150406P - ETHICAL ISSUES IN HUMAN FERTILITY

Presentation at a training program ‘Applying the Principles of Ethics to Clinical Practice:’ held at Aramco Dhahran April 6, 2015 by Professor Omar Hasan Kasule Sr. MB ChB (MUK). M{H (Harvard), DrPH (Harvard) Chairman of the Ethics Committee King Fahad Medical City.

LEARNING OBJECTIVES

To explore ethical issues concerning human fertility and IVF.

Key words

IVF, stem cell therapy, infertility

1.0 INTRODUCTION

1.1 Definition of infertility

1.2 Social consequences of infertility

1.3 Treatment of infertility

1.4 Ethical and legal controversies

2.0 IN VIVO INSEMINATION

2.1 Definition of in vivo insemination

2.2 Indications for in vivo insemination

2.3 Permissibility of in vivo insemination

2.4 Prohibited in vivo insemination

3.0 IN VITRO FERTILIZATION

3.1 Definition of IVF

3.2 Indications for IVF

3.3 Permissible IVF

3.4 Prohibited IVF

4.0 DISPUTES ABOUT PARENTHOOD

4.1 Disputes about maternity

4.2 Disputes about paternity

4.3 Post-mortem parenthood

5.0 CIVIL TRANSACTIONS RELATING TO IVF

5.1 Costs associated with IVF

5.2 Inheritance

6.0 FROZEN SPERMS, OVA, and EMBRYOS

6.1 Storage

6.2 Frozen embryos

7.0 OTHER CONTROVERSIAL ISSUES

7.1 Masturbation

7.2 Pre-implantation genetic diagnosis

7.3 Selective fetal reduction

7.4 Embryo splitting

7.5 Developing embryos for non-IVF purposes

7.6 Using embryos for cloning

7.7 Mixing of gametes or embryos

7.8 Commercial trading in sperms, gametes, or embryos

7.9 Use of gametes from cadavers or post-mortem insemination or IVF

CASE DISCUSSION

The panel consists of the following members:

·        A  Infertility Specialist who is concerned about the success rate at age 43 and the difficulties of raising a child as a 43 year-old single person.

·        A Counselor who is concerned about the legalities of using donor sperm in IVF and the ethical dilemmas of embryo cryopreservation for personal stem cell use in possibly 30 years.

·        An Obstetrician, who is also on the local Research & Development Committee and who knows about twin pregnancy rates after IVF and associated morbidity, and who is concerned about potential litigation and anti-discrimination legislation.

·        A consumer advocate who has personal conflicts with the patient and her capacity to pay for IVF as she has a low income.

·        A scientist who would rather use excess embryos for his research rather than to be stored for the patient's potential stem cell needs.

Case 1:

An older single woman who wishes to have IVF, with some embryos frozen for future stem cell therapy, as she has a family history of Parkinson's Disease.

Case 2:

An infertile couple was in the midst of an IVF procedure when the husband died soon after his semen was frozen. The wife wanted to obtain the semen and have a baby by a surrogate mother. A former wife also wanted the semen because she had a girl with leukemia who needed a compatible bone marrow donor, preferably a sister.

Case 3:

A recently married woman continued taking oral contraceptives prescribed for menstrual irregularities. Her husband wanted his wife to discontinue her contraception because he wanted to start a family immediately, but the wife refused.

Case 4:

A 14 year-old girl was admitted to the hospital for an abortion. She was two months pregnant from what she claimed was rape. The family was distraught and wanted the doctors to carry out the abortion immediately. The physicians were reluctant because there was no medical reason.

Case 5:

A couple who had eight girls in successive pregnancies desperately wished a boy. They decided to try IVF with selection of male gametes. The obstetricians refused because there was no medical indication since the couple had no problem in conceiving.

Case 6:

A child whose external appearance was female and had been brought up as a girl was taken to the hospital at 14 years of age because of delayed menstruation. The internal gonads and chromosomal patterns were male. The parents wanted a gender reassignment operation to conform to the genetic profile. The child refused to change from her familiar female identity.

Case 7:

A middle-aged woman without any medical condition asked her physician for hormonal treatment to appear younger. The physician refused because he judged the risk of cardiovascular and cancer complications to be more than the benefits.

Case 8:

A 14 year-old girl with cancer requiring chemotherapy was advised to have her ova removed and put in cold storage for the duration of the treatment. Her parents refused the procedure because they did not believe in IVF and she was not yet married.

REFERENCES

·        Whittaker A. Cross-border assisted reproduction care in Asia: implications for access, equity and regulations.Reprod Health Matters. 2011 May;19(37):107-16. 

·        Scientific Advisory Committee of the Royal College of Obstetricians and Gynaecologists.Multiple pregnancy following assisted reproduction.Hum Fertil (Camb). 2011 Mar;14(1):3-7.

 

·        NakhudaGS.Posthumous assisted reproduction.SeminReprod Med. 2010 Jul;28(4):329-35.

·        Chatzinikolaou N. The ethics of assisted reproduction.JReprodImmunol. 2010 May;85(1):3-8.

·        Lockwood GM. Social egg freezing: the prospect of reproductive 'immortality' or a dangerous delusion?Reprod Biomed Online. 2011 Sep;23(3):334-40.

·        Klein JU, Sauer MV. Ethics in egg donation: past, present, and future.SeminReprod Med. 2010 Jul;28(4):322-8.