2013Marek Vácha

It is not birth, marriage, or death, but gastrulation, which is truly the most important time in your life.

Lewis Wolpert (1986)

IVF+ET is not the only option for infertile coupels

less than 3% of all patient who seek treatment for infertility will need to use IVF

most infertile couples who seek evaluation and treatment respond well to less complicated treatment options, such as• hormonal therapy• artificial insemination

(Gilbert, S.C., Tyler, A.L., Zackin, E.J., (2005) Bioethics and the New Embryology. Sinauer Associates, Inc. W.H. Freeman & comp. Sunderland, MA U.S.A. p. 65)

World

In Denmark, for instance, in 2007, some 5 pecent of children were the result of ART.

In Australia, it is around 3 percent. In many Europian countries, it is about 3,5

percent. Jones, W.H., (2012) Personhood Revisited. Reproductive Technology, Bioethics, Religion and the Law.

Langdon Street Press. Minneapolis, MN. p.203

Jim Watson: uncorrectable mistake souled be made and that these mistakes were with human beings, and therefore the work should not be done

Leon Kass: emphasized the possibility of abnormalities

Paul Ramsey: procreation is God´s work and humans should not be involved

Jones, W.H., (2012) Personhood Revisited. Reproductive Technology, Bioethics, Religion and the Law. Langdon Street Press. Minneapolis, MN. p. 18

„Because the new procedures for in vitro fertilization and laboratory culture of human embryos probably carry a serious risk of damage to any child so generated, there appears to be no ethical way to proceed.

One cannot ethically choose for a child the unknown hazards that he must face and simultaneously choose to give him life in which to face them.“

The New England Journal of Medicine, 1971 Jones, W.H., (2012) Personhood Revisited. Reproductive Technology, Bioethics, Religion

and the Law. Langdon Street Press. Minneapolis, MN. p.19

„there is at present no way of finding out in advance whether or not the viable progeny of the procedures of in vitro fertilization, culture, and transfer of human embryos will be deformed, sterile or retarded. “

The New England Journal of Medicine, 1971 Jones, W.H., (2012) Personhood Revisited. Reproductive Technology, Bioethics,

Religion and the Law. Langdon Street Press. Minneapolis, MN. p.19

„I must judge that in vitro fertilization constitutes unethical medical experimentation on possible future human beings, and therefore it is subject to absolute moral prohibition. “

The Journal of the American Medical Association, 1972 Jones, W.H., (2012) Personhood Revisited. Reproductive Technology, Bioethics,

Religion and the Law. Langdon Street Press. Minneapolis, MN. p.20

First „test tube baby“

July, 25, 1978 – Louise Brown

Louise Brown with her parents, 25-year-oldin 2003

A Delivery. LB. Patrick Steptoe right, Robert Edwards left

They persisted through more than 40 embryo transfers before obtaining their first pregnancy. Unfortunately it was ectopic and had to be aborted. Louise Brown was born from the second pregnancy.

2010: Nearly four million babies have been born using IVF fertility treatment since

1978. 2012: 5 million

„I had a normal conception and pregnancy despite my abnormal childhood.“

http://www.boston.com/news/health/articles/2010/08/06/a_first_for_the_first/?page=1

1983 = donation of oocyte 1993 = ICSI 2000 = PGD

1982 - Brno – first IVF at eastern block, GIFT. But till 1987 at ČR 10 children only

1988 – first twins at ČR 1994 – first triplets at  ČR

1. Ovarian stimulation2. Egg retrieval3. Fertilization (IVF)4. Embryotransfer (ET)

Happy are all who fear the Lord, who follow His ways… Your wife shall be like a fruitful vine within your house; your children, like olive saplings around your table… jsou neplodní lidmi druhé kategorie…?

Numbers of Sperms

1940 113 millions /ml

1990 66 millions /ml

the number of „normal“ sperm fell from 60 million per mL to 20 mL in the same period(Carlsen, E., Giwercman, A., Keiding, N., Skakkebaek, N., (1992) Evidence of decreasing quality of semen during past 50 years. Brit. Med. J. 305: 609-613)

Man Examination: Spermiogram

Normal spermiogram Pathological Spermiogram

Woman Examintaion Ultrasound

Ovulation cycle Anovulation

Useful terms AIH - homologous fertilization = artificial

insemination husband AID - heterologous fertilization = artificial

insemination donor “ (Encyclopedia of Bioethics,4/2219)

IVF + ET

Therapy I. MUDr. Karel Janíček

discussion, explanation of the situation conception optimum

menses calendar, density of the cervical mucus, ovulation testes etc.

Psychotherapy

Therapy II. MUDr. Karel Janíček

Stimulation of Ovulation

Therapy III. MUDr. Karel Janíček

Intrauterinne insemination

Therapy IV. MUDr. Karel Janíček

In vitro fertilization (IVF)

Therapy V.MUDr. Karel Janíček

ICSI (intracytoplasmatic sperm injection)

Testicular Biopsy for ICSI e.g. here:http://www.medicalvideos.us/play.php?vid=1363

ICSI e.g. herehttp://www.dnatube.com/video/2716/ICSI--Intracytoplasmic-Sperm-Injection

USA

the average cost per delivery in 1994 was $ 66,667 for couples undergoing their first cycle of oocyte maturation...

