The Straits Times, 16 March 2012
Image source: Amazon.com
The authors….    Professor Bart Fauser & Professor Paul Devroey
Outline1.   How to design a baby?2.   What couples want and how we deal with it3.   The infertility epidemic4.   Infertili...
How to design a baby?
Assisted reproductive techniques In vitro fertilisation (IVF)
Fathers of IVF            Robert Edwards & Patrick Steptoe
World’s First IVF baby                         Images: The Telegraph, UK
Issues with IVF Respond with too few eggs Ovarian hyper simulation syndrome Ability of an embryo to implant in the uter...
Assisted reproductive techniques Micromanipulation or Micro-insemination sperm transfer (MIST)                   Image: J...
The Straits Times, 25 April 1989, Page 1
The Straits Times, 25 April 1989, Page 1
Assisted reproductive techniques Intracytoplasmic sperm injection (ICSI)                                     Image: MyFer...
IVF vs. ICSI Figures for Europe    In 2001, 49 % of all assisted reproductive techniques were with     ICSI    In 2003,...
A. In vitro fertilisation             (IVF)           B. Micromanipulation or             Micro-insemination             s...
What couples want and how we        deal with it?
Singleton or twin pregnancy?
The Infertility Epidemic   Image: MedIndia.net
Causes of infertility Blocked tubes / hormonal problems (female) Low sperm count or morphology (male) Female age Uteri...
Infertility Treatments for      Fertile People
Preimplantation genetic screening (PGD) A technique which screens multiple IVF embryos Used to   improve embryo selecti...
Saviour siblings Parents conceive a healthy, disease-free baby    Use the baby’s blood cells are used to cure the elder ...
Gender selection In the name of “family balancing”’    Not allowed in most European countries, but not     disallowed in...
Fertility preservation Preserve the fertility of those undergoing treatment or those who postpone having kids Oncologist...
Surrogacy                                 Image source: Guardian.co.ukImage source: JustFamilies.org
Who Pays? :The Social Implications
Infertility: a disease? WHO’s definition of reproductive health“... that people are able to have a responsible , satisfyi...
Infertility: a disease? The authors’ argument“....if we accept WHO claim that ‘health’ is not just the absence of disease...
Labelling “infertility” as a disease               Justification                    for              Funding
Paying for infertility treatment Little consistency among European governments about who should pay Denmark had the most...
Treatment in developing countries Role of children is associated with cultural beliefs and  practice in these countries ...
Whose responsibility? Assisted reproduction ‘does have potential’ to contribute  to total fertility and influence populat...
How Far Can We Go?
Robert Edwards Awarded Nobel prize in Medicine in 2010   IVF was introduced in 1976   Opposition from the    Catholic C...
Looking ahead…. Posthumous reproduction Pregnancy in older women
In conclusion….
Baby-making : what the new reproductive treatments mean for families & society
Baby-making : what the new reproductive treatments mean for families & society
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Baby-making : what the new reproductive treatments mean for families & society

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A book review presentation on Baby-making : what the new reproductive treatments mean for families & society by Bart Fauser & Paul Devroey for H6792, Science & Technology Sources & Services.

Presented by Nurashikin Jasni & V Somasundram on 16 October 2012

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  • A few months ago, I came across an online article which mentioned that animals on earth might outnumber the human beings in the distant future. This got me worried….http://mamalim.files.wordpress.com/2012/03/img_1136.jpgThis March, I came across this article from The Straits Times about retrieving the eggs from the female humans , freezing them and use them for conception later when the patient wishes to have children Got me thinking how this may actually help to increase Singapore’s fertility rate, not drastically but maybe slightly Open video: http://youtu.be/GeigYib39Rs
  • We reviewed Baby-making : what the new reproductive treatments mean for families and societyBy Bart Fauser & Paul Devroey published in 2011- mentionthat the book is inclined towards European countries
  • http://www.igoandpractice.nl/2009/woensdag_REPR.htmProfessorBart Fauser is the Chair of Departments of Reproduction & Gynaecology, Obstetrics & Neonatology at the University Medical Center in Utrecht, Netherlands.Professor Paul Devroey is the Clinical Director of the Center of Reproductive Medicine at the Free University of Brussels in BelgiumEach have written over 300 scientific papers and 3 books , as well as being editors for several medical journals.
