1. The Art of ART : Assisted Reproductive Technology Mary L. Davenport, M.D. Berkeley Students for Life March 4, 2009

2. What is ART? Assisted Reproductive Technologies: Fertility therapies where eggs and sperm are manipulated Fertility therapies where eggs and sperm are manipulated Involve surgically removing eggs from women and combining them with sperm in the laboratory Involve surgically removing eggs from women and combining them with sperm in the laboratory

3. ART: Assisted Reproductive Technology Predominantly IVF – In Vitro Fertilization Predominantly IVF – In Vitro Fertilization Expensive Expensive Most attempts fail to produce a live birth Most attempts fail to produce a live birth Separates procreation from the marital act Separates procreation from the marital act Large loss of embryos in failure to implant, discarding embryos, pre- implantation diagnosis, freezing, selective reduction Large loss of embryos in failure to implant, discarding embryos, pre- implantation diagnosis, freezing, selective reduction

4. TYPES OF ART SART 1999 IVF

5. ASSISTED REPRODUCTIVE TECHNOLOGY Major philosophical and ethical shift in reproductive medicine Major philosophical and ethical shift in reproductive medicine Emphasis changed from healing and eradicating disease to control of procreation Emphasis changed from healing and eradicating disease to control of procreation

6. REPRODUCTIVE CHRONOLOGY 1934 Gregory Pincus: First animal IVF 1934 Gregory Pincus: First animal IVF 1944 John Rock: First human IVF 1944 John Rock: First human IVF 1960 FDA approves “the pill” 1960 FDA approves “the pill” 1978 First IVF baby 1978 First IVF baby 2001 421 U.S. ART clinics with 41,000 live births annually 2001 421 U.S. ART clinics with 41,000 live births annually

7. GREGORY PINCUS GREGORY PINCUS 1934 First in vitro fertilization of rabbit eggs 1934 First in vitro fertilization of rabbit eggs Criticized as “mad scientist” Criticized as “mad scientist” Developed oral contraceptives in 1950’s Developed oral contraceptives in 1950’s

8. Dr. John Rock 1890-1984 1936 First doctor to open a Rhythm clinic in Boston 1936 First doctor to open a Rhythm clinic in Boston 1944 First IVF; created four embryos in secret 1944 First IVF; created four embryos in secret 1954 Collaborated with Pincus on U.S. clinical trials of the pill 1954 Collaborated with Pincus on U.S. clinical trials of the pill

9. STEPTOE AND EDWARDS Birth of Louise Brown First IVF Baby, 1978

10. Why ART? Why ART?

11. Infertility: Extremely Prevalent Definition: inability to achieve pregnancy in one year Definition: inability to achieve pregnancy in one year 17-26% of couples worldwide (90 million women) 17-26% of couples worldwide (90 million women) 27-47% of infertile couples have impaired male fertility; decline in semen quality worldwide over last 50 years 27-47% of infertile couples have impaired male fertility; decline in semen quality worldwide over last 50 years

13. Why the increase in infertility? Delayed marriage and child-bearing Delayed marriage and child-bearing Sexually transmitted diseases Sexually transmitted diseases Hormonal contraception Hormonal contraception Abortion Abortion Obesity Obesity Environmental Pollution Environmental Pollution

14. FERTILITY CLOCK

15. What is IVF?

16. IVF (in vitro fertilization) is a method in which egg cells are fertilized by sperm cells outside the mother’s womb (in vitro). The resulting embryos are then transferred back into the uterus.

17. STEPS IN IVF Follicle suppression Follicle suppression Controlled ovarian hyperstimulation Controlled ovarian hyperstimulation Aspiration of eggs from follicles Aspiration of eggs from follicles Fertilization, incubation and selection of embryos Fertilization, incubation and selection of embryos Embryo transfer Embryo transfer Pregnancy test Pregnancy test

