The Art of The Art of ARTART::Assisted Reproductive Assisted Reproductive TechnologyTechnology

Mary L. Davenport, M.D.Mary L. Davenport, M.D.

Berkeley Students for LifeBerkeley Students for Life

March 4, 2009March 4, 2009

What is ART?What is ART?

Assisted Reproductive Assisted Reproductive Technologies:Technologies:

Fertility therapies where eggs and Fertility therapies where eggs and sperm are manipulatedsperm are manipulated

Involve surgically removing eggs Involve surgically removing eggs from women and combining them from women and combining them with sperm in the laboratorywith sperm in the laboratory

ART: Assisted Reproductive TechnologyART: Assisted Reproductive Technology

Predominantly IVF – In Vitro FertilizationPredominantly IVF – In Vitro Fertilization ExpensiveExpensive Most attempts fail to produce a live birthMost attempts fail to produce a live birth Separates procreation from the marital Separates procreation from the marital

actact Large loss of embryos in failure to Large loss of embryos in failure to

implant, discarding embryos, pre-implant, discarding embryos, pre-implantation diagnosis, freezing, implantation diagnosis, freezing, selective reductionselective reduction

TYPES OF ART SART 1999

IVF

ASSISTED REPRODUCTIVE ASSISTED REPRODUCTIVE TECHNOLOGYTECHNOLOGY

Major philosophical and ethical Major philosophical and ethical shift in reproductive medicineshift in reproductive medicine

Emphasis changed from healing Emphasis changed from healing and eradicating disease to control and eradicating disease to control of procreationof procreation

REPRODUCTIVE CHRONOLOGYREPRODUCTIVE CHRONOLOGY

1934 Gregory Pincus: First animal 1934 Gregory Pincus: First animal IVFIVF

1944 John Rock: First human IVF1944 John Rock: First human IVF 1960 FDA approves “the pill”1960 FDA approves “the pill” 1978 First IVF baby1978 First IVF baby 2001 421 U.S. ART clinics with 41,000 2001 421 U.S. ART clinics with 41,000

live births annuallylive births annually

GREGORY PINCUSGREGORY PINCUS

1934 First in vitro 1934 First in vitro fertilization of rabbit fertilization of rabbit eggseggs

Criticized as “mad Criticized as “mad scientist” scientist”

Developed oral Developed oral contraceptives in contraceptives in 1950’s1950’s

Dr. John RockDr. John Rock1890-19841890-1984

1936 First doctor 1936 First doctor to open a Rhythm to open a Rhythm clinic in Bostonclinic in Boston

1944 First IVF; 1944 First IVF; created four created four embryos in secretembryos in secret

1954 1954 Collaborated with Collaborated with Pincus on U.S. Pincus on U.S. clinical trials of clinical trials of the pillthe pill

STEPTOE AND EDWARDSSTEPTOE AND EDWARDSBirth of Louise BrownBirth of Louise BrownFirst IVF Baby, 1978First IVF Baby, 1978

Why ART?Why ART?

Infertility: Extremely PrevalentInfertility: Extremely Prevalent

Definition: inability to achieve Definition: inability to achieve pregnancy in one yearpregnancy in one year

17-26% of couples worldwide (90 17-26% of couples worldwide (90 million women)million women)

27-47% of infertile couples have 27-47% of infertile couples have impaired male fertility; decline in impaired male fertility; decline in semen quality worldwide over last 50 semen quality worldwide over last 50 yearsyears

Why the increase in infertility?Why the increase in infertility?

Delayed marriage and child-bearingDelayed marriage and child-bearing Sexually transmitted diseasesSexually transmitted diseases Hormonal contraceptionHormonal contraception AbortionAbortion ObesityObesity Environmental PollutionEnvironmental Pollution

FERTILITY CLOCK

What is IVF?What is IVF?

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

STEPS IN IVFSTEPS IN IVF

Follicle suppressionFollicle suppression Controlled ovarian hyperstimulationControlled ovarian hyperstimulation Aspiration of eggs from folliclesAspiration of eggs from follicles Fertilization, incubation and selection of Fertilization, incubation and selection of

embryosembryos Embryo transferEmbryo transfer Pregnancy testPregnancy test

FOLLICLE SUPPRESSION ANDFOLLICLE SUPPRESSION ANDCONTROLLED OVARIAN HYPERSTIMULATIONCONTROLLED OVARIAN HYPERSTIMULATION

ASPIRATION OF EGGSASPIRATION 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 TRANSFEREMBRYO TRANSFER

IVF:IVF:

WHY NOT?WHY NOT?

IVF Why not?IVF Why not?