  • There are actually 8 chapters in the book but this six were the most intriguing that we would like to highlightThe first three looks at the technological aspects of assisted reproduction techniques & the reasons behind infertilityThe last three looks at social impacts of these techniques
  • This is the first chapter – how to design a babyThe introduction of the contraceptive pill in the early 1960s was a revolution in human reproduction. The pill would take pregnancy out of sex and remove the risk from the pleasure.For many women on the pill sex would now be about recreation, not procreation. IVF like an immaculate conception would take the sex out of the pregnancy Thus while the pill allowed couples to have sex w/o children, IVF allow couples to have children w/o the sex.
  • Is the first and original technique which brought about the revolution of assisted reproductionWe will now show you the In Vitro fertilisation video.In the IVF process, the ovaries are simulated to release the eggs with the course of gonadotrophins (fertility drugs / protein hormones)The eggs (in follicular fluid) are taken from the ovary and mixed with sperm cells to achieve fertilisation in the labafter two to five days, one or two embryos are transferred to the uterus for pregnancy.
  • IVF was brought about by twoUK scientists Robert Edwards and Patrick Steptoe. They are the Fathers of IVF.It started off when Edwards had successfully induced follicle growth, ovulation and pregnancy in laboratory mice to clarify the timing of these stages of development, which then evolved to rabbits.This encouraged Edwards to experiment on humans Steptoe joined Edwards in Cambridge to work on a programme which combined basic and clinical research in reproductive physiology whose ultimate objective was the treatment of infertility.
  • Following on a successful treatment by Dr Patrick Steptoe and Professor Robert Edwards, a mother Leslie Brown was successfully conceived after treatmentwas given.On 25 May 1978, the first birth from IVF, Louise Brown was born and this brought upon a revolution in human reproduction and bringing about normal science to treat human infertility. Since the birth of the baby, Louise Brown, there have been more than 4 million through IVF born throughout the world.
  • Despite the first success achieved using the IVF technique, there are issues still being encountered till today. This IVF technique achieved is not a direct solution to infertility problems. Although there are close monitoring and adjustments to the dose of gonadotrophins (fertility drugs or protein hormones), some women may still respond with too few eggs. On the other hand, there are women whommay produce too many developing follicles, and resulted in ovarian hyper stimulation syndrome (OHSS) with is health-threatening.For the third point, the ability of an embryo to implant in the uterus varies between 30 and 60 per cent and choosing the right embryo is critical. Because of this, multiple embryos have been transferred historically, to give the couple a better overall chance of pregnancy.This can increase the risks of multiple pregnancy, low birth weight, etc.Therefore, few clinics transfer more than two embryos in routine cases. Any remaining good quality embryos are stored in deep-freeze liquid nitrogen and left for later opportunities if the initial attempt fails or for a second pregnancy.This led to the development of normal science to treat human infertility Conventional IVF could not treat male infertility, which is caused by too few motile sperm cells which leads to the development of micromanipulation or Micro-insemination sperm transfer (MIST).
  • (MIST)where beneath the lens of a high-magnification microscope, a few sperms are injected beneath the outer layer of a human egg through sub-zonal insemination, where one of the sperms fertilises the egg. and I am proud to say Singapore pioneered this technique
  • In 1988, at the National University Hospital of Singapore, Soon-Chy Ng and ArifBongso reported the world's first live birth following the direct transfer of an embryo fertilised by a single sperm cell directly delivered by hand, not by nature.
  • In this process, only the best sperm cells are selected to fertilise the egg with the help of a tiny glass tube penetrating the outer layer of the egg.
  • Another technique which i am going to cover is a much more direct fertilisation .One carefully selected sperm cell is selected by a skilled embryologist which is then directly injected into an egg to become an embryo The authors mentioned that ICSI broadens the indications for IVF to provide an effective treatment for all forms of male infertility and gives the clinic even greater control over the entire assisted reproduction procedure such as sperm selection etc.
  • As you can see this is the figure of the use of the assisted reproductive techniques of IVF and ICSI in Europe. IVF remains the dominant technique in UK, Netherlands, Denmark & Sweden
  • This illustration sums up the three assisted reproductive techniques that I have covered so far.
