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PubMed2006

Exploring the discourse between genetic counselors and Orthodox Jewish community members related to reproductive genetic technology.

OBJECTIVE: Genetic technology is complex, relatively new and involves sensitive issues pertaining to personhood and reproduction. While ethno cultural barriers to genetic care are well documented, little attention has been devoted to understanding religious beliefs pertaining to genetic services. This study evaluated the discourse between genetic counselors and Orthodox Jewish community members' perceptions of reproductive genetic technology. METHODS: A cross section of the Orthodox Jewish community was sampled through purposeful and snowball recruitment for in-depth interviews with key informants. RESULTS: Genetic counselors felt apprehensive about serving the Orthodox Jewish population and were unaware of social norms, religious and cultural practices unique to this population. Similarly, Orthodox Jewish consumers exhibited major misgivings about genetic testing. Importantly, stereotypic expectations by both counselors and consumers exacerbated existing communication difficulties. CONCLUSION: Cultural differences and poor communication between genetic counselors and Orthodox Jewish community members impeded the ability of the Orthodox Jewish community to utilize genetic services. PRACTICE IMPLICATIONS: This work illuminates complex issues pertaining to medical encounters between providers and patients with ideological, social and cultural differences. In particular, issues of access to care and transcultural competence in serving religious minority groups, such as Orthodox Jews are presented. On the whole, this group is largely unrecognized in the minority health literature in spite of barriers and challenges that they face. Findings of this study may have application to other cloistered and highly observant religious groups when dealing with reproductive technology and other populations with diverse values, beliefs and behaviors pertaining to reproductive health.

Attitude of Health Personnel↗
PubMed2006

Endometriosis and assisted reproduction: the role for reproductive surgery?

PURPOSE OF REVIEW: The aim of this review paper is to discuss the relationship between endometriosis and assisted reproductive technology. More specifically, the following clinically relevant issues will be discussed. (1) Does the presence of endometriosis affect the outcome of assisted reproductive technology? (2) Does surgical treatment for endometriosis prior to or after assisted reproductive technology treatment affect the outcome of assisted reproductive technology? (3) Is assisted reproductive technology a risk factor for the recurrence of endometriosis after medical or surgical therapy? RECENT FINDINGS: The review is based on recently published review papers/meta-analyses or international guidelines as published by the European Society of Human Reproduction or the American Society of Reproductive Medicine, updated with a selective review of recent papers searching PubMed with the key words 'Endometriosis', 'Assisted Reproduction', 'IVF', 'IUI' and 'Reproductive Surgery'. SUMMARY: At the end of this review, a practical proposal for the clinical management of women with endometriosis-associated subfertility is proposed, based on our own experience.

Endometriosis↗
PubMed2003

Factors affecting commercial application of embryo technologies in New Zealand: a modelling approach.

New reproductive technologies include sexed sperm and embryo-based technologies. The technology of sperm sexing, for various reasons, is not available in New Zealand and its use has not been modelled. Embryo technologies are however already in use on a limited scale and various scenarios for their use in both the dairy and beef industries in New Zealand have been modelled. This review briefly discusses the various technologies available and some of their potential strengths and weaknesses. In the dairy industry, modelling has been used to simulate the production of breeding bulls for large breeding companies and the production of replacement heifers in dairy herds. For the beef industry, similar modelling has been carried out to determine the opportunities for more efficient beef production. All the models confirmed that at current levels of performance, embryo-based reproductive technologies are usually not profitable in New Zealand except in niche market situations where the returns from the resulting offspring are significantly greater than can be obtained from natural mating or artificial insemination (AI) reproduction systems. This is confirmed by the low uptake of these technologies in this country to date. Even if performance lifts to levels similar to AI, profitability is likely to occur only if the costs of pregnancies to embryo-based reproductive technologies can occur at prices less than two to four times greater than AI or natural mating. This break-even requirement depends on the returns that can be achieved and the advantages that can be captured by the technology over and above those available from AI or natural mating. Two new uses for reproductive technologies in dairy cattle could be the proliferation of novel or rare genotypes from gene discovery programs and improving the female reproductive rate for optimal marker assisted selection. In both these uses the technology is not at present competing with AI or natural mating. The challenge exists therefore for the biological scientists to satisfy these requirements, coupled with the ethical and human factors involved in the introduction of any new technology. Potential end users of the technologies have been surveyed. They are quite positive about the technologies provided they can use them profitably and are keen to obtain more information about them.

