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The Art of The Art of ARTART::Assisted Reproductive Assisted Reproductive TechnologyTechnology
Mary L. Davenport, M.D.Mary L. Davenport, M.D.
Berkeley Students for LifeBerkeley Students for Life
March 4, 2009March 4, 2009
What is ART?What is ART?
Assisted Reproductive Assisted Reproductive Technologies:Technologies:
Fertility therapies where eggs and Fertility therapies where eggs and sperm are manipulatedsperm are manipulated
Involve surgically removing eggs Involve surgically removing eggs from women and combining them from women and combining them with sperm in the laboratorywith sperm in the laboratory
ART: Assisted Reproductive TechnologyART: Assisted Reproductive Technology
Predominantly IVF – In Vitro FertilizationPredominantly IVF – In Vitro Fertilization ExpensiveExpensive Most attempts fail to produce a live birthMost attempts fail to produce a live birth Separates procreation from the marital Separates procreation from the marital
actact Large loss of embryos in failure to Large loss of embryos in failure to
implant, discarding embryos, pre-implant, discarding embryos, pre-implantation diagnosis, freezing, implantation diagnosis, freezing, selective reductionselective reduction
TYPES OF ART SART 1999
IVF
ASSISTED REPRODUCTIVE ASSISTED REPRODUCTIVE TECHNOLOGYTECHNOLOGY
Major philosophical and ethical Major philosophical and ethical shift in reproductive medicineshift in reproductive medicine
Emphasis changed from healing Emphasis changed from healing and eradicating disease to control and eradicating disease to control of procreationof procreation
REPRODUCTIVE CHRONOLOGYREPRODUCTIVE CHRONOLOGY
1934 Gregory Pincus: First animal 1934 Gregory Pincus: First animal IVFIVF
1944 John Rock: First human IVF1944 John Rock: First human IVF 1960 FDA approves “the pill”1960 FDA approves “the pill” 1978 First IVF baby1978 First IVF baby 2001 421 U.S. ART clinics with 41,000 2001 421 U.S. ART clinics with 41,000
live births annuallylive births annually
GREGORY PINCUSGREGORY PINCUS
1934 First in vitro 1934 First in vitro fertilization of rabbit fertilization of rabbit eggseggs
Criticized as “mad Criticized as “mad scientist” scientist”
Developed oral Developed oral contraceptives in contraceptives in 1950’s1950’s
Dr. John RockDr. John Rock1890-19841890-1984
1936 First doctor 1936 First doctor to open a Rhythm to open a Rhythm clinic in Bostonclinic in Boston
1944 First IVF; 1944 First IVF; created four created four embryos in secretembryos in secret
1954 1954 Collaborated with Collaborated with Pincus on U.S. Pincus on U.S. clinical trials of clinical trials of the pillthe pill
STEPTOE AND EDWARDSSTEPTOE AND EDWARDSBirth of Louise BrownBirth of Louise BrownFirst IVF Baby, 1978First IVF Baby, 1978
Why ART?Why ART?
Infertility: Extremely PrevalentInfertility: Extremely Prevalent
Definition: inability to achieve Definition: inability to achieve pregnancy in one yearpregnancy in one year
17-26% of couples worldwide (90 17-26% of couples worldwide (90 million women)million women)
27-47% of infertile couples have 27-47% of infertile couples have impaired male fertility; decline in impaired male fertility; decline in semen quality worldwide over last 50 semen quality worldwide over last 50 yearsyears
Why the increase in infertility?Why the increase in infertility?
Delayed marriage and child-bearingDelayed marriage and child-bearing Sexually transmitted diseasesSexually transmitted diseases Hormonal contraceptionHormonal contraception AbortionAbortion ObesityObesity Environmental PollutionEnvironmental Pollution
FERTILITY CLOCK
What is IVF?What is IVF?
IVF (in vitro fertilization) is a IVF (in vitro fertilization) is a method in which egg cells are method in which egg cells are fertilized by sperm cells outside the fertilized by sperm cells outside the mother’s womb (in vitro). The mother’s womb (in vitro). The resulting embryos are then resulting embryos are then transferred back into the uterus.transferred back into the uterus.
STEPS IN IVFSTEPS IN IVF
Follicle suppressionFollicle suppression Controlled ovarian hyperstimulationControlled ovarian hyperstimulation Aspiration of eggs from folliclesAspiration of eggs from follicles Fertilization, incubation and selection of Fertilization, incubation and selection of
embryosembryos Embryo transferEmbryo transfer Pregnancy testPregnancy test
FOLLICLE SUPPRESSION ANDFOLLICLE SUPPRESSION ANDCONTROLLED OVARIAN HYPERSTIMULATIONCONTROLLED OVARIAN HYPERSTIMULATION
ASPIRATION OF EGGSASPIRATION OF EGGS
IVF LAB: FOLLICULAR FLUID
HIGH QUALITY EGG
LOW QUALITY EGG
EMBRYOLOGIST MANIPULATING OVA AND SPERM
ICSI
INCUBATOR
HIGH QUALITY THREE DAY OLD EMBRYO
EMBRYO TRANSFEREMBRYO TRANSFER
IVF:IVF:
WHY NOT?WHY NOT?
IVF Why not?IVF Why not?
