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Surrogacy: the case for a conventional approach.

Legislation for the reproductive technologies made a false beginning when initial legislation chose to obscure the separation of genetic and social/legal parenthood resulting from the use of donor sperm and ova. This initial falsehood is compounding the difficulties of later attempts to deal with more complex issues. The NSW Law Reform Commission's arguments and recommendations with regard to surrogacy illustrate this problem. It is argued that legislation should work from precedent in matters of recognition and transfer of parenthood, and that the social ramifications of the new technologies should be identified as far as possible within existing social determinations. The nature of surrogacy and required legislation is explored in this context, and it is argued that surrogacy should be subject to essentially the same regulation as adoption, thus debarring commercialization but without legislative intervention into the area of private reproductive behaviour. It is suggested that such an approach will effectually discourage surrogacy as it provides no sureties for the 'commissioning' couple.

Adoption↗

Assisted fertility using electroejaculation in men with spinal cord injury--a review of literature.

OBJECTIVE: To review the effectiveness of rectal probe electroejaculation in terms of pregnancy in treatment of anejaculatory males due to spinal cord injury. The characteristics of electroejaculates also are examined. DATA IDENTIFICATION: All English language studies reporting pregnancies as a result of electroejaculation from men with spinal cord injury and related publications on electroejaculation were identified through MEDLINE search and manual scanning of recent relevant journals. RESULTS: Electroejaculation has become an accepted mode of semen procurement in anejaculatory individuals, with a success rate of approximately 60% to 90% varying among different centers. In general these electroejaculates exhibit high sperm counts but low motility and poor sperm function. Retrograde ejaculation is also common. Pregnancies using electroejaculates have been documented since 1975 in the form of case reports and small series. Assisted reproductive technology recently has been used in conjunction with electroejaculation. Although results are encouraging, pregnancy rates, however, cannot be accurately estimated because of the lack of large series in the literature. CONCLUSIONS: An increasing number of spinal cord-injured patients desiring fertility can achieve pregnancy through combined use of electroejaculation and assisted reproductive techniques. Larger series are needed to establish an accurate pregnancy rate. Elucidation by further studies on etiology of sperm dysfunction of these individuals may improve their prognosis.

Ejaculation↗

Controlled micromanipulation of human sperm in three dimensions with an infrared laser optical trap: effect on sperm velocity.

Individual human sperm can be micromanipulated in three dimensions using a 1.06 microns Nd:YAG laser trap. Single sperm swimming with velocities in the range of 65 to 85 microns/sec can be trapped with 40 mW of power through 120 seconds without a deleterious effect on velocity. Even though it will be necessary to further evaluate the effects of laser light on specific functions of sperm, our data suggest that decreasing the time of manipulation to a minimum will increase the safety of the micromanipulation procedures. Laser traps may play a role in assisted reproductive technology by facilitating the selective transport of individual sperm.

Analysis of Variance↗

Legal conceptions: regulating gametes and gamete donation.

The growing scope of gamete donation and the manipulation of gametes makes it essential to develop a coherent theory of the nature of gametes and the claims which may be made in relation to them. The nature of gametes is ambiguous, they blur the distinctions between persons and property, but the current legal framework which governs gamete donation and manipulation fails to address their status. This leaves unanswered fundamentally important questions about control of processes involving gametes and rights to use or control the gametes themselves and the information which they represent. These are claims which are rooted in the concept of property. A property based analysis highlights the themes of autonomy, personhood and control which lie at the heart of the claims made in relation to gametes and an account based on the notion of property for personhood offers a more coherent justification for recognising claims in gametes and mediating disputes. This perspective exposes the inadequacies and inconsistencies of the legal construction of gametes and the legal regulation of gamete donation. The present legal framework has not sought to develop a coherent construction of gametes, but to constrain the practices of the assisted reproductive technologies (including gamete donation) within a framework which is presented as least damaging to the traditional ideologies of the creation of the family.

Bioethics↗

Evolving ethics in medically assisted reproduction.

Ethical problems arising from the application of assisted reproductive technology are discussed for four specific areas, namely embryo research, multiple pregnancies, preimplantation genetic diagnosis (PGD) for social sexing, and finally PGD with HLA typing.

Ethics, Medical↗

Programming ovulation in the menstrual cycle by a simple innovative approach: back to the future of assisted reproduction.