  • This chapter deals with ‘designer babies’ – where personal traits such as hair and eye colour can be “tailor-made”
  • In 2009, it caused an uproar: - where critics claimed that this kind of conceptual discrimination was more a kind of medicine which deselects embryos with unwanted genes or gene variants not for reasons of health but of cosmetics.Before the widespread availability of ICSI, in the 1990S, donor insemination was the only treatment available to counter male infertility. Much efforts were taken to match the basic characteristics of the sperm donor with those of the recipient patient
  • Clinics are aware that by transferring just one embryo, to avoid the health risks of the mother and the twins, can lower their chances of success. Authors pointed out the complications that could occur to the mother and the child for multiple pregnancies A study of all IVF clinics in Netherlands found that most couples are happy to have twins Guidelines and regulations have been put in place for the number of embryos that could be transferred, and some patients have been denied treatment based on these regulations.
  • http://www.medindia.net/news/featured-news/infertility.jpgThis chapter highlights the causes of infertility in human beings which actually lead to these assisted reproduction techniques.
  • http://www.infobarrel.com/Causes_and_Management_of_Infertility_and_SubfertilityThese are some of the biological factors that may cause infertility. [point 3] smoking, excess alcohol, and drug abuse have all linked to reduced male fertility such as low sperm count Female age is one of the reason for the rise of infertility as some women are putting off the time to start a family and reached the“social age deadline” for child bearing.
  • An interesting chapterCovers on treatments which were originally developed for the infertile but fertile humans also use some of these techniques for various reasonsMain cause for fertile people to use these techniques is due to preimplantation genetic screening also known as PGD [next slide]
  • A technique which screens multiple IVF embryos Together with the techniques of IVF & ICSI,PGD is used to select one or two embryos for various reasons such as selecting embryos which are unaffected by disease genes, for traits selection or gender selection, etc.Increase the chances of getting pregnantMake the single embryo transfer efficient & avoiding multiple pregnanciesPGD has been responsible for the birth of thousands of healthy babies.Authors state that if such births had been left to nature, without the use of PGD, these babies would have been at serious risk of inheriting genetic diseases from their parents. We will now look at the reasons why fertile people use these techniques.
  • Anyone has read this book or saw the movie adaption? A story about the younger female child who was conceived after PGD, so that she can be a bone marrow match for her elder sister who is suffering from leukemia. The younger sister seeks legal help to prevent her parents from transplantingher bone marrow to the sick sister.
  • The plot of that book relates to the concept of saviour siblingsPGD is used by parents to conceive a healthy & disease-free baby, where the baby’s blood cells can be used to cure the elder child who may be suffering from diseases such as leukemiaThis has been approved by the Human Fertilisation & Embryology Agency which is UK’s regulatory agency, responsible for ensuring that the requirements of fertility legislation are met by registered clinics However, this has encountered much controversies & moral issues such ascreating another life for the sole purpose of curing the other child
  • PGD has also been used to select the gender of a yet-to-be born child in the name of “family balancing”Not allowed in most European countries, but not disallowed in USBrings about an ethical debate which is not easy to resolve as attitudesvary greatly according to religion and culture.Authors state that gender selection might cause a population imbalance, in favour of boysEuropean Convention on Human Rights & Biomedicine disapproves gender selection for any reason other than a medical indication such as sex-related diseases
  • Some assisted reproduction techniques are used to preserve the fertility of those undergoing cancer treatment or those who postpone having kids Study shows that more women were surviving breast cancer and most lose the ability to conceive due to undergoing treatments such as chemotherapy or radiography.In this technique, before patients undergo cancer treatments, their eggs are collected, freezed and stored so that they can use it once they are cured Authors put a stand that oncologists have a responsibility that the cancer treatment may impair their fertility permanently and the appropriate patients should be referred to reproductive specialists asap. Egg-freezing is alsoused by healthy, fertile women who are keen to establish careers before starting a family.Authors predict that egg-freezing will be increasingly offered to a young female population who are keen to establish careers & finances before starting a family.
  • Involves at least 3 individuals:A couple unable or unwilling to deliver a healthy babyA surrogate mother who is prepared to undertake pregnancy & delivery on the couple’s behalfTwo ways a surrogate mother can help:By allowing her own eggs to be fertilized with the male partner’s spermBy receiving the transfer of embryos created through IVF from egg & sperm from both parents-to-beSerial surrogacy in India where surrogate mothers make it commercial by undertaking multiple pregnancies for monetary purposes.Illegal in EuropeLeads to issues such as:Surrogate mother refusing to hand over the baby to the genetic parentsWho should sponsor the surrogate mother/ Financial agreementsMiscarriage – still pay?