Animals↗
PubMed2005

Preterm birth and low birth weight after assisted reproductive technology-related pregnancy in Australia between 1996 and 2000.

OBJECTIVE: To describe patterns of preterm birth and low birth weight (LBW) for infants born after assisted reproductive technology (ART) and determine whether these were associated with maternal or treatment characteristics. DESIGN: Retrospective cohort study of national population data of infants conceived through ART. SETTING: Australian birth records from 1996 to 2000. PATIENT(S): Eighteen thousand, four hundred twenty-nine liveborn and stillborn infants conceived through ART. INTERVENTION(S): In vitro fertilization, intracytoplasmic sperm injection, and gamete intrafallopian transfer. MAIN OUTCOME MEASURE(S): Preterm birth and LBW. RESULT(S): Preterm birth and LBW were more common among singletons and twins conceived with IVF and born to nulliparous mothers. Preterm birth and LBW were, respectively, 1.3 times and 1.5 times more likely to occur among singletons conceived by transfer of fresh embryos, compared with transfer of frozen embryos. Preterm birth and LBW was more common among couples who had female-factor infertility compared with male-factor infertility. CONCLUSION(S): The transfer of fresh embryos and female-factor infertility were independently associated with preterm birth and LBW for both singletons and twins after ART.

Adult↗
PubMed2002

Fertility options for HIV patients.

PURPOSE OF REVIEW: This paper reviews the latest reproductive options for HIV infected couples. In light of the new treatment options and improved prognosis for HIV patients, policymakers have issued recent statements to guide physicians in the care of HIV patients desiring fertility. We will review the advances in reproductive technologies and ethical considerations that have led to these most recent statements. RECENT FINDINGS: Millions of young adults of reproductive age are afflicted with the HIV virus. With the improvement in treatment options for HIV patients and the increase in their life expectancy it is not surprising that many HIV patients desire children. Assisted reproductive technologies can assist serodiscordant couples in achieving pregnancy while at the same time minimizing risk of HIV transmission to the uninfected partner. Several European fertility clinics have a great deal of experience in providing both intrauterine inseminations and in-vitro fertilization to serodiscordant couples without seroconversion of the uninfected female partners. This is both a medical and an ethical issue. Guidelines from policymakers regarding this issue have changed over the years as a result of both changes in disease prognosis and the reproductive technologies. SUMMARY: Reproductive technologies provide a logical way to minimize HIV transmission for HIV couples desiring pregnancy. Although the most recent research is compelling, much more needs to be performed in order to establish the safety of these techniques. Protocols need to be put in place in order to assist physicians in better serving these patients. In addition, many ethical and legal issues need to be addressed before these treatments can become standard of care in the United States.

Ethics, Medical↗
PubMed2003

Artificial insemination: the state of the art.

The history of research into artificial insemination (AI) is over two centuries old and its commercial application now spans 75 years. It is appropriate to reflect on the contribution of this powerful method of gene dispersal. AI remains as one of the most important assisted reproductive technologies. The three cornerstones for its application are: it is simple, economical and successful. The importance of AI will be challenged in the next few decades. The remarkable progress made in other assisted reproductive technologies does have the potential to rapidly generate offspring. The challenge for any of these reproductive technologies to attain widespread use is to match AI in being simple, economical and successful. This review aims at capturing the salient advances in AI, the comparisons with natural mating and other reproductive technologies, and, whether the future of AI will be challenged. It predicts what the new horizon looks like and the role that AI will play in the overall reproductive technologies landscape.

Animals↗
PubMed2005

A survey comparing TCM diagnosis, health status and medical diagnosis in women undergoing assisted reproduction.

INTRODUCTION: For many women, undergoing assisted reproductive technology can be a difficult experience, and can result in changes in physical and emotional health and wellbeing. Recent research has suggested that acupuncture may be helpful for women undergoing assisted reproductive technology. To date, there is no information describing the traditional Chinese medicine (TCM) syndromes seen in women undergoing assisted reproductive technology, or relationships between TCM and Western medicine diagnoses. OBJECTIVE: To examine the health status of women undergoing assisted reproductive technology from both Western and Chinese medicine perspectives. METHODS: One hundred and eighty women were included in the study. All underwent a TCM diagnosis, 177 (98.3%) completed the quality of life questionnaire SF36. Information about Western medicine diagnosis was collected from case notes and was available for 176 (97.7%) women. RESULTS: Women in the trial reported poorer health on several domains of the SF36 compared with the South Australian population. The most common TCM diagnosis was 'Kidney Yang deficiency', diagnosed for 53.9% of patients. A TCM diagnosis of Qi or 'Blood stagnation' was associated with poorer quality of life on the mental health, emotional role function and social function domains of the SF36. No associations were found between TCM diagnosis and physical or general health components of the SF36. CONCLUSIONS: Associations between TCM and reproductive health diagnoses were demonstrated. Emotional health and wellbeing is an important aspect of patient care that needs to be addressed in clinical practice and research studies, as the findings suggest that this aspect of their health is often poorer during assisted reproductive technology.

