% pregnancy rate, 47% live birth rate, and 27% singleton live – birth rate)

4. Artificial Insemination
Artificial insemination: Introducing semen into the uterus or oviduct by other than natural means.
Artificial Insemination is the process in which male gametes, the spermatozoa, are collected and introduced artificially into the female genital tract for the purpose of fertilization.
Other artificial methods for achieving fertilization have since been devised.
Artificial insemination was first developed for breeding cattle and horses.
Spermatozoa are collected from a chosen male and frozen, then thawed and used to impregnate females.

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.
In Vitro Fertilization (IVF), an assisted reproductive technology (ART) in which one or more eggs are fertilized outside a female's body.
This technique has been used extensively in animal embryological research for decades, but only since 1978 has it been successfully applied to human reproduction.
In human reproduction the process involves stimulation of the growth of multiple eggs by the daily injection of hormone medications.
It is also possible to conduct IVF without the use of the hormone medications; a single egg would develop and be retrieved.
The eggs are then recovered by one of two methods: sonographic egg recovery, which is the more common of the two, which uses ultrasound guidance to retrieve the eggs, or laparoscopic egg recovery, in which retrieval is made through a small incision in the abdomen.
Once the eggs are retrieved, they are placed in a special fluid medium, then semen that has been washed and incubated is placed with the eggs and left for approximately 18 hours.
The eggs are removed, passed into a special growth medium, and then examined about 40 hours later.
If the eggs have been fertilized and developed normally, the embryos are transferred to the woman's (or a surrogate's) uterus.
The probability of viable pregnancy is approximately 20 percent with one IVF cycle.

6. Intra-Cytoplasmic Sperm Injection
Intra-cytoplasmic sperm injection - is a lab procedure to help infertile couples undergo in vitro fertilization due to male factor infertility.
This was a technique that was developed in 1992, in order to deal with male infertility.
Doctors collect a single live sperm and inject it directly into the cytoplasm of the mother’s egg.
ICSI is routinely performed in cases where the man has extremely low sperm counts.
The resulting embryo is then inserted into the uterus using IVF procedures.

7. Gamete Intrafallopian Transfer (GIFT)
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.
In gamete intrafallopian transfer is a the technique is similar to IVF, but the harvested eggs and sperm are placed directly into the fallopian tubes, with fertilization occurring in the woman's body .

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.
In zygote intrafallopian transfer is a procedure that is similar to GIFT, but the beginning-stage embryos or zygotes are placed directly in the fallopian tubes.
With super ovulation uterine capacitation enhancement, which is what the woman is experiencing because of her daily hormone medications to stimulate the growth of multiple eggs.
Once the eggs have reached the right stage, intrauterine inseminations are done using the partner's specially treated sperm.
Donor oocyte programs are available in some places; donated eggs are used by women unable to use their own eggs to achieve pregnancy.
Assisted reproductive technology is used to retrieve eggs from donors and replace embryos in the recipient.

9. Frozen Embryos
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.
In 1984 a procedure was reported from Australia, with the embryo first being frozen for two months before it was successfully implanted.

10. ART Procedures Types of ART Procedures –United States 2002
Fresh-nondonor 74.2% (85,826 cycles)
Frozen-nondonor 14.2% (16,383 cycles)
Fresh-donor 8.0% (9,261 cycles)
Frozen-donor3.4% (3,922 cycles)
New Treatment Procedures 0.1% (146 cycles)
The number of ART clinics in the United States in 2002:428
Number of ART cycles reported for 2002 was 115,392

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: Oocyte 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” Surrogate mothers:
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 surrogacy23

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. 24

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. 25

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. 26

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. 27

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? 28

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: International 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