| Introduction
Setting
the Stage: Questions to Think About
Assisted
Reproductive Technology (ART) is the technology that can be used
to help men and women have children. There have been many scientific
advances affecting ART in recent years. These new advances have
also added to the ethical dilemmas associated with Assiated Reproductive
Technology.
Are
the increased medical risks to women undergoing ART therapies
worth it?
Once
an embryo is created, does it have moral status as a human being
or is it just someone’s property?
What
happens to an embryo if the “parents” divorce or one
of them dies?
Is
there an age when men and women are simply too old to become parents?
Introduction
Assisted
Reproductive Technology (ART) is the technology developed to aid
in the conception of children. Women or men who are unable to
have children due to some physical limitation (infertility) can
be helped with one of the several methods of ART. Infertility
is defined as the inability to conceive for a one-year or greater
period or a period of 6 months if a woman is over 35. Also included
in the definition is the inability to carry the baby to term or
having had 2 or more miscarriages in the past. Recent statistics
show that infertility has been diagnosed in approximately 17%
of all couples.
The
reasons for infertility vary and can be seen in both males and
females. The most common causes of infertility in males are low
sperm count, immobile sperm, previous STDs (sexually transmitted
diseases), prostate infection or testicular injury. For women,
causes of infertility are various and include problems with ovulation,
blocked fallopian tubes, previous STDs, polyps or fibroids, endometriosis,
previous IUD (intrauterine device used for contraception), infections
and age (over 35). There is also 5 – 10% rate of unexplained
infertility.
There
are several different approaches to ART depending upon the physical
needs and/or difficulties assessed. Artificial insemination is
the procedure that positions sperm that has been previously treated
either into the cervical canal, the uterus, the fallopian tubes
or the ovarian follicle by mechanical means such as the use of
a syringe. The most common form of artificial insemination is
intrauterine insemination (IUI). IUI is usually done in the office
setting and takes just a few minutes. A catheter is inserted through
the vagina and into the uterine cavity where the sperm are injected.
Unlike in vitro fertilization the physician cannot immediately
tell if fertilization has taken place and the woman is pregnant.
In
vitro fertilization (IVF) is the process of combining an egg with
sperm in a petri dish where fertilization takes place. (The success
ate is approximately 20% to 25%). This process results in an embryo.
The embryo is then implanted into the woman’s uterus via
a non-surgical vaginal approach. All forms of in vitro fertilization
require preparation of the woman and sometimes the sperm and eggs.
To prepare for IVF the woman is first stimulated into ovulation
through the use of hormones. Then the eggs are retrieved either
vaginally or through laparoscopic surgery. Fertilization then
takes place in the lab (Petri dish). After fertilization the embryo
is transferred into the uterus.
Another
form of IVF is gamete intrafallopian transfer (GIFT). As in IVF
the woman is given fertility medication to stimulate egg production
after which the eggs are retrieved. The sperm is also collected
from the man as in IVF. Then sperm and egg are
surgically placed into the fallopian tube of the woman where hopefully
fertilization will occur. Zygote intrafallopian transfer (ZIFT)
occurs much like IVF and GIFT in the preparatory phases. However,
the difference is that with ZIFT a zygote, which is a fertilized
egg at the 2-cell stage, is transferred into fallopian tubes.
Intracytoplasmic sperm injection (ICSI) is used when there is
severe male infertility. This procedure uses microscopic instrumentation
to fertilize a specially prepared egg with one sperm. The fertilized
embryo is then transferred into the uterus of the woman as in
IVF. There are several more variations of assisted reproduction.
However, the purpose here is only to inform the discussion.
The
rapid rate of new scientific technology brings with it new ethical
dilemmas. Ethical questions that affect ART are the subject of
this module. A few scenarios that will be shared that will engage
you in critical thinking regarding a subject that most, at some
point in their life, will encounter, either personally or anecdotally.
There
have been several studies that have presented information on increased
medical risks to women undergoing ART therapies and pregnancies
as well as increased risk of low birth weight and disease for
infants. The question can be asked whether it is morally acceptable
to subject families to this increased risk of harm with insufficient
scientific data on reproductive technologies available? One can
also ask if patients are not fully aware of all risks can a truly
informed consent be made. On the other hand, nearly 20% of couples
currently feel the anguish, shame, and frustration of not being
able to get pregnant. With the technology available since 1978
is it cruel not to grant access to those who need ART to further
their quest for biological children of their own?
The
list of ethical concerns grows when donors are used in ART. With
young women being paid $5,000 – $10,000 per ovulation cycle
sale of human eggs is becoming a booming business. Some additional
questions to ask are:
•
Will this lead to exploitation of young, low-income women?
• What are the long-term effects of multiple cycles of hormonal
treatment and egg retrieval?
• Once embryos are made do they have moral status or do
they become property?
• What are the legal implications of divorce or death on
embryos in storage? Whose rights take precedence husband or wife?
Women
who are past the physical childbearing age can now use ART to
become impregnated. Recently women in their 60s have delivered
babies and begun their roles as parents. To date, the oldest woman
to give birth is 66 years old. In these cases opinions greatly
differ on questions such as:
•
Is 60 too old for a woman to give birth?
• Is it too old for a man to become a father?
• Is this a chance of a lifetime for a woman who has been
unable to give birth until now?
• Will the current trend of postponing childbearing and
thereby increasing age gap affect society as a whole? If so, how?
If not, why not?
These
concerns and many more have come up as there are now over 3 million
ART babies since the birth of the first test-tube baby, Louise
Brown, in 1978. Answers are coming slowly, mostly on a case-by-case
basis as these issues arrive in the legal system. Some see regulation
as an answer to some of the current ethical dilemmas; fertility
centers are currently not regulated in the U.S. Most centers only
undergo self-monitoring on guidelines given by organizations such
as ASRM (The American Society for Reproductive Medicine). There
are also those who feel that government interference will only
hold back the practice of medicine and scientific progress in
the area of ART. As current high school students you soon will
likely aid in the process of defining or redefining the ethics
of ART.
Educational
Objectives
•
Become familiar with the uses and methodology of Assisted Reproductive
Technology (ART)
•
Develop an understanding of the types of ethical issues raised
by the rapid advances in scientific technology
•
Grasp several core values utilized in the process of ethical decision-making
•
Broaden critical thinking abilities
•
Formulate an ethical position concerning at least one ethical
conflict in ART
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