...rising to over $ 114,250 for those couples on their sixth attempt this does not include the hospital fees for

multiple births (which often exceeded $ 100 000)

(Gilbert, S.C., Tyler, A.L., Zackin, E.J., (2005) Bioethics and the New Embryology. Sinauer Associates, Inc. W.H. Freeman & comp. Sunderland, MA U.S.A. p. 77)

USA

Right now, it is strictly a market economy, and there is very little regulation put on any physician who wants to start a clinic.

If a couple knows it might be possible to have a genetically related child if only they were wealthy enough, does it frustrate more people than it helps?

(Gilbert, S.C., Tyler, A.L., Zackin, E.J., (2005) Bioethics and the New Embryology. Sinauer Associates, Inc. W.H. Freeman & comp. Sunderland, MA U.S.A. p. 77)

Egg retrievalhttp://www.sdfertility.com/ivf_video_egg_retrieval.htm

in general, each egg is incubated for 12 - 18 hours with 50 000 - 100 000 motile sperm

fertilization rates are between 50% - 70%

Embryotransfer: usually 3 day after fertilization (embryo has 6-8 cells)

semen sample is placed into a thick solution and only those sperm that are able to swim to the top are collected• this selected for motile sperm , and motility is

usually a good sign that sperm are alive and well

selective sperm are then capacitated artificially by incubating them for few hours in a solution containing high amounts of protein and calcium ions

if IVF has been achieved but, after a number of cycles, implantation into the uterus consistently fails, the physicians may suggests assisted hatching

a microscopic hole is made in the zona pellucida prior to inserting the embryo into uterus

http://www.youtube.com/watch?v=ah3An0vYz-U• this technique will usually ensure

that the embryo is able to hatch from the zona pellucida in time to adhere to the uterus

1983: the first transfer of a cryopreserved ("frozen and thawed") human embryo

the succes rate is 50% - 33% of the succes rate of the fresh embryo

2005, after one round of gamete retrieval

age of the women• under 35 years: 31%• 35 - 37 years: 25,5%• 38 - 40 years: 17,1%• over 40 years: less than 5%

(Gilbert, S.C., Tyler, A.L., Zackin, E.J., (2005) Bioethics and the New Embryology. Sinauer Associates, Inc. W.H. Freeman & comp. Sunderland, MA U.S.A. p.69)

www.uzis.cz

it is the current opinion that these children are as normal as any children born to infertile couples.

Jones, W.H., (2012) Personhood Revisited. Reproductive Technology, Bioethics, Religion and the Law. Langdon Street Press. Minneapolis, MN. p.21

Donation of gamets

up to 85 % IVF+ET is taking place with the help of ICSI Sweden: every citizen 18+ has the right to

know his or her biological parents When Sweden passed a law in 1985 requiring

that the identity of the semen donor should be recorded to enable the child at eighteen years of age to contact the biological father, this resulted in the almost total disappearance of donors in Sweden and frequent referral of couples to other parts of Scandinavia

at ČR is donation anonymous

Australia: A registry identifying donors is open to children at age eighteen, equialent to the law on adoption

American states, however, have uniformly protected the identity of donors and recipients

(Dorff, E.N., (2003) Matters of Life and Death. A Jewish Approach to Modern Medical Ethics. The Jewish Publication Society, Philadelphia, PA, p. 86)

Ovarial hyperstimulation syndrome

women who had used fertlility drugs had three times the risk of invasive epithelial ovarian

cancer compared to women without a history of infertility

four times the risk of ovarian tumors of low malignant potential seen among women lacking a history of infertility

mood swings

prenatal sex selection

in almost all cases, males have been preferred. for sex selection

to have intercourse in the summertime (Aristotle) ligation testicles (the right one was believed to

contain the male-producing semen) eating certain foods mating in particular times in woman´s menstrual

cycle wearing boots to bed

(Gilbert, S.C., Tyler, A.L., Zackin, E.J., (2005) Bioethics and the New Embryology. Sinauer Associates, Inc. W.H. Freeman & comp. Sunderland, MA U.S.A. p. 96)

the preference for sons stems from the patriarchal structure in which most social resonsibilities are carried out by males, including sons´traditional role of caring for parents during old age, and the culatural practice of providing a dowry to the new son-in-law at a daughter´s wedding

girls thus are a social and financial liability

there are 100 million fewer living women than we should expect 44 million fewer in China 37 million fewer in India

(Blackburn, S., (2001) Ethics. A Very Short Introduction. Oxford University Press, Oxford, p. 50)

A study based on 1,1 million Indian household in 1997 showed that although

numbers of boys and girls born were almost equal for the first child

759 girls were born per thousand boys for second children

and only 719 girls per thousand boys for third children

this practice accounted for 10 million fewer indian girls being born over the last 20 years

(Mepham, B., (2008) Bioethics. An Introduction for the Biosciences. Oxford University Press, Oxford, p. 125)

http://www.bbc.co.uk/news/world-south-asia-13264301

In Bombay, a 1985 survey found that 96% of aborted female fetuses were aborted after amniocentesis revealed their sex

One study found that out of 8 000 reported abortions, 7 999 of them were of female fetuses

(Gilbert, S.C., Tyler, A.L., Zackin, E.J., (2005) Bioethics and the New Embryology. Sinauer Associates, Inc. W.H. Freeman & comp. Sunderland, MA U.S.A. p. 99)

2008: the indian government has developed a financial incentive program. It is offering to pay poor families nearly $ 3000 to have and raise daughters.

