Screening practices and beliefs of assisted reproductive technology programs

Racial disparities in access to reproductive health and fertility care in the United States

PURPOSE OF REVIEW

To examine the status of racial and ethnic inequalities in fertility care in the United States (U.S.) at inception of 2022. This review highlights addressable underpinnings for the prevalent differentials in access to and utilization of infertility treatments and underscores gaps in preventive care as key contributors to racial and ethnic disparities in risk burden for subfertility and infertility.

RECENT FINDINGS

Significant gaps in access to and utilization of fertility care are consistently reported among racial and ethnic minorities, particularly Black and Hispanic women. Access to and utilization of contraceptives, human papilloma virus vaccination rates, preexposure prophylaxis use, and differentials in treatment of common gynecologic disorders are relevant to the prevalent racial and ethnic disparities in reproductive health. The spectrum of differential in reproductive wellness and the magnitude of reproductive health burden afflicting racial minorities in the U.S. raise concerns regarding systemic and structural racism as plausible contributors to the prevalent state of affairs.

SUMMARY

Despite efforts to reform unequal reproductive health practices and policies, racial and ethnic disparities in fertility care are pervasive and persistent. In addition to measures aimed at reducing barriers to care, societal efforts must prioritize health disparity research to systematically examine underpinnings, and addressing structural racism and interpersonal biases, to correct the prevalent racial inequities and mitigate disparities.

Access to infertility evaluation and treatment in two public fertility clinics and the reasons for withholding it: a prospective survey cohort study of healthcare professionals

OBJECTIVES

Study the proportion of patients affected by involuntary childlessness who are denied fertility treatment and the reasons behind this in a publicly funded healthcare system.

DESIGN

Survey study using prospectively collected information by healthcare professionals.

SETTING

Two university-affiliated fertility clinics in Sweden.

PARTICIPANTS

Single women and couples in heterosexual and homosexual relationships seeking fertility evaluation and treatment between November 2017 and April 2018 (943 individual cases).

PRIMARY AND SECONDARY OUTCOME MEASURES

Number and proportion of individuals who were either denied, delayed or granted fertility treatment directly. Furthermore, the reasons behind delaying or completely withholding treatment.

RESULTS

The majority of those seeking evaluation were heterosexual couples (75%), while 14% were single women and 7.5% were same-sex couples. The great majority of those undergoing evaluation were granted treatment either directly (85%) or after in-depth evaluation (7.5%), while 7.5% were denied treatment. Among those who were denied treatment, there were a greater proportion of single women and couples seeking treatment with donated gametes. Among heterosexual couples, gamete origin was not associated with treatment refusal. Although age did not differ between those granted and denied treatment, a higher body mass index (in both recipient and partner, when applicable) was observed among those being refused treatment. Fertility specialists in Sweden focused their assessment on parental factors that may indirectly entail a risk of harm to the future child, such as medical and psychiatric conditions of the individuals involved, their financial constraints and other social reasons, substance abuse and female obesity.

CONCLUSION

Being single or receiving treatment with donated gametes can both be reasons for withholding fertility treatment. Although difficult to operationalise, parenting assessment in Sweden is employed interchangeably in treatments with donated gametes (legally mandated assessment) and even autologous gametes (non-legally mandated assessment)-making evident a need for clear official policy guidelines regulating these assessments and the provision of treatment.

Fertility Physicians’ Opinions and Attitudes on Access to Assisted Reproductive Technology: An Asia-Pacific Perspective

Background: Fertility physicians are gatekeepers of assisted reproductive technology (ART) and have immediate control over access to fertility care. However, little is understood about their attitudes and willingness to provide and support different procedures. Therefore, we examined fertility physicians’ perspectives on support of public funding and willingness to provide care in various scenarios.

Methods: We invited fertility physicians attending the 8th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2018) to participate in a 10-minute survey. Participants completed the survey anonymously and in private.

Results: 78 out of 105 fertility physicians from 12 countries completed the survey (response rate = 74.3%). Mean age was 44.9 years (SD = 11.1). A majority of respondents supported public funding for ART: 76.3% for intrauterine insemination and 80.5% for in vitro fertilization. For controversial procedures, a majority agreed to provide social egg freezing (88.5%) compared to sex selection (25.6%) and gene editing for nonmedical reasons (19.2%), p < 0.001 for both comparisons. Support for public funding was also significantly higher for social egg freezing (51.3%) compared to sex selection (23.1%) and gene editing for nonmedical reasons (20.5%), p < 0.001 for both comparisons. For eligibility criteria, willingness to provide treatment to single women (50.0%) was significantly higher compared to other nontraditional family structures — single men (33.3%), p < 0.001, male homosexual couples (33.3%), p = 0.002, female homosexual couples (32.1%), p = 0.001 and unmarried heterosexual couples (32.1%), p = 0.004. Consistently, support for public finding was significantly higher for single women (32.1%) compared to single men (23.1%), p = 0.013, male homosexual couples (20.5%), p = 0.020, and unmarried heterosexual couples (20.5%), p = 0.006.

Conclusions: These results show support for public funding and conservative opinions toward ART for nontraditional family structures among physicians in the Asia-Pacific region.

