1. Problems with the In Vitro Fertilisation Treatment of Heterosexual Couples Health Law and Bioethics Georgi Avramov, Student Number: 004794, Erasmus + Student from Sofia University “St. Kliment Ohridsky”

2. What Is Inferitily?  One possible definition: infertility is the failure to conceive after a specific period of time of regular, unprotected sexual intercourse, or the occurrence of three or more consecutive miscarriages or stillbirths.  Specific period of time:  standard definition – 12 months;  World Health Organisation (WHO) – 2 years;  some demographers – 5 years. (Image source: http://portugalresident.com/facing-and-treating-infertility)  Actual incidence of fertility problems – unknowable; now assumed - one in six heterosexual couples.

3. What are assisted reproductive technologies?  Assisted reproductive technology (ART) is the use of reproductive technology to treat infertility. Examples include in vitro fertilization (IVF) and its possible expansions, such as:  cryopreservation of sperm, oocytes, embryos;  artificial insemination;  in vitro generated gametes;  IVF;  cloning etc.

4. 1. Cryopreservation  What is Cryopreservation? Freezing of:  sperm (first frozen 1949);  embryos (first frozen 1983);  eggs (until recently considered as unsafe procedure, now possible). (Image source: http://sites.davidson.edu/bio362_art/?page_id=38)

5. 2. Assisted Insemination by Husband/Partner (AIH/AIP)  It is the assisted insemination with sperm of the husband or the partner.  No longer the optimum treatment for men with poor quality sperm.  Continues to be used in case of treatments such as chemotherapy, that will render the man infertile.

6. 3. Donor Insemination (DI)  1 st recorded DI – end of the 19 th century.  Disapproved and not acceptable until recently.  Common reasons – partner’s infertility, genetic disease, sexual dysfunction.  DI – still the only chance in cases of a man, who could not produce any sperm, or a woman without a partner.  Low success rates. (Image source: http://ivfmohali.com/our-services/donor-insemination-d-i/)

7. 4. Oocyte (Egg) Donation (Image source: http://www.simpledonations.com/egg-donors/)  Important differences from DI:  Finite number of eggs;  Much more uncomfortable and invasive;  First used in IVF treatment in 1984;  The freezing of eggs is also in infancy compared to the freezing of sperm;  Some countries prohibit it.  Common reasons - ovarian failure, a serious genetic abnormality; also multiple failed IVF treatment with own eggs.  Procedure – like the IVF treatment.  Advantage – biological connection to the child, always a legal mother of the child.

8. 5. Gamete Intra-Fallopian Transfer (GIFT)  In Vivo - egg retrieval in the same way as IVF, but instead of being placed in a petri dish with the sperm, the eggs and the sperm are injected into the woman’s fallopian tube.  Common reasons - no abnormality in a woman’s fallopian tubes and the couple’s infertility is “unexplained”. (Image source: http://lakecharlesobgyn.com/Complete/397- GIFT.aspx)

9. 6. Micromanipulation: Intra- Cytoplasmic Injection (ICSI) and Sub-Zonal Insemination (SUZI)  ICSI:  injection of a single sperm into an egg with a very fine glass needle;  if fertilisation occurs - zygote(s) will be transferred to the women’s uterus in the same way as in conventional IVF;  common reasons - sperm cannot penetrate an egg naturally (extremely low sperm count or poor motility).  SUZI:  microinjection of a small number of sperm into the egg;  it might be used if normal fertilisation has failed to occur.  Success rates improved dramatically over the years.

10. 7. Cloning  Dolly the sheep – 1997.  In theory could be used to increase the numbers of embryos created in an IVF cycle, or to create a duplicate embryo that could be tested for genetic abnormailities and discarded, while its intact “twin” could subsequently be implanted. (Image source: http://usatoday30.usatoday.com/tech/science/gene tics/2006-07-04-dolly-anniversary_x.htm)

11. (8.) In Vitro Fertilisation (IVF) History:  Research began in the 1930s.  1 st successfully performed on mouse in 1958.  IVF with human gametes - pioneered by Robert Edwards and Patrick Steptoe during the 1960s and 1970s -> first IVF baby, Louise Brown (25.07.1978).  Initially - hostility to IVF and scepticism about its safety and efficacy. (Image source: http://www.dailymail.co.uk/news/article-2515585/Louise-Brown-Worlds- test-tube-baby-pays-emotional-tribute-parents.html) (Image source: http://www.dailymail.co.uk/health/article-3173446/World-s-test-tube- baby-reveals-mother-received-blood-splattered-HATE-MAIL-born-including-letter- containing-plastic-foetus.html)

12. In Vitro Fertilisation (IVF) (Image source: http://www.mexicalihealthcare.com/procedure/In-Vitro- Fertilization/21) Procedure: 1. Commonly hormonal treatment – producing more eggs. 2. Removal of the eggs from the ovarian follicles through laparoscopy or transvaginal aspiration and placing them in a culture that allows them to mature further. 3. Providing of sperm. 4. Putting the mature eggs into a petri dish with sperm (usually from the woman’s partner). 5. If fertilisation occurs the resulting zygote(s) may be places in the woman’s uterus, or frozen to be used at a later date.

13. In Vitro Fertilisation (IVF) Nowadays:  IVF is now the most common treatment for infertility (99 % of all procedures).  Success rates - depend on a number of factors. The most recent report from 2009 found:  Pregnancy achieved - 29.4% of all cycles (higher or lower depending on the age of the woman);  Live births - 22.4% on average (higher or lower depending on the age of the woman).  More than 5 million babies have been born in the world as a result of an IVF treatment.

14. The Steinkamp Family (in 2008) (Image source: http://www.kinderwunsch-nrw.de/templates/media/pdf/SpiegelDokumente-25_05_2008.pdf)

15. The Steinkamp Family nowadays

16. Problems with IVF Treatment  Unnaturalness  Child welfare  Ignoring Infertile Women  Equality  Low success rates  Multiple pregnancies  Informed decision – not informed enough  Infertility treatment “takes over” patient’s lives  Extremely expensive

17. What and How Should We Regulate?  Access to treatment  Consultation and informed consente  Status and Use of Gametes  Procedure  Paternity  Regulating new technologies

18. Thank You for Your attention and participation!