LOSS OF LIFELOSS OF LIFE
IVF OUTCOMES
SART 1999
Pregnancy Rates: Nondonor Eggs SART,CDC, 2004
LOW QUALITY EMBRYO
TANK FOR FREEZING EMBRYOS
MFPRMFPRMULTIFETAL PREGNANCY REDUCTIONMULTIFETAL PREGNANCY REDUCTION
ART Outcomes by Age SART, CDC, 2004
COMPARISON OF OWN AND DONOR EGGSCOMPARISON OF OWN AND DONOR EGGS
Pregnancy Loss by Age: CDC
IVF why not?IVF why not?IVF permits the use of donor ova and IVF permits the use of donor ova and sperm and cloned embryossperm and cloned embryos
Violates traditional Judeo-Christian concept of Violates traditional Judeo-Christian concept of marriage marriage
Legal and biologic confusion Legal and biologic confusion ““Commercialization” of human life—sale of ova Commercialization” of human life—sale of ova
and spermand sperm Donor ova and sperm illegal in many countriesDonor ova and sperm illegal in many countries Cloned embryos can be usedCloned embryos can be used Cloning a dangerous technology and makes Cloning a dangerous technology and makes
massive abuses possiblemassive abuses possible
COMPARISON OF OWN AND DONOR EGGSCOMPARISON OF OWN AND DONOR EGGS
Egg donor
Characteristics:
e.g. Hair color,
Weight
Ethnicity…
CLONED HUMAN EMBRYOCLONED HUMAN EMBRYO
PANAYIOTIS ZAVOS, PH.DPANAYIOTIS ZAVOS, PH.D..
CURRRENTLY CURRRENTLY CONDUCTING CONDUCTING HUMAN CLONING HUMAN CLONING EXPERIMENTS IN EXPERIMENTS IN UNDISCLOSED UNDISCLOSED COUNTRY WITH COUNTRY WITH DRS. SEVERINO DRS. SEVERINO ANTORINI AND ANTORINI AND BEN-ABRAHAMBEN-ABRAHAM
GOAL: GOAL: PROVIDING PROVIDING CHILDLESS CHILDLESS COUPLES WITH COUPLES WITH THE ABILITY TO THE ABILITY TO CLONE CLONE THEMSELVES AS THEMSELVES AS A FORM OF A FORM OF REPRODUCTIONREPRODUCTION
IVF Why not?
MULTIPLE BIRTHS
IVF why not? Multiple birthsIVF why not? Multiple births Multiple pregnancies with IVF (37.4%)Multiple pregnancies with IVF (37.4%) Triplets or more 8.4% (4.9% of live births)Triplets or more 8.4% (4.9% of live births) Prematurity: Average with triplets 33 weeks; 85% Prematurity: Average with triplets 33 weeks; 85%
survivesurvive Prematurity: Quadruplets average 29 weeks; Prematurity: Quadruplets average 29 weeks;
70% survive70% survive Fetal risks: mental/physical disabilities such as Fetal risks: mental/physical disabilities such as
blindness, cerebral palsy; 5% in twins, 10% in blindness, cerebral palsy; 5% in twins, 10% in triplets, 50% in quadrupletstriplets, 50% in quadruplets
Fetal risks: death; seven times more likely to die Fetal risks: death; seven times more likely to die in the first year; 40x more likely to die in infancyin the first year; 40x more likely to die in infancy
Maternal risks: toxemia, diabetes, hemorrhageMaternal risks: toxemia, diabetes, hemorrhage Family risks: depression, social isolation, divorceFamily risks: depression, social isolation, divorce
IVF: ExpensiveIVF: Expensive Medication: $1,500-$7,000 per cycleMedication: $1,500-$7,000 per cycle Office visits, egg retrieval, fertilization, Office visits, egg retrieval, fertilization,
assisted hatching, cryofreezing of embryo assisted hatching, cryofreezing of embryo (six months),ultrasound, lab tests: (six months),ultrasound, lab tests: $12,000-18,000 $12,000-18,000 PER CYCLEPER CYCLE; ;
Egg donation $3,000-$50,000Egg donation $3,000-$50,000
IVF: Additional CostsIVF: Additional Costs Hospital costs - Singleton $10,000; Hospital costs - Singleton $10,000;
Twins $20,000; Triplets $40,000Twins $20,000; Triplets $40,000 Intensive care of baby: $100,000-Intensive care of baby: $100,000-
$150,000 per month$150,000 per month Work time lost--daily medical visitsWork time lost--daily medical visits Frequently not covered by insuranceFrequently not covered by insurance
Benitez v North Coast Women’s Medical GroupBenitez v North Coast Women’s Medical Group
Lesbian couple desired pregnancyLesbian couple desired pregnancy ObGyn group declined to perform IUI ObGyn group declined to perform IUI
(Intrauterine insemination) because of (Intrauterine insemination) because of marital status (or sexual orientation ?) marital status (or sexual orientation ?) based on physicians’ religious beliefsbased on physicians’ religious beliefs
Lower court found in favor of the doctorsLower court found in favor of the doctors California Supreme Court found in favor California Supreme Court found in favor
of Benitezof Benitez
R. Alta Charo, J.D.R. Alta Charo, J.D.Professor of LawProfessor of LawUniversity of WisconsinUniversity of Wisconsin
““The Celestial Fire The Celestial Fire of Conscience: of Conscience: Refusing to Refusing to Deliver Medical Deliver Medical Care”Care”
New England Journal New England Journal of of Medicine Medicine
June 16, 2005June 16, 2005
The McCaughey Septuplets 1997
The Chukwu Octuplets
Dr, Michael Kamrava