Adult↗
PubMed2003

Assisted reproduction--Islamic views on the science of procreation.

The field of assisted reproduction is one of the fastest growing areas in medicine. The development of new and sophisticated techniques all aim to give reproductive technologies and scientists a better understanding of reproductive biology. The development of new techniques may also be able to improve the chances of an infertile couple towards achieving a pregnancy. However the ethics and legality of assisted reproductive technology must not be brushed aside. Islamic scholars whose reference basis resides in the Holy Quran and the Hadith have addressed different issues relating to assisted reproductive technology. Some of the issues remain controversial and need detailed discussion before it can be deemed as appropriate and legible for use as guidelines in the development of the processes involved.

Beginning of Human Life↗
PubMed2002

Human cloning: three mistakes and an alternative.

The current debate on the ethics of cloning humans is both uninspired and uninspiring. In large measure this is because of mistakes that permeate the discourse, including the mistake of thinking that cloning technology is strictly a reproductive technology when it is used to create whole beings. As a result, the challenge this technology represents regarding our understanding of ourselves and the species to which we belong typically is inappropriately downplayed or exaggerated. This has meant that important (albeit disquieting) societal issues and species-type concerns have not been fully explored. This paper, intended as a corrective, suggests that we take an alternate view of human cloning as both an enhancement and a reproductive technology. This proposed shift in the framework for analysis counters the current narrow framing of the issues and introduces new questions about the prospect of modifying the species.

Bioethics↗
PubMed2004

Ethics of testicular stem cell medicine.

The ethical issues raised by advances in reproductive technology allowing the transplantation of testicular stem cells to enable infertile men and cancer patients, including the pre-pubertal, to have children, and to provide new contraceptive prospects for fertile men are discussed. Consideration of respect for the patient's autonomy, the need for informed consent and the health of any offspring resulting from such a procedure are included. Topics covered include: the problems raised by cases needing consent for the transplantation of testicular stem cells from pre-pubertal and adolescent patients; the legal status of stem cells; the arguements for treating such tissue as property which might serve as a means of guaranteeing respect for patients' rights in disputed cases; aspects of patents and the ethics of allowing commercial traffic of such material; questions relating to health and safety, as well as xenotransplantation technology in humans; and posthumous procurement use of germ cells from minors. Proposals are made to enhance informed and effective consent, while supporting patient determination, choice, autonomy and technological advances. The paper appeals to the emerging EU directives in relation to tissue procurement, storing and use of tissue and cells to adopt a pragmatic and meaningful position which will help enhance patient determination and autonomy in relation to the emerging technologies in reproductive medicine, whilst providing a pragmatic way forward for fertility clinics and laboratories to function.

Ethics, Medical↗
PubMed2001

Using Augustine in contemporary sexual ethics. A response to Gilbert Meilaender.

In response to Gilbert Meilaender's innovative interpretation of Augustine and of Roman Catholic teaching, the author suggests (1) that Meilaender attributes to Augustine a more positive view of sexual pleasure than the texts will support, (2) that modern Roman Catholic teaching suggests that love should have priority over procreation as a meaning of sex; and (3) that the moral logic of Meilaender's argument does not require a rejection of all reproductive technologies. Nonetheless, the author agrees that a more critical attitude should be adopted toward the reasons for which technologically assisted reproduction is promoted and undertaken, as well as toward its social impact.

Catholicism↗
PubMed2000

Management of hydrosalpinx: reconstructive surgery or IVF?

