2011Marek Vácha

It is not birth, marriage, or death, but gastrulation, which is truly the most important time in your life.

Lewis Wolpert (1986)

citizenship year

AR: Number of cycles

on the whole donors of oocytes women going to the IVF+ET

Czech Rep.

2007

15169 593 14576

European Union 2045 11 2034

Outside EU 528 1 527

On the Whole 17742 605 17137

Czech Rep.

2008

17300 1271 16029

EU 3328 9 3319

Outside EU 721 1 720

On the Whole 21349 1281 20068

Czech Rep.

2009

17299 1243 16056

EU 4453 1 4452

Outside EU 761 0 761

On the Whole 22513 1244 21269

Zdroj dat: Národní registr asistované reprodukce, ÚZIS ČR

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-oldin 2003

A Delivery. LB. Patrick Steptoe right, Robert Edwards left

They persisted through more than 40 embryo transfers before obtaining their first pregnancy. Unfortunately it was ectopic and had to be aborted. Louise Brown was born from the second pregnancy.

2010: Nearly four million babies have been born using IVF fertility treatment

since 1978.Prof. Edwards a Louise Brownová v roce 2008, kdy L. Brownová oslavila 30. narozeniny. Dítě počala přirozenou cestou.

1983 = donation of oocyte 1993 = ICSI 2000 = PGD

Czech Rep.

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

Useful terms AIH – artificial insemination husband) AID artificial insemination donor) “ (Encyclopedia of Bioethics,4/2219)

IVF + ET

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…

preimplantation diagnostics spare embryos pregnancy reduction

preimplantation diagnostics spare embryos

may be disposed on frozen experimented on

pregnancy reduction

there are about 400 000 human embryos stored in cylinders filled with liquid nitrogen in the USA although the 90 % success rate with thawed

embryos may be acceptable for laboratory animals, it probably is not acceptable with humans

once frozen, the embryos may outlive the donor and thus raise the possibility of postmortem conception and birth

women could postpone pregnancy without risking either infertility or the disease of preganancy that afflict older women by conceiving at a young age (thus avoiding the old-age dangers like Down syndrome)

The in vitro fertilized embryo has four possible fates implantation, in the hope of producing from it a

child death, by active killing or disaggregation, or by

"natural" demise use in manipulative experimentation

embryological, genetic, extraction of stem cells etc.

use in attemps at perpetuation in vitro beyond the blastocyst stage (in the future)

up to 85 % IVF+ET is taking place with the help of ICSI Sweden: every citizen 18+ has the right to

know his or her biological parents When Sweden passed 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 total disappearance of DI in Sweden and frequent referral of couples to other parts of Scandinavia

at ČR is donation anonymous

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

PGD

Pro PGD se tedy z osmibuněčného embrya bere jedna buňka

Czech Rep.: chromosomes 13, 16, 18, 21, 22, X, Y

new uses include PGD to detect mutations for susceptibility to cancer and for ate onset diseases such as Alzheimer´s disease

In adition, parents with children needing hematopoietic stem cell transplant have used PGD to ensure that their next child is free of disease and a good tissue match for an existing child

(Robertson, J.A., (2003) Journal of Medical Ethics 29: 213-16)

the first succesfull use of PGD was in 1990 for testing of aneuploidy in low prognosis IVF patients and for single gene and X linked diseases 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 inherited breast, ovarian or bowel cancer, though it was stressed that the particular circumstances 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 low success rate, 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)

for testing of aneuploidy in low prognosis IVF patients

and for single gene and X linked diseases in at risk couples

for p53 mutations for BRCA 1 and 2 mutations for Alzheimer´s disease for Huntington disease for HLA matchin to na existing child

it may also ensure that the new child does not also suffer from that same disease

intelligence height sexual orientation beauty hair and eye colour strenght memory perfect or "absolute" pitch

Parents clearly have the right to instill or develop a child´s musical ability after birth

They might reasonably argue that they shoudl have that right before birth as well

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 Czech rep. 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.

...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 counseling interactions.

these difficulties have been highlighted of late by the surfacing of a new kind of genetic counseling request: parents with certain disabilities who seek help in trying to assure that they will have a child who shares their disability.

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)

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)

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 worth living, one can say that life itself is a cruelty to the child

But when a child is born in less than ideal circumstances, or is partially disabled in ways that do not entail tremendous suffering, there seems no way to argue that the child herself has been harmed.

Against FOR

in our society everyone agrees that whites have an easier time than blacks. But do you think a black person would undergo operations to become white?

when Gorbachev visited the U.S., he used an interpreter to talk to the President. Was Gorbachev disabled?

deaf people lack the ability to hear

if deafness is considered a disability, one that substantially narrows a child´s carreer, marriage, and cultural options in the future, then deliberately creating a deaf child counts as a moral harm

If Deafness is considered a culture, as Deaf activists would have us agree, then deliberately creating a Deaf child who will have only very limited options to move outside of that culture, also counts as a moral harm

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)

Arguments Against

a feminist approach: techniques for assisting human reproduction bear a striking resemblance to techniques used to facilitate reproduction in livestock

Arguments Against

laboratory fertailization is a peculiar treatment for oviduct obstruction in that it requires the creation of a new life to "heal" an existing one.

