1. Assisted Reproductive Technology (ART) Adapted from Mary L. Davenport, M.D. (UCLA at Berkeley), 2009

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

4. 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

5. 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

6. 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

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

8. Why ART? Why ART?

9. 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

11. 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

12. FERTILITY CLOCK

13. What is IVF?

14. 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.

15. 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

16. FOLLICLE SUPPRESSION AND CONTROLLED OVARIAN HYPERSTIMULATION

17. ASPIRATION OF EGGS ASPIRATION OF EGGS

18. IVF LAB: FOLLICULAR FLUID

19. HIGH QUALITY EGG

20. LOW QUALITY EGG

21. EMBRYOLOGIST MANIPULATING OVA AND SPERM

22. ICSI

23. INCUBATOR

24. HIGH QUALITY THREE DAY OLD EMBRYO

25. EMBRYO TRANSFER

26. IVF: WHY NOT?

27. IVF why not? IVF permits the use of donor ova and sperm and cloned embryos 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? Cloned embryos? Issues with loss of embryos Issues with loss of embryos

28. IVF Why not? MULTIPLE BIRTHS

30. 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

31. 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

32. 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

33. 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

34. The McCaughey Septuplets 1997

36. The Chukwu Octuplets