  • We have now seen how infertility treatments are being used for fertile peopleNow we will move on to this chapter which:Who should bear the costs of the treatments: the government or the coupleslooks into the availability of treatment in other parts of the worldAnd whether infertility can be classified as a disease
  • This perspective of WHO’s definition of infertility has been seized by many consumer groups to justify for better services and full reimbursements of infertility treatments
  • Some state that since it is a disease, it requires some form of state funding.However, there has been increasingly strong argument today that just because infertility is labelled as a ‘disease’, it cannot be justified for funding.
  • Little consistency among European governments about who should pay Patients in one region may be eligible for state-funded IVF while in another nearby region, the local health authority may have no funds availableIn May 2001, due to cuts in annual government spending, Danish government announced that IVF & ICSI would no longer be provided as free public health treatment
  • Cultural beliefs and practice a woman unable to have a baby may be disinherited, ostracised or abandoned as an unwanted wife in a polygamous relationship. In such cases infertility can lead to deep psychological suffering and social exclusion, and not just with the quality-of-life considerations which is the driving factor for most couples in developed countries. Case for treatment would be stronger if cost of IVF was lesserCould be done by simplifying the investigations and treatments
  • UK Study – authors highlighted a study by health economists who proposed an investment of 12,931 pounds to achieve a single live birth from IVF would actually be worth 8.5 times that amount to the UK Treasury in future tax revenue1Proposing that it would pay handsome reward in the futureNo European country (and Singapore ) has embraced IVF as part of dedicated population policy.Even those countries (like Belgium) which do provide IVF to their citizens as part of their nationalised health service do so as a result of a fair and equitable health policy, not a population policy. State has a legitimate role to play in the safe application of our IVF technologies and under what conditions they are most reasonably used. 1 Connolly M, Gallo F, Hocrens S, Ledger W, 'Assessing long-run economic benefits attributed to an IVF-conceived singleton based on projected lifetime net tax contributions in the UK' Human Reproduction 2009; 24: 626-32·
  • Explains about what lies ahead in the assisted reproduction techniques ; particularly the normal science following the techniques
  • Was awarded Nobel Peace Prize for the development of IN vitro fertilization. Nobel Assembly stated that his contributions represent a milestone in the development of modern medicine OppositionThe Catholic church has consistently opposed TVF because it removes conception from sexual intercourse and because the embryo bas the moral status of a human being from the moment of conception, has the potential to be destroyed. Same protection principle as abortion
  • Posthumous reproduction - states that technology allows the sperm or the egg to be retrieve from the humans and stored before deathConcerns about for the welfare of the child and the psychological condition of the surviving partner Pregnancy in older women – state that women’s life expectancy has increased and the use of egg donation can achieve higher success rate in these womenMaria del Carmen Bousada de Lara (Spain, lied aboutheragewhenseekingtreatment in Los Angeles)OmkariPanwar (India, gave birth to twins – a boy & a girl, Panwar, givenIVF treatment with oocytes donation)
  • Baby-making : what the new reproductive treatments mean for families & society

    1. 1. The Straits Times, 16 March 2012
    2. 2. Image source: Amazon.com
    3. 3. The authors…. Professor Bart Fauser & Professor Paul Devroey
    4. 4. Outline1. How to design a baby?2. What couples want and how we deal with it3. The infertility epidemic4. Infertility treatments for fertile people5. Who pays? : the social implications6. How far can we go?
    5. 5. How to design a baby?
    6. 6. Assisted reproductive techniques In vitro fertilisation (IVF)
    7. 7. Fathers of IVF Robert Edwards & Patrick Steptoe
    8. 8. World’s First IVF baby Images: The Telegraph, UK
    9. 9. Issues with IVF Respond with too few eggs Ovarian hyper simulation syndrome Ability of an embryo to implant in the uterus (30to 60 %) Risks of multiple pregnancies Unable to treat male inferitility  micromanipulation technique
    10. 10. Assisted reproductive techniques Micromanipulation or Micro-insemination sperm transfer (MIST) Image: Journal of Clinical Endocrinology & Metabolism
    11. 11. The Straits Times, 25 April 1989, Page 1
    12. 12. The Straits Times, 25 April 1989, Page 1
    13. 13. Assisted reproductive techniques Intracytoplasmic sperm injection (ICSI) Image: MyFertilityChoices.com
    14. 14. IVF vs. ICSI Figures for Europe  In 2001, 49 % of all assisted reproductive techniques were with ICSI  In 2003, proportion increased to 55% and to 63 % in 2005  In some European countries use of ICSI outweighed IVF  Germany (70%), Italy (73%), Belgium (75%), Spain (83%) & Turkey (97%) - as of 2005  IVF remains the dominant technique in UK, Netherlands, Denmark & Sweden
    15. 15. A. In vitro fertilisation (IVF) B. Micromanipulation or Micro-insemination sperm transfer (MIST) C. Intracytoplasmic sperm injection (ICSI)Image: Journal of Clinical Endocrinology & Metabolism
    16. 16. What couples want and how we deal with it?