18. FOLLICLE SUPPRESSION AND CONTROLLED OVARIAN HYPERSTIMULATION

19. ASPIRATION OF EGGS ASPIRATION OF EGGS

20. IVF LAB: FOLLICULAR FLUID

21. HIGH QUALITY EGG

22. LOW QUALITY EGG

23. EMBRYOLOGIST MANIPULATING OVA AND SPERM

24. ICSI

25. INCUBATOR

26. HIGH QUALITY THREE DAY OLD EMBRYO

27. EMBRYO TRANSFER

28. IVF: WHY NOT?

29. IVF Why not? LOSS OF LIFE

30. IVF OUTCOMES SART 1999

31. Pregnancy Rates: Nondonor Eggs SART,CDC, 2004

32. LOW QUALITY EMBRYO

33. TANK FOR FREEZING EMBRYOS

34. MFPR MULTIFETAL PREGNANCY REDUCTION

35. ART Outcomes by Age SART, CDC, 2004

36. COMPARISON OF OWN AND DONOR EGGS

37. Pregnancy Loss by Age: CDC

38. IVF why not? IVF permits the use of donor ova and sperm and cloned embryos Violates traditional Judeo-Christian concept of marriage Violates traditional Judeo-Christian concept of marriage Legal and biologic confusion Legal and biologic confusion “Commercialization” of human life—sale of ova and sperm “Commercialization” of human life—sale of ova and sperm Donor ova and sperm illegal in many countries Donor ova and sperm illegal in many countries Cloned embryos can be used Cloned embryos can be used Cloning a dangerous technology and makes massive abuses possible Cloning a dangerous technology and makes massive abuses possible

39. COMPARISON OF OWN AND DONOR EGGS

40. Egg donor Characteristics: e.g. Hair color, Weight Ethnicity…

41. CLONED HUMAN EMBRYO

42. PANAYIOTIS ZAVOS, PH.D. CURRRENTLY CONDUCTING HUMAN CLONING EXPERIMENTS IN UNDISCLOSED COUNTRY WITH DRS. SEVERINO ANTORINI AND BEN-ABRAHAM CURRRENTLY CONDUCTING HUMAN CLONING EXPERIMENTS IN UNDISCLOSED COUNTRY WITH DRS. SEVERINO ANTORINI AND BEN-ABRAHAM GOAL: PROVIDING CHILDLESS COUPLES WITH THE ABILITY TO CLONE THEMSELVES AS A FORM OF REPRODUCTION GOAL: PROVIDING CHILDLESS COUPLES WITH THE ABILITY TO CLONE THEMSELVES AS A FORM OF REPRODUCTION

43. IVF Why not? MULTIPLE BIRTHS

45. IVF why not? Multiple births Multiple pregnancies with IVF (37.4%) Multiple pregnancies with IVF (37.4%) Triplets or more 8.4% (4.9% of live births) Triplets or more 8.4% (4.9% of live births) Prematurity: Average with triplets 33 weeks; 85% survive Prematurity: Average with triplets 33 weeks; 85% survive Prematurity: Quadruplets average 29 weeks; 70% survive Prematurity: Quadruplets average 29 weeks; 70% survive Fetal risks: mental/physical disabilities such as blindness, cerebral palsy; 5% in twins, 10% in triplets, 50% in quadruplets Fetal risks: mental/physical disabilities such as blindness, cerebral palsy; 5% in twins, 10% in triplets, 50% in quadruplets Fetal risks: death; seven times more likely to die in the first year; 40x more likely to die in infancy Fetal risks: death; seven times more likely to die in the first year; 40x more likely to die in infancy Maternal risks: toxemia, diabetes, hemorrhage Maternal risks: toxemia, diabetes, hemorrhage Family risks: depression, social isolation, divorce Family risks: depression, social isolation, divorce

46. IVF: Expensive Medication: $1,500-$7,000 per cycle Medication: $1,500-$7,000 per cycle Office visits, egg retrieval, fertilization, assisted hatching, cryofreezing of embryo (six months),ultrasound, lab tests: $12,000-18,000 PER CYCLE; Office visits, egg retrieval, fertilization, assisted hatching, cryofreezing of embryo (six months),ultrasound, lab tests: $12,000-18,000 PER CYCLE; Egg donation $3,000-$50,000 Egg donation $3,000-$50,000

47. IVF: Additional Costs Hospital costs - Singleton $10,000; Twins $20,000; Triplets $40,000 Hospital costs - Singleton $10,000; Twins $20,000; Triplets $40,000 Intensive care of baby: $100,000- $150,000 per month Intensive care of baby: $100,000- $150,000 per month Work time lost--daily medical visits Work time lost--daily medical visits Frequently not covered by insurance Frequently not covered by insurance

48. Benitez v North Coast Women’s Medical Group Lesbian couple desired pregnancy Lesbian couple desired pregnancy ObGyn group declined to perform IUI (Intrauterine insemination) because of marital status (or sexual orientation ?) based on physicians’ religious beliefs ObGyn group declined to perform IUI (Intrauterine insemination) because of marital status (or sexual orientation ?) based on physicians’ religious beliefs Lower court found in favor of the doctors Lower court found in favor of the doctors California Supreme Court found in favor of Benitez California Supreme Court found in favor of Benitez

49. R. Alta Charo, J.D. Professor of Law University of Wisconsin “The Celestial Fire of Conscience: Refusing to Deliver Medical Care” New England Journal of Medicine New England Journal of Medicine June 16, 2005 June 16, 2005

50. The McCaughey Septuplets 1997

52. The Chukwu Octuplets

54. Dr, Michael Kamrava