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It is not birth, marriage, or death, but gastrulation, which is truly the most important time in your life. Lewis Wolpert (1986). 2011 Marek Vácha. Assisted reproduction. Numbers of Sperms. 1940 113 millions /ml 1990 66 millions /ml
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It is not birth, marriage, or death, but gastrulation, which is truly the most important time in your life. Lewis Wolpert (1986) 2011 Marek Vácha Assistedreproduction
Numbers of Sperms 1940 113 millions /ml 1990 66 millions /ml the number of „normal“ sperm fell from 60 million per mL to 20 mL in the same period (Carlsen, E., Giwercman, A., Keiding, N., Skakkebaek, N., (1992) Evidence of decreasing quality of semen during past 50 years. Brit. Med. J.305: 609-613)
First „test tube baby“ • July, 25, 1978 – Louise Brown Louise Brown with her parents, 25-year-old in 2003 A Delivery. LB. Patrick Steptoe right, Robert Edwards left
They persisted through more than 40 embryo transfers before obtaining their firstpregnancy. Unfortunately it was ectopic and had to be aborted. Louise Brown was born from the second pregnancy.
Prof. Edwards a Louise Brownová v roce 2008, kdy L. Brownová oslavila 30. narozeniny. Dítě počala přirozenou cestou. 2010: Nearly four million babies have been born using IVF fertility treatment since 1978.
1983 = donation of oocyte • 1993 = ICSI • 2000 = PGD
CzechRep. • 1982 - Brno – first IVF at eastern block, GIFT. But till 1987 at ČR 10 children only • 1988 – first twins at ČR • 1994 – first triplets at ČR
Usefulterms • AIH – artificial insemination husband) • AID artificial insemination donor) • “ (Encyclopedia of Bioethics,4/2219)
Belgiumfrom 01/06/2003 on: compensation of 6 cycles of IVF • Woman till 35 years • 1. cycle - one embryo • 2. cycle - • one (if there is one or more embryos of the highest quality are at disposal) or • two embryos (if there is no embryo of highest quality ) • 3. - 6. cycle - max. two embryos • Woman 35 - 39 years • 1. and 2. cycle - max. 2 embryos • 3. - 6. cycle - max. 3 embryos • Woman 39 - 42 years • 1. - 6. cycle - without limitations
Happy are all who fear the Lord, who follow His ways… Your wife shall be like a fruitful vine within your house; your children, like olive saplings around your table… Infertility = social stigma
preimplantation diagnostics spare embryos pregnancy reduction Ethical Problems
preimplantation diagnostics • spare embryos • may be disposed on • frozen • experimented on • pregnancy reduction Ethical Problems
there are about 400 000 human embryosstored in cylindersfilled with liquidnitrogen in the USA • although the 90 % successrate with thawedembryos may be acceptable for laboratoryanimals, it probably is not acceptable with humans • oncefrozen, the embryos may outlive the donor and thusraise the possibility of postmortemconception and birth • women could postpone pregnancy without risking either infertility or the disease of preganancy that afflictolder women by conceiving at a youngage (thusavoiding the old-agedangers like Down syndrome) SpareEmbryos
The in vitrofertilized embryo has four possible fates • implantation, in the hope of producing from it a child • death, by activekilling or disaggregation, or by "natural" demise • use in manipulativeexperimentationembryological, genetic, extraction of stem cells etc. • use in attemps at perpetuation in vitrobeyond the blastocyst stage (in the future) ExtracorporealEmbryos
up to 85 % IVF+ET is taking place with the help of ICSI • Sweden: everycitizen 18+ has the right to know his or her biologicalparents • When Swedenpassed a law in 1985 requiring that the identity of the semen donor should be recorded to enable the child at eighteen years of age to contact the biological father, this resulted in the almost totaldisappearance of DI in Sweden and frequentreferral of couples to other parts of Scandinavia • at ČR is donationanonymous Donation of gamets