All this simply emphasizes the uniqueness of the reproductive organs in that their proper function involves other people, and calls attention to the fact that infertility is not a disease, like heart disease or stroke, even though obstruction of a normally patent tube or vessel is the proximate cause of each

Kass, R.L., (2002) Life, Liberty and the Defense of Dignity. Encounter Books, 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 age limits 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

notable cases in the UK were the applications to the HFEA from two set of parents (the Hashmi and Whitaker families) for permission to select embryos (=saviour siblings) to treat their existing children, who suffered from beta-thalassaemia and rare non-inherited disease Diamond-Blackfan anaemia respectively

in each case, the proposed strategy was to harvest stem cells from umbilical cord blood following the birth of the younger sibling,with the aim of using stem cells in a bone marrow transplant and subsequently curing the disease in the older child through the production of healthy blood cells

The Hashmis were granted permission 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 older sibling

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 direct benefit to the younger sibling – because DBA is not inherited

…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

Stephen Blood died from meningitis in 1995

prenatal sex selection

there are 100 million fewer living women than we should expect 44 million fewer in China 37 million fewer in India

(Blackburn, S., (2001) Ethics. A Very Short Introduction. Oxford University Press, Oxford, p. 50)

A study based on 1,1 million Indian household in 1997 showed that although

numbers of boys and girls born were almost equal for the first child

759 girls were born per thousand boys for second children

and only 719 girls per thousand boys for third children

this practice accounted for 10 million fewer indian girls being born over the last 20 years

(Mepham, B., (2008) Bioethics. An Introduction for the Biosciences. Oxford University Press, Oxford, p. 125)

http://www.bbc.co.uk/news/world-south-asia-13264301

preimplantation genetic diagnosis

the American Medical Association has advised physicians that sex selection of this kind in the absence of any accompanying health problems is not something that physicians should do.

(Richards, J.E., Hawley, R.S., (2005) The Human Genome. A User´s Guide. 2nd ed. Elsevier Academic Press, Burlington, MA, USA, p.386)

- if PGD is not permitted, pregnancy and abortion might occur instead

following a public consultation exercise in the UK, the HFEA announced in 2003 that it had decided to ban sex-selection for „family balancing“, although permitting it where a child of one sex would risk inheriting a serious genetic disorder

„Your child will be female, which increases the risk of sexual abuse, domestic violoence and poverty.“

the American Medical Association has advised physicians that sex selection of this kind in the absence of any accompanying health problems is not something that physicians should do.

(Richards, J.E., Hawley, R.S., (2005) The Human Genome. A User´s Guide. 2nd ed. Elsevier Academic Press, Burlington, MA, USA, p.386)

generally, the sex selection in USA is made for the second or third baby, not for the first

Convention on Human Rights and Biomedicine (Oviedo

Convention) 1997 Chapter IV - Human genome

Article 11 - Non-discriminationAny form of discrimination against a person on grounds of his or her genetic heritage is prohibited.

Article 12 - Predictive genetic testsTests which are predictive of genetic diseases or which serve either to identify the subject as a carrier of a gene responsible for a disease or to detect a genetic predisposition or susceptibility to a disease may be performed only for health purposes or for scientific research linked to health purposes, and subject to appropriate genetic counselling.

Article 13 - Interventions on the human genomeAn intervention seeking to modify the human genome may only be undertaken for preventive, diagnostic or therapeutic purposes and only if its aim is not to introduce any modification in the genome of any descendants.

Article 14 - Non-selection of sexThe use of techniques of medically assisted procreation shall not be allowed for the purpose of choosing a future child's sex, except where serious hereditary sex-related disease is to be avoided.

Convention on Human Rights and Biomedicine (Oviedo Convention)1997

Article 14 - Non-selection of sex

The use of techniques of medically assisted procreation shall not be allowed for the purpose of choosing a future child's sex, except where serious hereditary sex-related disease is to be avoided.

Ovum donation

UK

In 2003 in the UK only 20 eggs were donated for research, and in general those that are surplus to requirements in IVF programmes tend to be of poor quality.

this led the HFEA in 2007 to permit researchers to reimburse women up to £250 for their eggs, although the donors will be required to show that they are „acting altruistically“

women donating eggs in this way may also have the fee for their own IVF treatment halved, which would be equivalent to a payment of about £1500

UK

critics suggests that this is likely to result in the exploitation of poorer women, many of whom may be induced to travel to Britain from abroad to sell their eggs.

(Mepham, B., (2008) Bioethics. An Introduction for the Biosciences. Oxford University Press, Oxford, p. 143)

Possible scenarios of the future

Collins, F., (2006) The Language of God. Free Press, New York, p. 269)