    17. 17. Singleton or twin pregnancy?
    18. 18. The Infertility Epidemic Image: MedIndia.net
    19. 19. Causes of infertility Blocked tubes / hormonal problems (female) Low sperm count or morphology (male) Female age Uterine dyfunction Ovarian dyfunction Sperm dyfunction Premature menopause Image: Infobarrel.com
    20. 20. Infertility Treatments for Fertile People
    21. 21. Preimplantation genetic screening (PGD) A technique which screens multiple IVF embryos Used to  improve embryo selection for IVF  increase the chance of pregnancy and  make single embryo transfer more efficient. Used to select embryos which are unaffected by suspect gene from fertile parents
    22. 22. Saviour siblings Parents conceive a healthy, disease-free baby  Use the baby’s blood cells are used to cure the elder child suffering from diseases Approved by the Human Fertilisation & Embryology Agency in UK Controversies & moral issues
    23. 23. Gender selection In the name of “family balancing”’  Not allowed in most European countries, but not disallowed in US Ensues an ethical debate, which is not easy to resolve Approved only on the grounds of medical indication where serious hereditary sex-related disease is to be avoided.
    24. 24. Fertility preservation Preserve the fertility of those undergoing treatment or those who postpone having kids Oncologists have a responsibility to refer patients to reproductive specialists Egg-freezing – used by healthy, fertile women who are keen to establish careers before starting a family
    25. 25. Surrogacy Image source: Guardian.co.ukImage source: JustFamilies.org
    26. 26. Who Pays? :The Social Implications
    27. 27. Infertility: a disease? WHO’s definition of reproductive health“... that people are able to have a responsible , satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. 1 ” Anything short of the above ideal therefore falls short of WHO’s definition of health which is the “state of complete physical, mental and social well being”. 2 1 http://www.who.int/topics/reproductive_health/en/index.html 2 http://www.who.int/about/definition/en/print.html
    28. 28. Infertility: a disease? The authors’ argument“....if we accept WHO claim that ‘health’ is not just the absence of diseases but is also a psycho- social state of well-being, that reproductive health is not just about having children but having the potential to meet one’s reproductive rights to safe and fulfilling parenthood, then the treatment of infertility does indeed lay claim to social support. (p. 207) ”
    29. 29. Labelling “infertility” as a disease Justification for Funding
    30. 30. Paying for infertility treatment Little consistency among European governments about who should pay Denmark had the most generous state funding policies in Europe , providing reimbursement s for up to 3 cycles of treatments  In May 2001, Danish government announced that IVF & ICSI would no longer be provided as free public health treatment  Nevertheless, in 2007, the 4 to 9 % of all children born in Denmark had been conceived by assisted reproduction
    31. 31. Treatment in developing countries Role of children is associated with cultural beliefs and practice in these countries Growth of IVF in China & India  keeping pace with their rapid economic growth Investigation and treatment of infertility remain largely neglected in poorer regions of Latin America, Asia & Africa Case for treatment would be stronger if cost of IVF was lesser  Could be done by simplifying the investigations and treatments
    32. 32. Whose responsibility? Assisted reproduction ‘does have potential’ to contribute to total fertility and influence population structure Reasons for not having children are not just biological  Working hours, child care, maternity leave, etc. Some countries have adopted pro-fertility policies to encourage childbirth  E.g. Spain’s baby bonus, France’s ‘code de familie’ Authors bring an economical perspective on funding assisted reproduction – UK Study
    33. 33. How Far Can We Go?
    34. 34. Robert Edwards Awarded Nobel prize in Medicine in 2010  IVF was introduced in 1976  Opposition from the Catholic Church  Extent to which IVF has necessitated the discarding of embryos
    35. 35. Looking ahead…. Posthumous reproduction Pregnancy in older women
    36. 36. In conclusion….

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