Australia: A registry identifying donors is open to children at age eighteen, equialent to the law on adoption • American states, however, have uniformly protected the identity of donors and recipients • (Dorff, E.N., (2003) Matters of Life and Death. A Jewish Approach to Modern Medical Ethics. The Jewish Publication Society, Philadelphia, PA, p. 86)
women who had used fertlility drugs had • three times the risk of invasive epithelial ovarian cancer compared to women without a history of infertility • four times the risk of ovarian tumors of low malignant potential seen among women lacking a history of infertility Ovarianhyperstimulation syndrome (OHSS)
PGD Pro PGD se tedy z osmibuněčného embrya bere jedna buňka
CzechRep.: chromosomes 13, 16, 18, 21, 22, X, Y new usesinclude PGD to detectmutations for susceptibility to cancer and for ateonsetdiseases such as Alzheimer´s disease In adition, parents with childrenneedinghematopoietic stem cell transplant have used PGD to ensure that their next child is free of disease and a good tissuematch for an existing child (Robertson, J.A., (2003) Journal of Medical Ethics 29: 213-16) PID
the first succesfull use of PGD was in 1990 • for testing of aneuploidy in lowprognosis IVF patients • and for single gene and X linkeddiseases in at risk couples • in 2006 the HFEA agreed in principle to allow PGD for cases where there was believed to be a risk of inheritedbreast, ovarian or bowel cancer, though it was stressed that the particularcircumstances would need to be considered carefully for each application • HFEA = The Human Fertilisation and Embryology Authority is the UK's independent regulator overseeing the use of gametes and embryos in fertility treatment and research. The HFEA licenses centres carrying out IVF, other assisted conception procedures and human embryo research, and provides a range of detailed information for patients, professionals, the public and Government. • PGD is still (2008) a new procedure, with a lowsuccessrate, which has only so far resulted in the birth, worldwide, of about 1 000 children(and about 100 in the UK) • (Mepham, B., (2008) Bioethics. An Introduction for the Biosciences. Oxford University Press, Oxford, p. 132) PGD
for testing of aneuploidy in lowprognosis IVF patients • and for single gene and X linkeddiseases in at risk couples • for p53 mutations • for BRCA 1 and 2 mutations • for Alzheimer´s disease • for Huntingtondisease • for HLA matchin to na existing child • it may also ensure that the new child does not also suffer from that same disease New Medical Use of PGD
intelligence • height • sexualorientation • beauty • hair and eye colour • strenght • memory • perfect or "absolute" pitch • Parentsclearly have the right to instill or develop a child´s musical ability after birth • They mightreasonablyargue that they shoudl have that right beforebirth as well Non-medicalUses of PGDIn the Future
BRCA 1 • on the chromosome 17 • BRCA 2 • on the chromosome 13 • about 13.2 percent (132 out of 1,000 individuals) of women in the general population will develop breast cancer • in Czechrep. about 10 % women • compared with estimates of 36 to 85 percent (360–850 out of 1,000) of women with an altered BRCA1 or BRCA2 gene. • In other words, women with an altered BRCA1 or BRCA2 gene are 3 to 7 times more likely to develop breast cancer than women without alterations in those genes. • Lifetime risk estimates of ovarian cancer for women in the general population indicate that 1.7 percent (17 out of 1,000) will get ovarian cancer, compared with 16 to 60 percent (160–600 out of 1,000) of women with altered BRCA1 or BRCA2 genes. BRCA 1 and BRCA 2
Genetic Dilemmas • ...by privileging patient autonomy and by definig the patient as the person or couple who has come for counseling, there seems no space in which to give proper attention to the moral claims of the future child who is endpoint of many counselinginteractions. • these difficulties have been highlighted of late by the surfacing of a new kind of genetic counselingrequest: parents with certain disabilities who seek help in trying to assure that they will have a child who shares their disability.