Tubal disease remains the most important factor in female infertility. Many investigators reported that patients with hydrosalpinx had a decreased clinical pregnancy rate and an increased miscarriage rate, resulting in a decreased ongoing pregnancy rate when compared to that of patients with other types of tubal disease. Different studies showed a deleterious effect of the presence of hydrosalpinx on the outcome of in vitro fertilization-embryo transfer, because toxic agents flowing from the hydrosalpinx to the uterus impair the implantation rate. Operative laparoscopy is effective in the treatment of hydrosalpinges (Stage I or II). Fertility outcome is related to tubal damage. Patients with Stage III and IV disease should be managed from the beginning with in vitro fertilization. Excision of hydrosalpinx(-ges) improves the pregnancy potential after in vitro fertilization. We believe that assisted reproductive technology and reproductive surgery can be complementary. The development of laparoscopic surgery and in vitro fertilization improved the pregnancy rate in patients with tubal factor infertility.

Embryo Implantation↗
PubMedDate not supplied

Laparoscopic Fertility-Promoting Procedures of the fallopian tube and the uterus.

Assisted reproductive technology and reproductive surgery can be complementary, and the feasibility of laparoscopic suturing has facilitated conducting reproductive surgery entirely by laparoscopy. Young women with tubal disease can be offered surgery, whereas older women, with their rapid decline in fertility, are better treated with in vitro fertilization (IVF). IVF should be the first line of treatment for women with a severe degree of hydrosalpinx, or with extensive and dense adhesions. However, the presence of hydrosalpinx decreases IVF pregnancy rates. In those whose hydrosalpinx is seen on ultrasound, especially after failed IVF cycles, a laparoscopic salpingectomy can be done. For tubal anastomosis, the superior results of this procedure are well established. The association between uterine myoma and infertility is unclear. However, in those with a distorted uterine cavity, and no other cause of infertility, myomectomy can be considered; myomectomy can be done by laparoscopy. Because of the risks of uterine rupture, proper closure of the uterine incision is of utmost importance.

Fallopian Tube Diseases↗
PubMed2005

Opinions about new reproductive genetic technologies: hopes and fears for our genetic future.

OBJECTIVE: To identify underlying beliefs and values shaping Americans' opinions about the appropriate use of new reproductive genetic technologies (RGTs), including preimplantation genetic diagnosis, hypothetical genetic modification, and sperm sorting for sex selection. DESIGN: Scenarios with ethical dilemmas presented to 21 focus groups organized by sex, race/ethnicity, religion, age, education, and parental status. SETTING: A city in each state: California, Colorado, Massachusetts, Michigan, and Tennessee. PARTICIPANT(S): One hundred and eighty-one paid volunteers, ages 18 to 68. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Beliefs and values that shape participants' opinions about the appropriate use of new RGTs. RESULT(S): Regardless of demographic characteristics, focus group participants considered six key factors when determining the appropriateness of using RGTs: [1] whether embryos would be destroyed; [2] the nature of the disease or trait being avoided or sought; [3] technological control over "natural" reproduction; [4] the value of suffering, disability, and difference; [5] the importance of having genetically related children; and [6] the kind of future people desire or fear. CONCLUSION(S): Public opinions about the appropriate use of RGTs are shaped by numerous complementary and conflicting values beyond classic abortion arguments. Clinicians and policy-makers have the opportunity to consider these opinions when creating messages and crafting policy.

Adolescent↗
PubMed2006

Changing their minds with time: a comparison of hypothetical and actual reproductive behaviors in parents of children with cystic fibrosis.

OBJECTIVE: Newborn screening for cystic fibrosis, with appropriate counseling, enables carrier parents to be informed early about future reproductive choices. Previous studies have assessed attitudes toward reproductive decisions in a hypothetical pregnancy or have measured reproductive behaviors. We aimed to measure parent attitudes to reproductive technologies and to compare prospectively these attitudes with later reproductive behaviors. METHODS: Parents of children who had cystic fibrosis and were aged 2 to 7 years were surveyed at baseline using a written questionnaire that explored attitudes to prenatal testing and termination of pregnancy in a hypothetical pregnancy. Parent knowledge and access to genetic counseling services also were assessed. Five years later, we compared attitudes with actual reproductive behaviors. RESULTS: Fifty-six mothers participated at baseline, and 43 were resurveyed 5 years later. Parent knowledge of cystic fibrosis and genetics was very good. A total of 93% had met a genetic counselor at the time of diagnosis, and more than half had on at least 1 subsequent occasion. At baseline, 82% reported that they would be likely to have prenatal diagnosis in a subsequent pregnancy, and 56% reported that they would be likely to terminate an affected pregnancy. Twenty-seven mothers since had been pregnant, with prenatal diagnosis used in 33 of the 55 pregnancies. In 67%, the hypothetically reported behavior regarding use of prenatal testing was the same as their actual behavior. Five of the 33 tested pregnancies were affected; all ended in termination. Reproductive choices in relationship to the number of children wanted, together with attitudes toward prenatal diagnosis and termination of pregnancy, were dynamic over time, with decisions having changed in both directions. CONCLUSIONS: This cohort of parents has actively used reproductive technologies since the birth of a child who has cystic fibrosis that was diagnosed by newborn screening. The dynamic aspect of reproductive choices highlights the importance of ongoing access to genetic counseling beyond the initial period of diagnosis and education, regardless of whether parents report that they expect to use reproductive technologies.

