Chapter 3.

1 : The Effects of Assisted Human

Reproduction

Assisted Reproductive Technology also known as ART has given

hopes to millions of couples suffering from infertility but it has also
introduced countless ethical, legal and social challenges.

History of Assisted Reproductive Technology

Infertility has traditionally been an area of

medicine in which physicians had limited means to help their
patients. The landscape of this field changed dramatically
with the announcement of the birth of Louise Brown in 1978
through in vitro fertilization (IVF). This historic moment was
eloquently encapsulated by Howard Jones who observed
“Eleven forty-seven p.m. Tuesday, July 25, 1978, was surely a
unique moment in the life of Patrick Steptoe. This was the
hour and minute he delivered Louise Brown, the world’s first
baby, meticulously, lovingly, and aseptically conceived in the
laboratory, but popularly referred to as the world’s first test
tube baby”. The importance of this birth to scientists,
clinicians, and most particularly infertile patients throughout
the world cannot be overstated. In several short decades, IVF
has exploded in availability and use throughout the world.

Worldwide, more than 70 million couples are

afflicted with infertility. Since the first successful IVF
procedure in 1978, the use of this and related technologies
has expanded to become commonplace around the globe.
Over the past decade, the use of ART services has increased
at a rate of 5–10% annually.

100

98
In Vitro fertilization

IVF is a form of assisted reproductive

technology (ART). This means special medical
techniques are used to help a woman become
pregnant. It is most often tried when other, less
expensive fertility techniques have failed.

101

99
There are five basic steps to IVF:

• Step 1: Stimulation, also called super ovulation

Medicines, called fertility drugs, are given to the woman to boost egg
production. Normally, a woman produces one egg per month. Fertility drugs tell the
ovaries to produce several eggs. During this step, the woman will have regular
transvaginal ultrasounds to examine the ovaries and blood tests to check hormone
levels.

• Step 2: Egg retrieval

A minor surgery, called follicular aspiration, is done to remove the eggs
from the woman's body. The surgery is done as an outpatient procedure in the
doctor's office most of the time. The woman will be given medicines so she does not
feel pain during the procedure. Using ultrasound images as a guide, the health care
provider inserts a thin needle through the vagina and into the ovary and sacs
(follicles) containing the eggs. The needle is connected to a suction device, which
pulls the eggs and fluid out of each follicle, one at a time. The procedure is repeated
for the other ovary. There may be some cramping after the procedure, but it will go
away within a day.

In rare cases, a pelvic laparoscopy may be needed to remove the eggs. If a

woman does not or cannot produce any eggs, donated eggs may be used.

• Step 3: Insemination and Fertilization

The man's sperm is placed together with the best quality eggs. The mixing
of the sperm and egg is called insemination.Eggs and sperm are then stored in an
environmentally controlled chamber. The sperm most often enters (fertilizes) an egg
a few hours after insemination.If the doctor thinks the chance of fertilization is low,
the sperm may be directly injected into the egg. This is called intracytoplasmic
sperm injection (ICSI).Many fertility programs routinely do ICSI on some of the eggs,
even if things appear normal.

• Step 4: Embryo culture

When the fertilized egg divides, it becomes an embryo. Laboratory staff will
regularly check the embryo to make sure it is growing properly. Within about 5
days, a normal embryo has several cells that are actively dividing. Couples who have
a high risk of passing a genetic (hereditary) disorder to a child may consider pre-
implantation genetic diagnosis (PGD). The procedure is done about 3 to 4 days after
fertilization. Laboratory scientists remove a single cell from each embryo and screen
the material for specific genetic disorders. According to the American Society for
Reproductive Medicine, PGD can help parents decide which embryos to implant.
This decreases the chance of passing a disorder onto a child. The technique is
controversial and not offered at all centers.
• Step 5: Embryo transfer
Embryos are placed into the woman's womb 3 to 5 days after egg retrieval
and fertilization.The procedure is done in the doctor's office while the woman is
awake. The doctor inserts a thin tube (catheter) containing the embryos into the
woman's vagina, through the cervix, and up into the womb. If an embryo sticks to
(implants) in the lining of the womb and grows, pregnancy results.More than one
embryo may be placed into the womb at the same time, which can lead to twins,
triplets, or more. The exact number of embryos transferred is a complex issue that
depends on many factors, especially the woman's age.Unused embryos may be
frozen and implanted or donated at a later date.
•

102

100
• Issues and Concerns

Practice Regulations and Multiple Gestation Pregnancies

The transfer of multiple embryos in a single cycle increases the rates of

multiple births. Because of the increased social costs and health risks associated with
multiple births, legislation or guidelines from professional societies have been
introduced in many countries restricting the number of embryos that may be transferred
per IVF cycle in an effort to limit the incidence of multiple gestations.

