BIOETHICS EDUCATION : LIFESTYLE, FERTILITY AND THE ASSISTED REPRODUCTIVE TECHNOLOGIES

Irina Pollard, Dept Biological Sciences, Macquarie University, Sydney, NSW 2109, Australia e-mail [email protected]

PART I - THE INFERTILITY PUZZLE

(from ‘Information Brochure’, North Shore Fertility Pty. Ltd.)

LIFESTYLE AND FERTILITY

OVERALL FITNESS AND THE CAPABILITY TO BEAR HEALTHY CHILDREN DEPENDS ON: 1. OUR GENES 2. THE CONDITIONS UNDER WHICH WE LIVE 3. THE WAYS IN WHICH WE BEHAVE

INFERTILITY – THE INABILITY TO ACHIEVE PREGNANCY

1. MEDICAL

a) After 12 months of unprotected sexual intercourse or

2. SOCIAL

b) Due to a diagnosed physical abnormality of the reproductive system; e.g., blocked fallopian tubes Non-engagement in a heterosexual relationship

3. THE INABILITY TO CARRY A PREGNANCY TO LIVE BIRTH

MEDICAL INFERTILITY

Affects 10-15% of couples attempting pregnancy

DISTRIBUTION OF CAUSE FEMALE INFERTILITY

(from Ian Pike’s guest lecture)

MALE INFERTILITY FERTILITY DECLINES WITH AGE

Female infertility increases from 30 years of age to the menopause Genetic anomalies in men also increases with age

(from Ian Pike’s guest lecture)

MANY CONCEPTUSES DO NOT SURVIVE

Human fecundity rate; i.e., the probability of achieving a clinical recognized pregnancy within any given menstrual cycle, is about 25% and high levels of fertilization failures or early developmental death, are the norm at conception Spontaneous abortion is one of Nature’s ways to counter negative genetic and environmental factors

MAXIMIZING FERTILITY AND REPRODUCTIVE OUTCOME: GENERAL HEALTH ISSUES THERE ARE SEVERAL THINGS POTENTIAL PARENTS CAN DO TO SIGNIFICANTLY IMPROVE THEIR REPRODUCTIVE HEALTH AND REDUCE THE CHANCE FOR ASSISTED REPRODUCTIVE TECHNOLOGY TREATMENT i) NUTRITION AND REPRODUCTION All essential nutrients in diet - women who are significantly overweight or underweight can have difficulty getting pregnant ii) EXERCISE AND REPRODUCTION Regular aerobic exercises but excessive can affect ovulation and sperm count iii) SUBSTANCE ABUSE AND REPRODUCTION Alcohol, nicotine, illicit drugs and some medications adversely affect the embryo, fetus and newborn iv) FOLIC ACID AND NEURAL TUBE DEFECTS Is recommended as daily food supplement prior to conception

Beans and green leafy vegetables are a rich source of folic acid (from E. Hyams ‘Plants in the Service of Man’. Dent & Sons, 1971)

MAXIMIZING FERTILITY AND REPRODUCTIVE OUTCOME: GENERAL HEALTH ISSUES CONTINUED v) TEMPERATURE EFFECTS AND SPERM QUALITY Optimum spermatogenesis 4 7˚ C below body temperature vi) PHYSICAL AND PSYCHOLOGICAL STRESS A relationship between emotion and fertility exists vii) REGULARITY OF INTERCOURSE 2-3 times per week, particularly around the time of ovulation viii) SCREENING TESTS Both partners have blood tests taken for HIV antibodies, hepatitis B&C, and females for immunity to Rubella (German Measles) – the virus known to cause major abnormalities in the fetus if contracted during early pregnancy

‘The Stairs of Age’ by Winter Carl Hansson (1777-1805)

POVERTY, POPULATION AND DEVELOPMENT

Today in industrialized countries the prospects for pregnant women and their fetuses is very good. In the US, for example, 80% of all established pregnancies culminate in the delivery of a live child; and once a child is born it has 99.3% chance for surviving infancy However, certain social/ethnic minority groups are significantly disadvantaged compared with the general population. Indigenous people in Australia and the United States, for example, experience various forms of difficulties simultaneously “

Good health is a basic human right, especially among poor people afflicted with disease who are isolated, forgotten, ignored, and often without hope. Just to know that someone cares about them can not only ease their physical pain but also remove an element of alienation and anger that can lead to hatred and violence