Abortion, Induced↗
PubMed2001

Assisted reproductive interventions and multiple birth.

OBJECTIVE: To investigate the contributions of ovulation-inducing drugs and assisted reproductive technologies to multiple birth. METHODS: This historic prospective study was conducted in a cohort of 13,151 women who delivered after 20 weeks' gestation between October 1996 and December 1999. The study setting was a Colorado health maintenance organization. Cases were women who were pregnant as a result of exposure to treatment with either assisted reproductive technologies or ovulation induction in the absence of assisted reproductive technologies. The main outcome measure was multiple birth. RESULTS: There was a significant association between assisted conception and multiple birth. Compared with women with naturally conceived pregnancies, there was a 25-fold likelihood (95% confidence interval 18, 35, P <.001) of multiple birth among women exposed to any of those treatments. In the total cohort the proportion of multiple births attributable to those treatments was 33%. After adjusting for the use of assisted conception and other covariates, we found no association between advanced maternal age and multiple birth. CONCLUSION: In this cohort, assisted reproductive interventions were strongly associated with multiple birth. Although a higher proportion of older women sought assisted reproductive technologies, we did not find an independent relationship between advanced maternal age and multiple birth. The increasing number of multiple births attributable to assisted conception raises public health concerns regarding multiple gestation-related maternal and infant morbidities.

Adolescent↗
PubMedDate not supplied

Oocyte freezing: here to stay?

Oocyte freezing is an established technology but, in contrast to embryo freezing, it has very limited application in clinical IVF programmes. Is there a chance that oocyte freezing will become an integrated routine in assisted reproductive technology? The delicate cytological architecture of the oocyte with a cold-sensitive spindle and a hardening zona have made the frozen oocyte 'unwanted' in assisted reproductive technology. Nevertheless, empirical improvements in freezing protocols and the use of ICSI for fertilization have led to an increasing number of live births. This mitigates against a simple ban on oocyte freezing. While efficiency of oocyte freezing can certainly be further improved by basic research, it is clear that there are humanitarian reasons for considering oocyte freezing as a future fully utilized assisted reproductive technology. The storage of the female genome as a particulate entity can provide an alternative in case of moral, ethical, legal or religious concerns about embryo freezing. Oocyte freezing can also offer hope for oocyte donation and preservation of fertility for women facing ovarian loss. The message is one of cautious optimism when looking for a place for oocyte freezing in routine assisted reproductive technology.

Animals↗
PubMed2006

Anti-mullerian hormone: clinical relevance in assisted reproductive therapy.

Anti-Müllerian Hormone (AMH) is a member of the transforming Growth Factor-B (TGF-B) family synthesized exclusively by the gonads of both sexes. Over the last four years, numerous studies have examined the clinical usefulness of serum AMH levels as a predictor of ovarian response and pregnancy in assisted reproductive technology cycles. Assessment of ovarian reserve in women undergoing assisted reproduction is useful in optimising the treatment protocol. Availability of a reliable measure of ovarian reserve is essential. Currently, serum AMH level seems to be more strongly related to the ovarian reserve and to be a more discriminatory marker of assisted reproductive technology outcome than follicle-stimulating hormone, inhibin B or estradiol, which are more commonly used markers. Our study involving 69 women undergoing a cycle of in vitro fertilisation (IVF) or intracytoplamic sperm injection (ICSI) treatment, confirmed these results. We have shown in this study that AMH is significantly correlated with the number of eggs collected and is of great interest as a negative predictive value for the success of assisted reproductive technology (ART). Further studies are needed to determine AMH cut-off values.

Anti-Mullerian Hormone↗