Assisted Reproductive Technology (ART) Adapted from Mary L. Davenport, M.D. (UCLA at Berkeley), 2009

What is ART? Assisted Reproductive Technologies: Fertility therapies where eggs and sperm are manipulated Fertility therapies where eggs and sperm are manipulated Usually involve surgically removing eggs from women and combining them with sperm in the laboratory Usually involve surgically removing eggs from women and combining them with sperm in the laboratory

ART: Assisted Reproductive Technology Predominantly IVF – In Vitro Fertilization Predominantly IVF – In Vitro Fertilization Expensive Expensive Most attempts fail to produce a live birth Most attempts fail to produce a live birth Large loss of embryos Large loss of embryos

REPRODUCTIVE CHRONOLOGY 1934 Gregory Pincus: First animal IVF 1934 Gregory Pincus: First animal IVF 1944 John Rock: First human IVF 1944 John Rock: First human IVF 1960 FDA approves “the pill” 1960 FDA approves “the pill” 1978 First IVF baby 1978 First IVF baby U.S. ART clinics with 41,000 live births annually U.S. ART clinics with 41,000 live births annually

GREGORY PINCUS GREGORY PINCUS 1934 First in vitro fertilization of rabbit eggs 1934 First in vitro fertilization of rabbit eggs Criticized as “mad scientist” Criticized as “mad scientist” Developed oral contraceptives in 1950’s Developed oral contraceptives in 1950’s

Dr. John Rock First doctor to open a Rhythm clinic in Boston 1936 First doctor to open a Rhythm clinic in Boston 1944 First IVF; created four embryos in secret 1944 First IVF; created four embryos in secret 1954 Collaborated with Pincus on U.S. clinical trials of the pill 1954 Collaborated with Pincus on U.S. clinical trials of the pill

STEPTOE AND EDWARDS Birth of Louise Brown First IVF Baby, 1978

Why ART? Why ART?

Infertility: Extremely Prevalent Definition: inability to achieve pregnancy in one year Definition: inability to achieve pregnancy in one year 17-26% of couples worldwide (90 million women) 17-26% of couples worldwide (90 million women) 27-47% of infertile couples have impaired male fertility; decline in semen quality worldwide over last 50 years 27-47% of infertile couples have impaired male fertility; decline in semen quality worldwide over last 50 years

Why the increase in infertility? Delayed marriage and child-bearing Delayed marriage and child-bearing Sexually transmitted diseases Sexually transmitted diseases Hormonal contraception Hormonal contraception Abortion Abortion Obesity Obesity Environmental Pollution Environmental Pollution

FERTILITY CLOCK

What is IVF?

IVF (in vitro fertilization) is a method in which egg cells are fertilized by sperm cells outside the mother’s womb (in vitro). The resulting embryos are then transferred back into the uterus.

STEPS IN IVF Follicle suppression Follicle suppression Controlled ovarian hyperstimulation Controlled ovarian hyperstimulation Aspiration of eggs from follicles Aspiration of eggs from follicles Fertilization, incubation and selection of embryos Fertilization, incubation and selection of embryos Embryo transfer Embryo transfer Pregnancy test Pregnancy test

FOLLICLE SUPPRESSION AND CONTROLLED OVARIAN HYPERSTIMULATION

ASPIRATION OF EGGS ASPIRATION OF EGGS

IVF LAB: FOLLICULAR FLUID

HIGH QUALITY EGG

LOW QUALITY EGG

EMBRYOLOGIST MANIPULATING OVA AND SPERM

ICSI

INCUBATOR

HIGH QUALITY THREE DAY OLD EMBRYO

EMBRYO TRANSFER

IVF: WHY NOT?

IVF why not? IVF permits the use of donor ova and sperm and cloned embryos IVF permits the use of donor ova and sperm and cloned embryos Violates traditional Judeo-Christian concept of marriage Violates traditional Judeo-Christian concept of marriage Legal and biologic confusion Legal and biologic confusion “Commercialization” of human life—sale of ova and sperm “Commercialization” of human life—sale of ova and sperm Donor ova and sperm illegal in many countries Donor ova and sperm illegal in many countries Cloned embryos? Cloned embryos? Issues with loss of embryos Issues with loss of embryos

IVF Why not? MULTIPLE BIRTHS

IVF why not? Multiple births Multiple pregnancies with IVF (37.4%) Multiple pregnancies with IVF (37.4%) Triplets or more 8.4% (4.9% of live births) Triplets or more 8.4% (4.9% of live births) Prematurity: Average with triplets 33 weeks; 85% survive Prematurity: Average with triplets 33 weeks; 85% survive Prematurity: Quadruplets average 29 weeks; 70% survive Prematurity: Quadruplets average 29 weeks; 70% survive Fetal risks: mental/physical disabilities such as blindness, cerebral palsy; 5% in twins, 10% in triplets, 50% in quadruplets Fetal risks: mental/physical disabilities such as blindness, cerebral palsy; 5% in twins, 10% in triplets, 50% in quadruplets Fetal risks: death; seven times more likely to die in the first year; 40x more likely to die in infancy Fetal risks: death; seven times more likely to die in the first year; 40x more likely to die in infancy Maternal risks: toxemia, diabetes, hemorrhage Maternal risks: toxemia, diabetes, hemorrhage Family risks: depression, social isolation, divorce Family risks: depression, social isolation, divorce

IVF: Expensive Medication: $1,500-$7,000 per cycle Medication: $1,500-$7,000 per cycle Office visits, egg retrieval, fertilization, assisted hatching, cryofreezing of embryo (six months),ultrasound, lab tests: $12,000-18,000 PER CYCLE; Office visits, egg retrieval, fertilization, assisted hatching, cryofreezing of embryo (six months),ultrasound, lab tests: $12,000-18,000 PER CYCLE; Egg donation $3,000-$50,000 Egg donation $3,000-$50,000

IVF: Additional Costs Hospital costs - Singleton $10,000; Twins $20,000; Triplets $40,000 Hospital costs - Singleton $10,000; Twins $20,000; Triplets $40,000 Intensive care of baby: $100,000- $150,000 per month Intensive care of baby: $100,000- $150,000 per month Work time lost--daily medical visits Work time lost--daily medical visits Frequently not covered by insurance Frequently not covered by insurance

Benitez v North Coast Women’s Medical Group Lesbian couple desired pregnancy Lesbian couple desired pregnancy ObGyn group declined to perform IUI (Intrauterine insemination) because of marital status (or sexual orientation ?) based on physicians’ religious beliefs ObGyn group declined to perform IUI (Intrauterine insemination) because of marital status (or sexual orientation ?) based on physicians’ religious beliefs Lower court found in favor of the doctors Lower court found in favor of the doctors California Supreme Court found in favor of Benitez California Supreme Court found in favor of Benitez

The McCaughey Septuplets 1997

The Chukwu Octuplets