61 In Vitro Fertilisation Flashcards
What is infertility?
- A dysfunction - not a disease
- A socially constructed disease
- A “terrible disease affecting our sexuality and well being” (Lord Winston)
How many couples have difficulty conceiving?
~ 1 in 7 ( ~ 3.5 million)
What is the % of couples who are infertile?
~ 5%
After 3 years of trying to conceive naturally without success, chances of pregnancy occurring within the next tear is…
<25%
Factors affecting fertility?
- Age
- Smoking
- Weight (BMI>30 or BMI<19)
Factors affecting a woman’s fertility?
- Ovulation disorder (21%)
- Tubal factor (15-20%)
- Endometriosis (6-8%)
Factors affecting a man’s fertility?
25% • Semen abnormality • Azoospermia • Immunological • Coital dysfunction
What is % of unexplained causes of fertility?
28%
Methods to treat infertility?
Assisted Reproductive Technologies (ART):
- In vitro fertilisation (IVF) - 2016: 68,000 treatment cycles
- Intrauterine insemination (IUI)
- IVF with intracytoplasmic sperm injection (ICSI)
- Use of donor sperm/eggs
- Surrogacy
What are the ages of IVF?
- Egg production stimulated by hormone therapy
• Suppress (GnRH agonist) then stimulate (FSH) then maturation (hCG) - Eggs retrieved from ovary
• Egg collection:
Ultrasound-guided transviginal aspiration or laparoscopy - Sperm sample provided
- Eggs and sperm combined to allow fertilisation
• Use ICSI if necessary; leave in incubator; check after 16-30hrs - Fertilized egg introduced into uterus
• Transfer after 2-6 days; use ultrasound; use progesterone for luteal phase support
Risks associated with IVF?
- Ovarian hyperstimulation syndrome:
• Due to super ovulation in response to the drugs
• Abdominal bloating, nausea/ vomiting, breathlessness, leg swelling - Transferral of several embryos - multiple births:
• Recommendation is for single embryo transfer - Welfare of the child:
• 1990 - need for a father
• 2008 - need for supportive parenting
Define the term “supportive parenting”
A woman shall not be provided with treatment services unless account has been taken of the welfare of any child who may be born as a result of the treatment (including the need for supportive parenting), and of an other child who may be affected by the birth
Guidelines for IVF in Scotland (updated 2017, from 2013)?
• <40 years old: (2 - 2013) 3 cycles of IVF
– Infertility with an appropriate cause of any duration
– Unexplained infertility of 2 years (heterosexual couples)
– Unexplained infertility following 6-8 cycles of donor insemination (same sex couples)
• 40-42 years old: 1 cycles of IVF
– No IVF before
–No evidence of low ovarian reserve
– Discussion of implications of IVF and pregnancy at this age
What % of IVF treatments, using own fresh eggs is successful?
26.5%
• 65% of women <37
What was the regulation of IVF when it was first introduced?
- 1978: 1st ‘test-tube” baby - Louise Brown
- Warnock Report 1984
- Human Fertilisation and Embryology Authority (HFEA)
- Human Fertilisation and Embryology Act 1990, 2008
What is HFEA?
Human Fertilisation and Embryology Authority:
- Regulator and info provide
- Regulate:
• Treatment (inspect and license clinics)
• Research (licenses for human embryo research)
What are the ethical issues surrounding IVF?
- Who should be able to access IVF?
- Use of gametes?
- Embryos (graded: use immediately, freeze, discard or research)
- Reproductive tourism
What are the 3 groups of people that present with ethical issues when receiving IVF?
Heterosexual couples
Homosexual couples
Single women
What was the homosexual couple case study for IVF?
NHS Greater Glasgow and Clyde – very public case in 2009; at first NHS GGC said no, but then overturned that decision (now included in SGG 2013)
What was the Elizabeth Pearce case study for IVF?
SINGLE WOMEN RECEIVING IVF
Case of Elizabeth Pearce (Ealing PCT) – using sperm bought from the US, and IVF funded by NHS
What are the ethical issues surrounding gametes in IVF?
If frozen…
- Must state how long
- What happens in event of death?
If donated….
- Is it okay to pay donors? In the UK compensation is allowed
- Should there be a limit to number of children created? UK limit is 10 families, US no limit
- Should children be able to find out who their biological parents are? In 2005, change in law to allow children to access info
Ethical issues surrounding embryo’s in IVF?
- How many should be made?
- How many should be implanted?
- What do we do with spares?
Ethical issues surrounding reproductive tourism?
- Cost
- Waiting lists
- Avoid legal restrictions
What is IVF with mitochondrial replacement?
- Media: “3 parent IVF”
- Recent HFEA report: mitochondrial donation
- Technique that allows those at risk of passing on certain mitochondrial conditions (carried on mtDNA) to avoid that risk
- Pro-nuclear transfer or maternal spindle transfer
- HFEA held public consultation (2012)
What 4 things must be considered in IVF with mitochondrial replacement?
- Modification of embryos and changing the germline
- Implications for identity and the status of the mitochondria donor
- General veins on the permissibility of the techniques
- Licensing models and further regulatory issues
What occurs in pronuclear transfer in IVF with mitochondrial replacement? (repair is done after fertilisation)
- • Parent’s fertilised egg with parent’s nuclear material and unhealthy mitochondria
• Donor’s fertilised egg with donor nuclear material and healthy mitochondria - • Parents’ nuclear material removed
• Donor material removed and destroyed - Parents’ nuclear material placed inside donor egg
What occurs in maternal spindle transfer in IVF with mitochondrial replacement? (repair is done before fertilisation)
1.
• Mother’s egg with mother’s nucleus and unhealthy mitochondria
• Donor’s egg with donor nucleus and healthy mitochondria
2.
• Mother’s nucleus removed
• Donor’s nucleus removed and destroyed
- Mother’s nucleus placed inside donor egg and fertilised
What are the regulation changes that have occurred in response to IVF with mitochondrial replacement?
- House of Commons: 03/02/15: MPs voted to amend the Human Fertilisation and Embryology Act 2008 and allow mitochondrial donation
- House of Lords: 24/02/15 peers voted to allow mitochondrial donation to be licensed for use
- HFEA: 15/12/16 approved use of mitochondrial donation in certain, specific cases
- HFEA: 16/03/17 approved first clinic application (Newcastle)
What is partial surrogacy?
Surrogate mother inseminated herself with commissioning father’s sperm
What is full surrogacy?
IVF (commissioning couple’s egg and sperm mixed in vitro and then transferred)
Who is the legal mother from birth (surrogacy cases)?
- Surrogate mother
* Parental order or adoption required
What is the Surrogacy Act 1985?
Surrogacy agreements are not unlawful but they are unenforceable
What are the 2 key reports on surrogacy?
Brazier and Warnock Report