LOSS OF LIFELOSS OF LIFE

IVF OUTCOMES

SART 1999

Pregnancy Rates: Nondonor Eggs SART,CDC, 2004

LOW QUALITY EMBRYO

TANK FOR FREEZING EMBRYOS

MFPRMFPRMULTIFETAL PREGNANCY REDUCTIONMULTIFETAL PREGNANCY REDUCTION

ART Outcomes by Age SART, CDC, 2004

COMPARISON OF OWN AND DONOR EGGSCOMPARISON OF OWN AND DONOR EGGS

Pregnancy Loss by Age: CDC

IVF why not?IVF why not?IVF permits the use of donor ova and IVF permits the use of donor ova and sperm and cloned embryossperm and cloned embryos

Violates traditional Judeo-Christian concept of Violates traditional Judeo-Christian concept of marriage marriage

Legal and biologic confusion Legal and biologic confusion ““Commercialization” of human life—sale of ova Commercialization” of human life—sale of ova

and spermand sperm Donor ova and sperm illegal in many countriesDonor ova and sperm illegal in many countries Cloned embryos can be usedCloned embryos can be used Cloning a dangerous technology and makes Cloning a dangerous technology and makes

massive abuses possiblemassive abuses possible

COMPARISON OF OWN AND DONOR EGGSCOMPARISON OF OWN AND DONOR EGGS

Egg donor

Characteristics:

e.g. Hair color,

Weight

Ethnicity…

CLONED HUMAN EMBRYOCLONED HUMAN EMBRYO

PANAYIOTIS ZAVOS, PH.DPANAYIOTIS ZAVOS, PH.D..

CURRRENTLY CURRRENTLY CONDUCTING CONDUCTING HUMAN CLONING HUMAN CLONING EXPERIMENTS IN EXPERIMENTS IN UNDISCLOSED UNDISCLOSED COUNTRY WITH COUNTRY WITH DRS. SEVERINO DRS. SEVERINO ANTORINI AND ANTORINI AND BEN-ABRAHAMBEN-ABRAHAM

GOAL: GOAL: PROVIDING PROVIDING CHILDLESS CHILDLESS COUPLES WITH COUPLES WITH THE ABILITY TO THE ABILITY TO CLONE CLONE THEMSELVES AS THEMSELVES AS A FORM OF A FORM OF REPRODUCTIONREPRODUCTION

IVF Why not?

MULTIPLE BIRTHS

IVF why not? Multiple birthsIVF 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% Prematurity: Average with triplets 33 weeks; 85%

survivesurvive Prematurity: Quadruplets average 29 weeks; Prematurity: Quadruplets average 29 weeks;

70% survive70% survive Fetal risks: mental/physical disabilities such as Fetal risks: mental/physical disabilities such as

blindness, cerebral palsy; 5% in twins, 10% in blindness, cerebral palsy; 5% in twins, 10% in triplets, 50% in quadrupletstriplets, 50% in quadruplets

Fetal risks: death; seven times more likely to die Fetal risks: death; seven times more likely to die in the first year; 40x more likely to die in infancyin the first year; 40x more likely to die in infancy

Maternal risks: toxemia, diabetes, hemorrhageMaternal risks: toxemia, diabetes, hemorrhage Family risks: depression, social isolation, divorceFamily risks: depression, social isolation, divorce

IVF: ExpensiveIVF: Expensive Medication: $1,500-$7,000 per cycleMedication: $1,500-$7,000 per cycle Office visits, egg retrieval, fertilization, Office visits, egg retrieval, fertilization,

assisted hatching, cryofreezing of embryo assisted hatching, cryofreezing of embryo (six months),ultrasound, lab tests: (six months),ultrasound, lab tests: $12,000-18,000 $12,000-18,000 PER CYCLEPER CYCLE; ;

Egg donation $3,000-$50,000Egg donation $3,000-$50,000

IVF: Additional CostsIVF: Additional Costs Hospital costs - Singleton $10,000; Hospital costs - Singleton $10,000;

Twins $20,000; Triplets $40,000Twins $20,000; Triplets $40,000 Intensive care of baby: $100,000-Intensive care of baby: $100,000-

$150,000 per month$150,000 per month Work time lost--daily medical visitsWork time lost--daily medical visits Frequently not covered by insuranceFrequently not covered by insurance

Benitez v North Coast Women’s Medical GroupBenitez v North Coast Women’s Medical Group

Lesbian couple desired pregnancyLesbian couple desired pregnancy ObGyn group declined to perform IUI ObGyn group declined to perform IUI

(Intrauterine insemination) because of (Intrauterine insemination) because of marital status (or sexual orientation ?) marital status (or sexual orientation ?) based on physicians’ religious beliefsbased on physicians’ religious beliefs

Lower court found in favor of the doctorsLower court found in favor of the doctors California Supreme Court found in favor California Supreme Court found in favor

of Benitezof Benitez

R. Alta Charo, J.D.R. Alta Charo, J.D.Professor of LawProfessor of LawUniversity of WisconsinUniversity of Wisconsin

““The Celestial Fire The Celestial Fire of Conscience: of Conscience: Refusing to Refusing to Deliver Medical Deliver Medical Care”Care”

New England Journal New England Journal of of Medicine Medicine

June 16, 2005June 16, 2005

The McCaughey Septuplets 1997

The Chukwu Octuplets

Dr, Michael Kamrava