In regions with the worst female-male ratios, families will receive $ 385 when the girl is born and another $ 2500 when she turns 18, provided that she has completed her education and remains unmarried.

Pierce, J., Randels, G., (2010) Contemporary Bioethics. Oxford University Press, NY, Oxford. p. 363

In China, the young men are known as guang gun-er ("bare branch") because they represent "branches of the family tree that would never bear fruit because no marriage partner might be found for them"

studies have shown that the guang gun-er commit a disproportionately high fraction of the crime in their respective areas.

And the gender imbalance in provinces like Anhui, Hainan, Guangdong and Jiangxi is already quite without parallel in a modern society, with between 30 and 38 per cent more males than females.

Ferguson, N., (2011) Civilization. The West and the Rest. Allen Lane, Penguin Books. New York.

PID is widely used to preventa the birth of sons in women known to be carriers for X-linked lethal or debilitating diseases.

For instance, a woman who is a carrier for the X-linked conditions hemophilia or musculrar dystrophy may not want to suffer through the "tentative pregnancy" associated with amniocentesis or chorionic villus sampling, and then have to decide wheataher or not to abort the male fetus should it prove to have the disease. Such women can instead undrgo in bitro fertiiliization and have only XX embryos implanted; the female infants whould be unaffected by X-linked diseases (although they have a 50% chance of being carriers)

(Gilbert, S.C., Tyler, A.L., Zackin, E.J., (2005) Bioethics and the New Embryology. Sinauer Associates, Inc. W.H. Freeman & comp. Sunderland, MA U.S.A. p. 95)

„Your child will be female, which increases the risk of sexual abuse, domestic violoence and poverty.“

the American Medical Association has advised physicians that sex selection of this kind in the absence of any accompanying health problems is not something that physicians should do.

(Richards, J.E., Hawley, R.S., (2005) The Human Genome. A User´s Guide. 2nd ed. Elsevier Academic Press, Burlington, MA, USA, p.386)

generally, the sex selection in USA is made for the second or third baby, not for the first

69% of interviewees though sex selection should be restricted in some way

80% thought that sex selection for nonmedical reasons shoud not be permitted at all.

(Gilbert, S.C., Tyler, A.L., Zackin, E.J., (2005) Bioethics and the New Embryology. Sinauer Associates, Inc. W.H. Freeman & comp. Sunderland, MA U.S.A. p. 101)

preimplantation genetic diagnosis

the American Medical Association has advised physicians that sex selection of this kind in the absence of any accompanying health problems is not something that physicians should do.

(Richards, J.E., Hawley, R.S., (2005) The Human Genome. A User´s Guide. 2nd ed. Elsevier Academic Press, Burlington, MA, USA, p.386)

- if PGD is not permitted, pregnancy and abortion might occur instead

following a public consultation exercise in the UK, the HFEA announced in 2003 that it had decided to ban sex-selection for „family balancing“, although permitting it where a child of one sex would risk inheriting a serious genetic disorder

Another major issue is the perception that choosing one sex is rejecting the other.

What message does it send to a mother´s sons if she is willing to spend thousands of dollars just to ensure that she does not have another boy?

What message does a little girl get from parents who are searching for ways to make sure their next child is a son?

sex selection is "the exercise of sexism at the most profound level, choosing who gets born, and which types of lives are acceptable." (The Human Genetics Alert Campaign)

When we select s product at the grocery store, we do so because we expet it to have certain characteristics and be of certain wuality. Similarly, in choosing a child´s sex, we are expecting the child to conform to our preconceived ideas of how the particular sex behaves.

Ovum donation

UK

In 2003 in the UK only 20 eggs were donated for research, and in general those that are surplus to requirements in IVF programmes tend to be of poor quality.

this led the HFEA in 2007 to permit researchers to reimburse women up to £250 for their eggs, although the donors will be required to show that they are „acting altruistically“

women donating eggs in this way may also have the fee for their own IVF treatment halved, which would be equivalent to a payment of about £1500

UK

critics suggests that this is likely to result in the exploitation of poorer women, many of whom may be induced to travel to Britain from abroad to sell their eggs.

(Mepham, B., (2008) Bioethics. An Introduction for the Biosciences. Oxford University Press, Oxford, p. 143)

Possible scenarios of the future

Collins, F., (2006) The Language of God. Free Press, New York, p. 269)