Dilemmas in ART – Looking for solutions

Kuldeep Jain

doi:10.4103/fsr.fsr_5_18

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Editorial

4 (

1

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doi:

10.4103/fsr.fsr_5_18

Dilemmas in ART – Looking for solutions

Kuldeep Jain

Editor-in-Chief, Fertility Science and Research

Address for correspondence: Dr. Kuldeep Jain, Editor-in-Chief, Fertility Science and Research, 23-24, Gagan Vihar, Main Road (Near Karkardooma Flyover), Delhi 110051, India E-mail: jainravi6@rediffmail.com

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This article was originally published by Wolters Kluwer - Medknow and was migrated to Scientific Scholar after the change of Publisher.

Though the assisted reproductive technology (ART) has given hope to a large number of couples suffering from infertility, it has also hosted innumerable technical, ethical, legal, and social challenges for the future.

Advancements in the field have resulted in a landmark shift in the way physicians and the general population perceive infertility and related issues. The reproductive science is unswervingly challenging the society to re-evaluate the way in which human life, social justice, and claims to resulting genetic offspring are viewed. These issues will challenge the technology and legal organizations to modify existing laws to accommodate its unique situations.

We also need to devote resources and energies to identify and remove the environmental and physical causes of infertility. Prevention, education, and increased access to appropriate and cost-effective fertility care, including insurance coverage, are also imperative so that more families throughout the world are able to have children when they are ready safely.

HISTORY AND EVOLUTION OF IN-VITRO FERTILIZATION GLOBALLY

The beginning

The history of in-vitro fertilization (IVF) and embryo transfer (ET) dates back as early as the 1890s when Walter Heape, a professor, and physician at the University of Cambridge, England, who had been conducting research on reproduction in a number of animal species, reported the first known case of embryo transplantation in rabbits, long before the applications to human fertility were even suggested.

In 1934, Pincus and Enzmann,^[1] from the Laboratory of General Physiology at Harvard University, published a paper in the Proceedings of the National Academy of Sciences of the USA, raising the possibility that mammalian eggs can undergo normal development in vitro. Fourteen years later, in 1948, Miriam Menken and John Rock^[2] retrieved more than 800 oocytes from women during operations for various conditions. One hundred and thirty-eight of these oocytes were exposed to spermatozoa in vitro. In 1948, they published their experiences in the American Journal of Obstetrics and Gynaecology.

However, it was not until 1959 that the indisputable evidence of IVF was obtained by Chang^[3] who was the first to achieve births in a mammal (a rabbit) by IVF. The newly ovulated eggs were fertilized, in vitro by incubation with capacitated sperm in a small Carrel flask for 4 h, thus opening the way to assisted procreation.

Professionals in the fields of microscopy, embryology, and anatomy laid the foundations for future achievements. The recent rapid growth of IVF–ET and related techniques worldwide are further supported by the social and scientific climate which favors their continuation.

Through the years, numerous modifications have been made in the development of IVF–ET in humans: refinement of fertilization and embryo culture media; earlier transfer of the embryo; improvements in equipment; use of a reduced number of spermatozoa in the fertilization dish, embryo biopsy among others.

The purpose of this introduction is to acknowledge those who initiated new steps in the development of the treatment protocols and techniques that we now use facilitating such simple and promising IVF–ET procedures.

Evolving assisted reproductive technology in modern era

In 1978, the world witnessed the birth of the first “test tube baby.”^[9] Since then, there have been explosive advances in ARTs. Current optimizations surrounding the delivery of IVF including the utilization of minimal stimulation protocols and gonadotropin-releasing hormone (GnRH) agonist cycle triggers are being increasingly utilized to maximize patient safety. Modifications, such as IVM and cryopreservation seen in the embryology laboratory, continue to improve pregnancy rates. Concurrent with these advancements in IVF has been the emergence of related technologies, such as embryonic genetic diagnostic and screening and oocyte freezing, which potentially has broad applications for both fertile and infertile couples. Another technology such as time-lapse imaging may be a powerful tool to select embryos best suited for uterine transfer in IVF cycles. As these relevant applications of ART become increasingly utilized, it is incumbent on the society to ensure that these resources are made available in a morally responsible and equitable manner.