OBJECTIVE: To synchronize the intercycle FSH elevation with exogenous E2 for programming ovulation in the menstrual cycle. DESIGN: Open single-arm study. SETTING: Teaching hospital. PATIENT(S): Twenty-six patients with infertility whose menstrual cycles normally lasted 25-35 days and who underwent our routine programming method for postcoital tests and ovulation evaluations. INTERVENTION(S): Participants received estradiol valerate (2 mg) twice a day from day 25 of the previous cycle until 1-15 days after the onset of menses. Women had ultrasonography on the last day of E2 treatment or on functional day 0 and 13 days later or on functional day 13. Hormones were determined on functional days 0, 3, 9, and 13. The increase in FSH in response to E2 withdrawal was defined as deltaFSH. MAIN OUTCOME MEASURE(S): LH surge and other ovulatory indices on functional day 13. RESULT(S): On functional day 13, 73% of the women had an LH surge. Fifteen percent had evidence of previous ovulation with low LH and elevated plasma P levels, and the remaining 12% had low LH levels and no evidence of past or imminent ovulation. Women with evidence of early ovulation were older and had higher FSH signal amplitude. CONCLUSION(S): It is feasible and practical to program ovulation in the menstrual cycle with exogenous E2. In 73% of women, the true duration of the follicular phase (intercycle FSH elevation to LH surge interval) remained constant (13 days). Hence, common fluctuations in menstrual cycle length mainly result from variations in the timing of the intercycle FSH elevation. Although rare, truly short follicular phases also exist (15%). This simple and practical system for programming natural ovulation offers new possibilities for using the menstrual cycle in assisted reproductive technology, at least in selected individuals.

Adult↗

What the king can not see.

This paper contrasts the ways in which the physician-scientist developing in vitro fertilization ("the king") sees the world and the way women experience it. It challenges the truth of what the king sees: i.e., that women have a desperate will to be mothers that must be fulfilled at all costs; that the way to make infertile women mothers is through the use of new reproductive technologies; that IVF programs are quite successful and that women who enter these programs actually come away with babies.

Attitude of Health Personnel↗

Ethical and legal aspects of in-vitro fertilization and artificial insemination by donor.

All areas of medical practice are shaped by ethical and legal mandates. When a physician provides infertility services, however, ethical and legal concerns reach an even greater prominence. The infertility specialist is in the awesome role of facilitating the creation of new life. A task of that level of importance brings with it responsibilities of an equal magnitude. Clinicians performing in-vitro fertilization and artificial insemination should be especially sensitive to the ethical and legal concerns raised by the selection of patients and donors, the informed consent process, and record-keeping. As reproductive technologies such as these develop, the clinician not only has a duty to monitor their safety and efficacy, but also to provide extensive information to the participants and to society at large to make possible informed decisions about how best to enhance the benefits and avoid the risks of these new technologies.

Confidentiality↗

Mono-ovulatory cycles: a key goal in profertility programmes.

Mono-ovulatory cycles for women are optimal because singleton pregnancies have a better outcome than multiples. Multiple births began to increase in the 1950s after the first appearance of effective ovulation induction for the treatment of anovulation. Since the 1980s when ovulation induction and IVF were more broadly applied to the treatment of unexplained and persistent infertility, there has been an unprecedented rise in multiple births. Strategies to achieve mono-ovulation during treatment of anovulatory patients are distinct from those for the treatment of ovulating patients who have unexplained and persistent infertility. Anovulatory patients with hypogonadotrophic hypogonadism can be treated with exogenous pulsatile GnRH, which restores normal gonadotrophin secretion, ovulation rates and conception rates. The multiple pregnancy rate is not increased with GnRH treatment. In patients with normogonadotrophic anovulation, attention should be given to diet and exercise before any other interventions are considered. Pharmacological induction of ovulation can be achieved with antiestrogen, gonadotrophin or pulsatile GnRH treatment; antiestrogen is the first choice with gonadotrophin more widely used for clomiphene citrate (CC)-resistant patients. Obesity and polycystic ovaries are common in this group, so that gonadotrophin and GnRH treatment are associated with lower responses compared with hypogonadotrophic hypogonadism, and higher multiple pregnancy rates. Low dosage protocols are being tested that may lower the multiple birth rates. The role of drugs enhancing sensitivity to insulin, e.g. metformin, remains undetermined. Laparoscopic ovarian diathermy achieves conception rates that are equivalent to gonadotrophin treatment, with fewer multiple births. Augmenting normal ovulation processes for couples with unexplained and persistent infertility is less effective. Pregnancy rates are statistically significantly higher with CC but the size of the increase is not clinically important. CC with intrauterine insemination is associated with a clinically important effect on conception. Achieving mono-ovulation is more difficult in assisted reproductive technology cycles because success depends on maintaining the level of FSH above the threshold level longer than normal in order to increase the number of mature follicles. Milder stimulation for IVF and IVF in the untreated cycle show great potential, however, especially in view of the trend toward transfer of a single embryo in assisted reproductive treatment cycles.

Anovulation↗

[Clinical features & diagnostic and therapeutic strategies of congenital absence of the vas deferens].

