Current Issue

Archives

Editorials

The Ethics of Gestational Surrogacy

Written by Dr Stacey Ellender

A Brief History of Surrogacy
Surrogacy is not new, although the practice has been altered with time. There is evidence that it was an accepted remedy for infertility in the ancient world. In the Hebrew scriptures, when Sara was unable to have a child, she told Abraham to be with her maid Hagar, so that she might bear him a son. A similar story was told of Rachel, Jacob, and the maid, Bilhah. In such stories, it was the wife who was perceived to be infertile, thus a stand-in for her, a surrogate wife, was the only remedy sought. The surrogate was, in most cases, of the same race and ethnicity as the wife, (though often younger) so as to produce a child readily acceptable to her, and passable as her own. But the surrogate was also likely to be of lower social position, a servant or a slave, and she had no choice in the matter; if the head of the household decided she would bear him a child, she complied. If she successfully gave birth, she might be acknowledged as the one who did so, but the child was raised by the man who impregnated her and his wife, and she had little or no place in that child’s life. Read more »

Creating a Reproductive Life Plan - The New Frontier

Written by Professor Robert Norman

Over the past three decades, assisted reproductive technology has made startling progress with respect to clinical protocols, pharmaceutical drugs, embryology, and quality management systems. We have seen pregnancy rates rise from single figures to those that exceed natural conception while we are able to drop the multiple pregnancy rates to below 5% in the top clinics by performing single embryo transfer. We have revolutionised the way assisted reproductive technology is practiced and are rightly proud of all that we have achieved for our patients. Read more »

Miscarriage after ART

Written by Dr. Stacey Ellender

Literature documenting how patients experience and perceive miscarriage is relatively new, generally dating back only so far as the late 1970s. Research in this area is often limited in scope; many published studies have had less than 50 subjects, and the women interviewed tended to be that subset of women who had the resources and desire to receive both early prenatal care and post-miscarriage counseling services. Additionally, many studies on miscarriage conflate all subjects who lost a pregnancy at less than 24 weeks of gestation into one group. From the literature, it is difficult to delineate the specific effects of early miscarriage when the studies often do not distinguish between the experiences of persons with first trimester and second trimester loss. Furthermore, the large majority of pregnancies that were the subject matter of these studies were conceived without medical intervention, making it difficult for fertility specialists to readily determine which of these studies are relevant to their practice. Read more »

Breaking Bad News to the ART Patient

Written by Dr. Stacey Ellender.

Bad news is any news that drastically and negatively alters the patient’s view of her or his future. For many years there was debate as to whether or not a physician should feel obligated to disclose information when the patient’s prognosis was particularly poor and no effective treatment was available. Read more »

Elective Single Embryo Transfer: The Way Forward?

Written by Dr. Peter Hollands.

When Louise Brown was born over 30 years ago, she resulted from one beautiful 8 cell embryo. In the subsequent years, the number of embryos transferred has varied with the general underlying thought that more embryos transferred lead to better overall results. Most of the early workers transferred 3 embryos, which then went up to 4 or even 5, as this seemed to give the greatest chance of pregnancy, especially in women over 40. As time went by, it became clear that multiple pregnancies were becoming routine in assisted conception and the complications, risks, and social and financial implications of these multiple pregnancies became matters of hot debate. As a result, the current trend, in patients under 35 with good prognosis, is to recommend elective single embryo transfer in fresh assisted conception cycles and much greater emphasis on embryo freezing followed by single
frozen embryo transfer. Read more »

Mitigating Medicalization in Assisted Reproduction

Written by Dr. Stacey Ellender.