Many aspects of clinical practice in ART raise challenging issues, controversies, and dilemmas for service providers:

(1) Surrogacy: Central concern surrounding the use of surrogates and gestational carriers is the possibility that financial pressures could lead to the exploitation and commercialization of the service.^[91] Additionally, the rights of the surrogate or gestational carrier to not relinquish the infant after delivery are not well described.^[92]

At present, issues surrounding the individual rights, exploitation, and citizenship of the resulting offspring of international gestational carriers are largely unresolved internationally.^[93] The proposed Indian Surrogacy (Regulation) Bill, 2016, inter alia, provides) to allow ethical altruistic surrogacy to the intending infertile Indian married couple only between the age of 23–50 years and 26–55 years for female and male respectively; (c) the intending couples should be legally married for at least five years and should be Indian citizens to undertake surrogacy or surrogacy procedures and prohibits surrogacy for international patients and commercial surrogacy.^[94]

One need to debate keeping the individual need of infertile couple who do not have an option other than surrogacy and do not have one in family, whether banning the commercial surrogacy is justified or it requires a regulation.

(2) Donor conception: It would be a challenging issue in coming decades. With growing information and technology, the clientele may not agree for donor cycles. Stimulation protocols and stem cells would play an important role.

(3) PGD: In the near future, with refinements in microarray technology and the definition of genetic sequences associated with certain physical characteristics, it is conceivable that specific physical or mental characteristics may be evaluated to guide the decision as to which embryos to transfer.^[95]

(4) Cryofrozen embryos: Embryo freezing is a robust and routine part of the IVF process, and approximately 60% of patients end up with some embryos in storage. This process provides patients with a “back-up” in case the initial fresh ET does not result in a pregnancy and if patients come back after few years to have a second child. Cryofrozen embryos of patients with single child norms would flood our cryobiology laboratories with challenges in disposing them.

However, the legal issues of whether an unborn is entitled to any rights, and if so what they are, have appeared in several different areas of law and need to be resolved.^[96]

(5) Fertility preservation: Fertility preservation for patients with cancer using IVM, oocyte Vitrification, and the freezing of intact human ovaries with their vascular pedicles have also been reported.^[97] However, this technology at present, in many countries, is only available to those with financial means. This poses ethical and social issues that will certainly see more attention in the future.

(6) Deteriorating male factor: Deteriorating male factor is the reduction of normal sperm count, motility, and morphology, and this increase in the deterioration of male factor and fertility fecundity has been a concern for ages. Various lifestyle factors such as tobacco smoking, chewing, and alcohol use as well as exposure to toxic agents might be attributed to the risk of declining semen quality and increase in oxidative stress and sperm DNA damage.^[98] To achieve an acceptable pregnancy rate in such cases, ISCI is the only option. This could be a big challenge in the countries which do not believe in sperm donation. Stem cell biology would play a major role in such cases.

(7) Posthumous use of gametes: Posthumous use of gametes occurs when the surviving partner of a person dying on a battlefield or due to other reasons wishes to obtain and use their gametes (sperm) to conceive a child to continue his lineage. It is not permitted in most of the countries. It is important to refer to the law in each state/territory, and/or National Health and Medical Research Council, to determine whether the removal and or use of gametes after a person dies is permissible, and if so the circumstances in which this may occur because posthumous use of gametes can pose legal issues such as legitimacy of child born, inheritance rights of a child, and lifelong psychosocial implications.^[99]

(8) Legal issues: Because of the rapidly evolving nature of the ART, legislation is often unable to keep pace and address all of the ethical and legal issues that are constantly emerging in the field. It is therefore incumbent upon physicians to continually monitor these issues and ensure that ART technologies are offered and delivered in a manner that balances patient care with social and moral responsibility.

CONCLUSION

ART as is a field that is dynamic and ever-changing. As technologies continue to proliferate, ethical and social challenges multiply, with complex questions of justice, rights, and conflicting principles continually rising. As an evolving society, we are long overdue to discuss these issues and to guard against leaving them solely in the province of researchers and reproductive medicine specialist.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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