Financial Aspect for IVF Treatment

Perhaps one of the most obvious ethical challenges surrounding ART is the
inequitable distribution of access to care. The fact that significant economic barriers to
IVF exist in many countries results in the preferential availability of these technologies
to couples in a position of financial strength. The cost of performing ART per live birth
varies among countries. The average cost per IVF cycle in the United States is USD
9,266. However, the cost per live birth for autologous ART treatment cycles in the United
States, Canada, and the United Kingdom ranged from approximately USD 33,000 to
41,000 compared to USD 24,000 to 25,000 in Scandinavia, Japan, and Australia. The
total ART treatment costs as a percentage of total healthcare expenditures in 2003 were
0.06% in the United States, 0.09% in Japan, and 0.25% in Australia . Some have
maintained that the cost for these cycles pales in comparison to the social advantages
yielded by the addition of productive members of society. This is especially true in
societies that have a negative or flat population growth rate coupled with an aging
population.

Preimplantation Genetic Testing

Preimplantation genetic screening (PGS) and diagnosis (PGD) offer the unique ability to
characterize the genetic composition of embryos prior to embryo transfer. Given the
recent successes of these technologies, the broader implementation of this technology in
the future is likely. Although controversial, using PGD to choose embryos solely on the
basis of gender is currently being practiced. Sex selection in the proper setting may offer
a substantial health benefit. For example, choosing to transfer only embryos of a certain
sex may confer a therapeutic benefit if used to avoid a known sex linked disorder.
However, sex selection PGD
purely for the preference of the parents could conceivably, if practiced on a large scale,
skew the gender proportions in certain nations where one gender is culturally preferred.
In the near future, with refinements in microarray technology and the defining 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. This possibility raises concerns on both ethical and practical levels.
Of more concern is the possibility that in the future, technology will permit the
manipulation of genetic material within an embryo. Rigorous public and scientific
oversight of these technologies is vital to ensure that scientific advances are tempered
with the best interests of society in mind.

103

101
Gamete Donation
Another ethical and legal issue surrounding the use of donated gametes is to
what extent the anonymity of the donor should be preserved. The issue of
anonymity as it relates to gamete and embryo donation is emotionally charged.
Indeed, the ability of human beings to know their genetic roots is universally
important, at the core of self
identity. Either egg and sperm donors may choose to or not to be anonymous,
though the vast majority in both groups generally chooses anonymity . The
American Society for Reproductive Medicine has identified four levels of gamete
donor information sharing depending on the wishes of the donor and recipient
parties. Recently, however, there is, increasing consideration of the rights of
offspring as it relates to donor gametes and anonymity. Advocates for allowing
either gamete donors or their offspring to break anonymity cite the medical
advantages of sharing medical information with their genetic offspring, in the
case of the donor, or learning about their genetic history directly, in the case of
offspring . Others simply argue that both donors and offspring have an inherent
right to meet and develop a relationship. Recent court rulings suggest that these
rights will become more visible in the future. The ethical and legal issues
surrounding anonymity and gamete donation are sure to be a centrally debated
issues within the field of ART for the foreseeable future.

Possible Deleterious Effects of ART

There are questions that remain outstanding regarding the use of IVF.
Conflicting data exists about the risks of IVF on the developing embryo. Multiple
studies have failed to find a clinically relevant association between IVF or
embryo cryopreservation and adverse maternal or fetal effects . Other studies
have suggested that infants of IVF pregnancies may be at a small but
statistically significant increased risk for rare epigenetic and other abnormalities
.Despite this controversy, there is a general consensus that IVF confers a small
but measurable increased risk for a variety of congenital abnormalities including
anatomic abnormalities and imprinting errors as compared to the general
population [63]. Some maintain, however, that this is secondary to an increased
baseline risk for these problems in the population of infertile patients.
Regardless of the cause, this small increased risk, while statistically significant
with extremely large sample sizes, will likely not be a powerful enough factor to
dissuade infertile couples from pursuing parenthood through IVF.

104

102
 Activity 1: Short Response

• In not more than 1000 words, cite some examples of assisted human reproduction
and what are their impacts in the society. Discuss the advantages and
disadvantages of using these assisted human reproduction methods.