OBJECTIVE: To investigate the clinical characteristics, diagnosis and therapeutic strategies of congenital absence of the vas deferens (CAVD). METHODS: We summarized the clinical data of 81 cases of CAVD and investigated clinical features, diagnosis and management of the disease. RESULTS: Seventy-nine cases of infertility were diagnosed as CAVD at the clinic, and 2 were diagnosed during surgical exploration. The population consisted of 40 cases of congenital bilateral absence of the vas deferens (CBAVD), 25 cases of congenital unilateral absence of the vas deferens (CUAVD), and 16 cases of segmental agenesis of the vas deferens. Seventy-four spouses received the treatment of assisted reproductive techniques, including intracytoplasmic sperm injection (ICSI) in 12 cases, and 4 of them achieved pregnancy. CONCLUSION: CAVD frequently presents with infertility. CBAVD may manifest as obstructive azoospermia, and CUAVD and segmental vasal agenesis as oligospermia, asthenospermia, or obstructive azoospermia. CAVD is usually not difficult to diagnose, but may be missed due to careless examination. Assisted reproductive technology (ART) plays a key role in the management of CAVD.

Adult↗

Where does a man stand on issues of assisted reproduction, surrogacy, artificial insemination within lesbian relationships and posthumous conception?

This article takes issues more commonly associated with women: assisted reproduction, surrogacy, artificial insemination within lesbian relationships and posthumous conception and considers what role a man may play in this domain. To this end the article commences with a short scenario of possible life events then traverses the current legal position to examine the extent that the law either facilitates or frustrates a man's desire and ability to fulfill the role of either father or parent in the above situations. The article considers the issues of assisted reproduction technology in both a regulated and an unregulated environment.

Australia↗

Live rhesus offspring by artificial insemination using fresh sperm and cryopreserved sperm.

Artificial insemination (AI) and the cryopreservation of sperm with full reproductive capabilities are vital in the armamentarium of infertility clinics and reproductive laboratories. Notwithstanding the fantastic successes with AI and sperm cryopreservation in numerous species, including humans and cattle, these assisted reproductive technologies are less well developed in other species of importance for biomedical research, such as genetically modified mice and nonhuman primates. To that end, AI at high efficiency in the rhesus macaque (Macaca mullata) and the successful cryopreservation of rhesus sperm is presented here, as are the complexities of this primate model due to differences in reproductive tract anatomy and gamete physiology. Cryopreservation had no effect on the ability of sperm to fertilize oocytes in vitro or in vivo. Post-thaw progressive motility was not affected by cryopreservation; however, acrosome integrity was lower for cryopreserved (74.1%) than for fresh sperm (92.7%). Fertilization rates did not differ when fresh (58.1%; n = 32/55) or cryopreserved sperm (63.8%; n = 23/36) were used for in vitro fertilization. Similarly, pregnancy rates did not differ significantly after AI with fresh (57.1%; n = 8/14) or cryopreserved sperm (62.5%; n = 5/8). Seven live rhesus macaques were born following AI with fresh sperm, and three live offspring and two ongoing pregnancies were obtained when cryopreserved sperm were used. Cryopreservation of rhesus sperm as presented here would allow for the cost-effective storage of lineages of nonhuman primates with known genotypes. These results suggest that either national or international centers could be established as repositories to fill the global needs of sperm for nonhuman primate research and to provide the experimental foundation on which to explore and perfect the preservation of sperm from endangered nonhuman primates.

Acrosome Reaction↗

There are gender differences in attitudes toward surrogacy when information on this technique is provided.

OBJECTIVE: We analyzed the data of a nationwide opinion survey reported in a previous study and clarified the importance of socioeconomic status and individual belief on people's opinion regarding the pros and cons of gestational surrogacy. In this study, we analyzed the data of this nationwide opinion survey to identify the effect of providing information about assisted reproductive technology (ART) on the people's attitude towards not only gestational surrogacy but also other ART procedures. STUDY DESIGN: This was a cross-sectional study. A nationwide opinion survey on ART was conducted in 2003. The participants included 3647 people (1564 people received only the questionnaire and 2083 people received the questionnaire and a brochure containing information about ART). Multivariate-adjusted odds ratio and 95% confidence interval were obtained using logistic regression models for understanding the manner in which the knowledge about ART affects the attitude of the general population towards ART, which uses donor gametes and surrogacy. RESULTS: With regard to gestational surrogacy, men in the brochure group could not clearly express their opinions when compared with those in the no-brochure group (odds ratio (OR): 0.69; 95% confidence interval (CI): 0.53-0.89). In contrast, with regard to donor insemination, women in the brochure group could clearly express their opinions when compared with those in the no-brochure group (OR, 1.24; CI, 1.02-1.52). Information about ART, especially in men, promoted disapproval of partial surrogacy (OR, 0.59; CI, 0.44-0.78) and gestational surrogacy (OR, 0.64; CI, 0.48-0.86). On the other hand, for other ART procedures, we found no significant association between receiving information via the brochure and people's attitude towards the technology. CONCLUSION: There were gender differences in attitude toward surrogacy that was affected by providing information about ART. Moreover, determining community attitudes, we observed that a good understanding of the information provided facilitates the expression of a clear opinion, thereby assisting respondents in deciding whether or not they approve of a certain technology.