Genetic Dilemmas • the two reported instances are in families affected by achondroplasia and by hereditary deafness • (Davis, D.S., (1997) Genetic Dilemmas and the Child´s Right to an Open Future. Hastings Center Report 27, no.2: 7-15)
DesignerBabies • a notable example was the selection by the deaf lesbian couple in the USA of a sperm donor who had an inherited form of deafness, so that any child produced by IVF would have a high chance of being deaf • as a result, the couple had two children, who were both deaf • they argued that deafness is not a disability buit a cultural identity, which they wanted their children to share with them • (Mepham, B., (2008) Bioethics. An Introduction for the Biosciences. Oxford University Press, Oxford, p. 147)
Is Creating a Deaf Child a Moral Harm? • How it can be said that one has harmed a child by bringing it into the world with a disability, when the only other choice was for the child not to have existed at all? • In the case of a child whose life is arguably not worthliving, one can say that life itself is a cruelty to the child • But when a child is born in less than idealcircumstances, or is partiallydisabled in ways that do not entailtremendoussuffering, there seems no way to argue that the child herself has been harmed.
in our society everyoneagrees that whites have an easier time than blacks. But do you think a black person would undergooperations to become white? • when Gorbachevvisited the U.S., he used an interpreter to talk to the President. Was Gorbachevdisabled? • deaf people lack the ability to hear Against FOR
ArgumentsAgainst • if deafness is considered a disability, one that substantiallynarrows a child´s carreer, marriage, and culturaloptions in the future, then deliberatelycreating a deaf child counts as a moral harm • If Deafness is considered a culture, as Deafactivists would have us agree, then deliberatelycreating a Deaf child who will have only very limited options to moveoutside of that culture, also counts as a moral harm
ArgumentsAgainst • A decision, made before a child is ever born, that confines her forever to a narrow group of people and a limited choice of careers, so violates the child´s right to an open future that no genetic counseling team should acquiesce in it. • (Davis, D.S., (1997) Genetic Dilemmas and the Child´s Right to an Open Future. Hastings Center Report 27, no.2: 7-15)
Argumenty For • "There is no great invention, from fire to flying, that has not been hailed as an insult to some God." (J.B.S. Haldane)
ArgumentsAgainst • a feminist approach: techniques for assisting human reproduction bear a striking resemblance to techniques used to facilitate reproduction in livestock
ArgumentsAgainst • laboratoryfertailization is a peculiartreatment for oviductobstruction in that it requires the creation of a new life to "heal" an existing one. • All this simplyemphasizes the uniqueness of the reproductiveorgans in that their proper function involves other people, and callsattention to the fact that infertility is not a disease, like heartdisease or stroke, even thoughobstruction of a normally patent tube or vessel is the proximate cause of each • Kass, R.L., (2002) Life, Liberty and the Defense of Dignity. EncounterBooks, New York, London. p. 110)
Argument of "Good Parenthood" • Good parenthood requires a balance between having a child for our own sakes and being open to the moral reality that the child will exists for her own sake, with her own talents and weakness, propensities and interests, and with her own life to make.
Should there be any agelimits for using IVF? • the world´s olders mothers were Omkari Panwar and Rajo Devi of India, who both gave birth at age seventy in 2008
SaviourSiblings • notablecases in the UK were the applications to the HFEA from two set of parents (the Hashmi and Whitakerfamilies) for permission to selectembryos (=savioursiblings) to treat their existingchildren, who suffered from beta-thalassaemia and rare non-inheriteddiseaseDiamond-Blackfananaemiarespectively • in each case, the proposedstrategy was to harvest stem cells from umbilicalcordbloodfollowing the birth of the youngersibling,with the aim of using stem cells in a bone marrowtransplant and subsequentlycuring the disease in the older child through the production of healthyblood cells
SaviourSiblings • The Hashmis were grantedpermission by the HFEA in 2001 to create and tissue-type embryos, because it was argued that the use of PGD would be in the interests of both the prospective child and its oldersibling • by contrast, the application made to the HFEA in 2002 by Whitakers was refused, on the grounds that the unborn child should not be exposed to the hazards of PGD when there was no directbenefit to the youngersibling – because DBA is not inherited
SaviourSiblings • …consequently, the couple went to the USA to receive PGD treatment,resulting in the birth of a son in 2003. • following a subsequent House of Lords ruling, the HFEA granted a license for use of saviour sibling PGD in the case of the Fletcher family, whose son also suffered from DBA
prenatal sex selection Sex Selection