Criteria to be 4 3 2 1
Assessed
1. Ideas Writing Writing presents Writing presents Writing presents
successfully the topic in an the topic in an topic in an
presents the topic interesting way. ordinary way. ordinary way.
in a novel or Writing includes Writing includes Concrete details
unique way. good concrete concrete detail, but and commentary
Writing includes detail and some commentary is are either weak or
excellent and insightful obvious, simplistic, missing.
specific concrete commentary. or generic.
detail and
insightful
commentary.
2. Organization Writing has a Writing has a Organization is Writing is aimless
compelling and logical flow of rough but and disorganized.
logical ideas. workable. It
flow of ideas. sometimes gets off
topic.
3. Topic Paragraphs have Paragraphs have Paragraphs have Paragraphs lack
Sentences focused and focused topic topic sentences topic sentences
and poignant topic sentences and that need to be and transitions.
Transitions sentences and obvious more focused and
smooth, almost transitions. rough transitions.
seamless
transitions.
4. Description Writing consistently Writing shows Writing includes Writing uses all
and effectively rather than tell, some showing but telling and no
shows rather than but details could needs more. showing.
tells through be more specific
specific and vivid and vivid.
details.
5. Word Choice Writing uses words Writing makes Writing uses words Writing uses the
that are striking some quality but that are dull or same words over
and fresh but also some routine uninspired. and over. Some
natural, varied, and or ordinary word Writing sounds like words may be
vivid. choices. you are trying too confusing or
hard to impress. inappropriate.

6.. Grammar Writing uses proper Writing has a few Writing has enough Writing has
Usage grammar 100% of grammar grammar errors to numerous
and Sentence the time. problems. distract a reader. grammar
Fluency Sentences flow well Sentences flow Some sentences do mistakes and
and vary in well but do not not flow well poor sentence
construction and vary much. and/or are not construction that
length. varied at all. make the paper
hard to read.
7.. Spelling and Writing uses Writing has a few Writing has enough Writing has
Punctuation correct punctuation errors to fix, but errors in the essay numerous errors
and spelling 100% generally uses to distract a reader. that make the
of the time. correct paper hard to
conventions. read.

105
103
Chapter 3.1.2 Mechanisms of action and effectiveness of
contraceptive methods

Method How it works Effectiveness: Effectiveness:

pregnancies per pregnancies per
100 women per 100 women per
year with year as commonly
consistent and used
correct use
Combined oral Prevents the
contraceptives release of eggs 0.3
7
(COCs) or “the from the ovaries
pill” (ovulation)
Thickens cervical
mucous to block
sperm and egg
from meeting and
Progestogen-only prevents ovulation
pills (POPs) or "the POP is a pill taken 0.3 7
minipill" to prevent
pregnancy. The
POP contains one
hormone -
progestogen
Thickens cervical
mucous to blocks
Implants sperm and egg 0.1 0.1
from meeting and
prevents ovulation
Thickens cervical
mucous to block
Progestogen only 0.2
sperm and egg 4
injectables
from meeting and
prevents ovulation
Monthly
injectables or Prevents the
combined release of eggs
0.05 3
injectable from the ovaries
contraceptives (ovulation)
(CIC)
Forms a barrier to
prevent sperm
Male condoms 2 13
and egg from
meeting
Forms a barrier to
prevent sperm 5
Female condoms 21
and egg from
meeting

106

104
Method How it works Effectiveness: Effectiveness:
pregnancies per pregnancies per
100 women per 100 women per
year with year as commonly
consistent and used
correct use
is a surgical
procedure for male
sterilization or
permanent
contraception.
During the
procedure, the
male vasa
Male sterilization deferentia are cut
0.1 0.15
(Vasectomy) and tied or sealed
so as to prevent
sperm from
entering into the
urethra and
thereby prevent
fertilization of a
female through
sexual intercourse.
is a surgical
procedure for
female sterilization
in which the
fallopian tubes are
permanently
Female sterilization
blocked or 0.5 0.5
(tubal ligation)
removed. This
prevents the
fertilization of eggs
by sperm and thus
the implantation of
a fertilized egg.
Prevents the
Lactational
release of eggs
amenorrhea 0.9 (in six months) 2 (in six months)
from the ovaries
method (LAM)
(ovulation)
Prevents
pregnancy by
Standard Days avoiding
5 12
Method or SDM unprotected
vaginal sex during
most fertile days.

107

105
Method How it works Effectiveness: Effectiveness:
pregnancies per pregnancies per
100 women per 100 women per
year with year as commonly
consistent and used
correct use
Prevents or delays < 1 for ulipristal
Emergency
the release of eggs acetate ECPs
contraception pills
from the ovaries. 1 for progestin-
(ulipristal acetate
Pills taken to only ECPs
30 mg or
prevent pregnancy 2 for combined
levonorgestrel 1.5
up to 5 days after estrogen and
mg)
unprotected sex progestin ECPs
The couple
prevents
pregnancy by
avoiding
unprotected Reliable
Calendar method
vaginal sex during effectiveness rates 15
or rhythm method
the 1st and last are not available
estimated fertile
days, by
abstaining or using
a condom.
Tries to keep
sperm out of the
Withdrawal (coitus 4
woman's body, 20
interruptus)
preventing
fertilization

108

106