Adult↗

The importance of integrating genetic testing into reproductive medicine: a retrospective observational study investigating the monogenic causes of human infertility in couples considering ICSI.

The genetic landscape of human infertility is complex with diverse etiologies. Identifying the underlying etiology is crucial for guiding reproductive decisions and improving management for infertile couples. Here, we aim to report on the molecular spectrum of monogenic genetic causes of reproductive failure. Over a 3-year period, we recruited all infertile couples considering assisted reproductive technologies (ART) for whom the underlying genetic cause had been identified, in either partner, using exome sequencing (ES). Clinical data of all participants along with their hormonal profiles, sonographic findings and spermograms were recorded. The study included 50 couples with primary infertility. Clinically, male factor infertility was documented in 26 patients, female factor infertility in 10, while reproductive failure was unexplained in the remaining 14 couples. All participating couples had potentially disease-causing variants in infertility genes. ES identified variants related to male infertility in 26 men, while variants in female infertility-related genes were detected in the remaining couples (n = 24). According to ACMG classification criteria, 78% (39/50) of couples harbored pathogenic/likely pathogenic (P/LP) variants, whereas 22% (11/50) carried variants of uncertain significance (VUS). In view of the identified genetic etiologies, the cohort was stratified into two groups based on the predicted reproductive outcome: (1) couples with significantly impaired reproductive potential, and (2) couples who can have biological children using appropriate medical interventions. However, classifications involving VUS were interpreted cautiously and considered exploratory. This study provides further evidence for the molecular heterogeneity of human infertility and highlights the usefulness of genetic testing for infertile couples pursuing ARTs.

Humans↗

Alternative strategies for the long-term preservation of spermatozoa.

A number of perceived future requirements for stored germplasm in agriculture, aquaculture, biotechnology and conservation are discussed in the present review. In the light of these broad demands, it is apparent that current approaches to gamete and embryo storage need considerable improvement, and that novel approaches to the technologies of germplasm preservation should be pursued if possible. The present article is presented in response to a request for novel future research ideas in this area. Early literature on desiccation, and later research into natural mechanisms of survival during desiccation, is considered in relation to the development of freeze-drying and vitrification methods. Developments in reproductive technologies themselves may mean that freeze-dried spermatozoa could realistically be used for direct intracytoplasmic microinjection of oocytes. Other radical methods that may achieve germplasm preservation are harvesting testicular cells in culture, cryopreserving immature or seasonally regressed testicular material, or a combination of both. Evidence from non-mammalian testicular culture systems, and recent success with the transmeiotic development of mouse spermatids in vitro, suggest that these approaches may eventually become feasible.

Animal Husbandry↗

The comfort and discomfort of infertility.

Infertility has been described as a life crisis by many authors. Nursing has a major role in assisting couples through the infertility diagnosis and treatment regimen. The role of nurses is expanding as technologic advances expand and families are created using donor eggs, donor sperm, expanded male infertility techniques, host uteri, and preimplantation genetic diagnosis. A framework for nurses to use to provide comfort in infertility is provided, as are suggestions regarding nursing interventions to assist infertile patients through the physical, social, psychospiritual, and environmental contexts. The couple using advanced reproductive technologies proceeds through the stages of grief to, it is hoped, resolution. Kolcaba's matrix can be used as a framework for nursing interventions to move couples along the continuum of ease, relief, and transcendence.

Adaptation, Psychological↗

Should we design our descendants?

Rapid breakthroughs in genetic research spurred by the Human Genome Project, advances in molecular biology, and new reproductive technologies are raising the prospect that we may eventually have the technical capacity to modify genes that are transmitted to future generations not only to treat or eliminate diseases but also to "enhance" normal human characteristics beyond what is necessary to sustain or restore good health. This paper explores the ethical and justice implications of such genetic modifications. It argues against developing these technologies primarily because it will not be possible to counter the deleterious justice impacts. It recommends the need for public education and public discussion, preferably with the religious community taking an active role, to shape decisions about future genetic research and applications, and for better regulation of genetic technologies with the potential for inheritable genetic alterations.

Genetic Diseases, Inborn↗