.” Former U.S. President Jimmy Carter http://www.cartercenter.org/healthprograms

PART II : ASSISTED REPRODUCTIVE TECHNOLOGY (ART)

Since the first ‘test-tube’ baby Louise Brown was born in Britain in 1978, more than a million children have been born through assisted reproduction

Social Impacts of Assisted Reproductive Technology

MAJOR ASSISTED REPRODUCTIVE TECHNOLOGIES (ART) _

Artificial insemination by donor or by husband (AID; AIH) _

In vitro

fertilization and embryo transfer (IVF-ET) _ Direct intra-peritoneal insemination (DIPI) _ Gamete intra-fallopian transfer (GIFT) _ Zygote intra-fallopian transfer (ZIFT) _ Intracytoplasmic sperm injection (ICSI) _ Sperm collection by way of microsurgery _ Embryo and sperm cryopreservation and storage _ Cytoplasmic transfer _ Preimplantation genetic diagnosis (PGD) _ Karyotyping and genetic manipulation _Tissue banking _ Ovulation induction _ Laparoscopy and hysteroscopy _ Laser laparoscopy _ Hystero-sonography _ Ultrasound scanning _ Egg and embryo donation _ Posthumous gamete donation

MALE-FACTOR INFERTILITY: STANDARD SEMEN PARAMETERS SPERM PARAMETER FERTILE RESULT 1. COUNT 2. MOTILITY >20 MILLION/ML

Drawing by Barbara Duckworth

>50% GOOD FORWARD PROGRESS 3. MORPHOLOGY >30% NORMAL 4. FERTILIZABILITY

(from Ian Pike’s guest lecture)

ARTIFICIAL INSEMINATION BY HUSBAND OR BY DONOR

Donor insemination is more successful than partner insemination, does not carry an increased risk of spontaneous abortion or congenital anomalies, and has advantages over adoption in that the child is genetically related to the mother and the couple can experience conception, pregnancy and delivery

INTRACYTOPLASMIC SPERM INJECTION (ICSI)

ICSI, in conjunction with IVF technology, has given hope to men with sever infertility problems Even immature spermatids (sperm precursor cells) can be harvested and used to fertilize the egg

FEMALE-FACTOR INFERTILITY: IN VITRO FERTILIZATION (IVF) TECHNOLOGY

AIM OF TREATMENT 1.

Menstrual Cycle Management 2. Control Ovaries by Drugs a) Drug 1 – block usual control mechanism from brain X ovary b) Drug 2 – Direct stimulation to the ovary c) Develop a batch of eggs

IN VITRO FERTILIZATION (IVF) TECHNOLOGY CONTINUED

3. Prepare Eggs for Fertilization 4. Drug 3 – induce ovulation 5. Harvest eggs

6. In vitro

fertilization

PROTOCOL - IVF TREATMENT CYCLE Key U/S Ultrasound Scan * FSH daily injections Blood hormone test (E = estradiol 17β) a GnRH analogue – daily injection

(from N.S. Fertility)

TECHNOLOGIES IN COMBINATION WITH IVF TECHNOLOGY PREIMPLANTATION GENETIC DIAGNOSIS (PGD)

Alternative to ultrasound, amniocentesis or chorionic villus sampling

STORAGE FOR FROZEN EMBRYO TRANSFER SPERM, EGG AND EMBRYO DONATION

1. Female Infertility Premature Menopause Genetic Disease Carrier Age Factor & Chronic

IVF

Failure Lack of / Unsuitable Uterus 2. Male Infertility Abnormal Semen 3. Couple Infertility Chronic

IVF

Failure Donor Egg Surrogacy Donor Sperm Donor Embryo

TECHNOLOGIES IN COMBINATION WITH IVF TECHNOLOGY CONTINUED SEX SELECTION AND DESIGNER CHILDREN ASSISTED REPRODUCTION : RISKS AND UNCERTAINTIES

Some researchers are questioning the safety of technologies such as ICSI and other invasive techniques, claiming that they may be linked to increased rates of birth defects and rare genetic imprinting disorders

Dolly the sheep – the world’s first cloned mammal was euthanized 14th February, 2003

(The Japan Times, February 16, 2003)

BALANCING RISKS AND UNCERTAINTIES

Research into cell and tissue differentiation using cultured embryonic stem cells from humans, and other species, may enable the control of differentiation and dedifferentiation in somatic cells. This could allow the production of tissues with enhanced stem cell components that may be used as universal donor cells for transplantation

(To day’s Life Sciences, March/April 1999)