The term “medicalization” first came into wide use in the early 1970s with the work of Eliot Freidson of New York University and Irving Kenneth Zola of Brandeis University. Since then there has been considerable scholarship on the subject, and numerous interpretations and definitions have emerged in the literature. Read more »

Review Articles

Importance of Screening Prospective Oocyte Donors for Optimal Reproductive Outcomes

Introduction
Over the past quarter century, there has been a dramatic rise in the number of people seeking infertility treatment. According to the 2002 National Survey of Family Growth, around 11.8% of women in the US, aged between 15 to 44 years, had impaired fecundity. The importance given to reproduction and the generation of progeny has led to the development of various assisted conception techniques and methods to overcome infertility. One such method is “third party reproduction”, which uses sperms, oocytes, or embryos donated by a donor to help infertile couples achieve parenthood. Read more »

Endometriosis and Infertility: Brief Review of Literature on Surgical Management Aspects

Introduction

Endometriosis, a common gynecological condition and a leading cause of infertility, affects around 2-10% of reproductive-aged women in the US, with a global prevalence of 0.5-5% and 25-40% in fertile and infertile women, respectively.1 Although most studies have established the association between endometriosis and infertility, there is a lack of sufficient understanding regarding a direct cause-and-effect link, particularly in early disease, when the pelvic anatomy is not disrupted. Hence, there also remains some ambiguity about the optimal management strategy for endometriosis-associated infertility. Read more »

Ovarian Reserve Assessment: When Time is Not on Your Side

Ovarian reserve (OR) is the repertoire of residual oocyte-granulosa cells that are available at any given age for procreation. Though a decline in OR is considered natural with an advancement in maternal age, the number of women delaying childbearing has increased over the past few decades, owing to lifestyle changes. According to the 2009 report of the National Center for Health Statistics (NCHS), the average age of women in the US opting for first-time motherhood increased by 3.6 years, from 21.4 in 1970 to 25 years in 2006. Similarly, the average age for first birth is nearing 30 years in other developed nations. Some premenopausal women experience an acceleration in the OR decline process due to which ovarian stimulation leads to suboptimal responses during infertility treatment. Further, these women may be at a higher risk of trisomic pregnancy and transgression into menopause at an earlier age. Read more »

Strategies to Prevent Ovarian Hyperstimulation Syndrome

Ovarian hyperstimulation syndrome (OHSS), an iatrogenic complication of ovulation induction, occurs in up to 10% of women opting for assisted reproduction, with a severe form of the syndrome in around 0.1-2.0% of the patients. The introduction of gonadotropin releasing hormone agonists (GnRHa) in 1987 to ovarian stimulation protocols resulted in an increase in the incidence of OHSS, mostly because of the aggressive ovarian stimulation made possible without the risk of premature ovulation. Read more »

Pre-implantation Genetic Diagnosis - Safety and Ethical Aspects

Pre-implantation genetic diagnosis (PGD) is one of the promising genetic and reproductive technologies that was developed during the mid 1980s in the United Kingdom, as an extension or alternative to prenatal diagnoses. With the technology opening up new avenues for genetic research, it offers hope to couples at a high risk of transmitting genetic disorders to their offspring, and also to those suffering from recurrent pregnancy loss and repetitive IVF failure. Read more »

Commentaries

Effects of Meiotic Maturation Stage on Oocyte Cryopreservation

Written by Professor Semra Kahraman

The ability to cryopreserve oocytes is of importance in certain clinical and social situations. However, an effective oocyte cryopreservation programme is yet to be developed. In contrast to unsatisfactory results of slow freezing, vitrification of oocytes has yielded comparable pregnancy rates with fresh oocyte retrieval treatments. However, vitrification has not been applied to immature germinal vesicle (GV)-stage oocytes, which are theoretically more resistant to the cryo-damage. In a recent study, researchers investigated whether immature and in vitro matured human oocytes can be successfully vitrified by comparing oocyte survival rates, fertilization, and embryonic development when oocytes are vitrified before and after in vitro maturation (IVM). Read more »

Use of Metabolomic Profiling in Predicting the Embryonic Reproductive Potential

Written by Professor Semra Kahraman

Higher rate of multiple pregnancies is still a major problem in IVF conceptions. Therefore, a primary goal of current assisted reproductive technology is to improve embryo implantation and pregnancy rates while avoiding the risk of higher order pregnancies. The solution is definitely based on the ability to identify the best and most viable embryos using a highly efficient selection procedure. New, non-invasive analytic spectrophotometric tests, including Raman and near-infrared (NIR) techniques, have been introduced to choose viable embryos, as an alternative to the current approach of subjective microscopy-based morphological assessment. Read more »