Child welfare assessments and the regulation of access to publicly funded fertility treatment

Assessment of the psychological and social circumstances of candidates for assisted reproduction is commonly justified with references to the welfare of the intended child. In nine focus group discussions with 64 clinic staff at four public fertility clinics in Sweden, the responsible use of public resources constituted another important justification for such assessments. Theoretically, this study draws on the identification of the role of regulatory conversations in decision makers' policy interpretations. Focus groups defined the desired outcome of assisted reproductive technology (ART) treatment as a well-functioning family, and represented the aim of ART treatment as solving problems without creating new problems for the candidates, the intended child or society. In the discourse of solving and preventing problems, the welfare of the child argument, the responsible use of resources argument and the discourse of personal responsibility merge. Lack of consideration for the circumstances in which the child will grow up was not considered a responsible use of resources because ART treatment would then risk creating more problems than it solved. The results of this study suggest that while publicly funded subsidization of fertility treatment has increased accessibility to ART treatment for candidates who lack the financial means to pay, clinic staff justified restricting access to ART treatment with concern for how public resources are spent.

A limited market: the recruitment of gay men as surrogacy clients by the infertility industry in the USA

Gestational surrogacy via egg donation is an expensive - and sometimes ambivalently undertaken - but increasingly popular route to planned fatherhood for some gay men. The surrogacy market in the USA plays an important role for gay men with the financial resources to access these services, as it is currently the only stable, commercial market in which there are legal protections for openly gay men. While a small, ethnographic and qualitative literature on the experiences of gay fathers via surrogacy exists, less is known about the state of the surrogacy industry towards gay men as clients. Here I investigate the surrogacy industry in the USA to ask how welcome gay men are in this market. I do so via a content analysis of patient/client recruitment on infertility clinic and surrogacy agency websites. Content analysis of 547 websites indicates that the majority of infertility clinics (62%) and 42% of surrogacy agencies do not directly advertise or appear to be welcoming to gay men. A minority of gay-friendly clinics and agencies, which cluster geographically, actively recruit gay men, creating a limited but niche market. The unequal recruitment of gay men as infertility clients reflects how normative ideas about gender, sexuality and social class are reproduced in the infertility industry. This, in turn, may impact gay men's procreative consciousness and decision-making about parenting, and exacerbate inequalities around their access to intentional genetic parenthood.

The acceptability of stem cell-based fertility treatments for different indications

STUDY QUESTION

What is the acceptability of using stem cell-based fertility treatments (SCFT) for different indications according to gynaecologists and the general public?

SUMMARY ANSWER

The majority of gynaecologists and the general public accept SCFT for the indications female or male infertility in young heterosexual couples, and female infertility in single women and same-sex couples.

WHAT IS KNOWN ALREADY

SCFT could result in genetic parenthood for intended parents with indications that cannot be treated using currently available methods, such as being in a same-sex relationship or female post-menopausal age. It is unclear whether the acceptability of SCFT differs between indications for treatment and whether gynaecologists and the general public differ in their assessments.

STUDY DESIGN SIZE, DURATION

In November 2015, a cross-sectional survey was disseminated among 179 gynaecologists and a panel of 1250 respondents comprising a representative sample of the Dutch general public.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The potential indications for future SCFT to achieve genetic parenthood were identified by literature review. A questionnaire was developed, reviewed by experts from different disciplines and tested among the general public. The questionnaire asked whether treating eight groups of intended parents with SCFT was acceptable or not. Regression analysis examined whether demographic characteristics influenced choices and whether the general public and gynaecologists differed in opinion.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 82 (46%) gynaecologists and 772 (62%) members of the general public completed the survey. The acceptability of using SCFT varied according to both gynaecologists and the general public between the eight groups of intended parents (P < 0.001). The majority of the Dutch general public accepts SCFT for six out of eight possible indications, namely female infertility in young heterosexual couples (94%), male infertility in young heterosexual couples (94%), unexplained infertility in young heterosexual couples (83%), female infertility in single women (69%), lesbian couples (68%) and gay couples (62%). The majority of gynaecologists also found treating these groups acceptable, except for the indication of unexplained infertility, which was only accepted by a minority of gynaecologists (43%). A minority of both the general public and gynaecologists accepted SCFT for fertile women who want a child that is genetically only her own (27 and 6%, respectively) and for female infertility in heterosexual couples in which the woman is over 50 years of age (17% and 26%, respectively). Attaching low importance to religion, having progressive political preferences, not having a university degree, having experienced infertility, being a woman, being older and not being of European ethnicity were positively associated with considering using SCFT acceptable for one or multiple indications.

LARGE SCALE DATA

N/A.

LIMITATIONS REASONS FOR CAUTION

The generalizability of our findings to future decades or other countries might be limited as opinions about novel technologies change over time and might vary across cultures. Support among gynaecologists and the general public is interesting but not proof of ethical acceptability.

WIDER IMPLICATIONS OF THE FINDINGS

Once proven safe and effective, fear of limited acceptability by the general public is unwarranted, and thus should not stop gynaecologists from offering SCFT to single infertile women and same-sex couples in addition to young infertile heterosexual couples.

STUDY FUNDING AND COMPETING INTEREST(S)

Funded by the Young Academy of the Royal Netherlands Academy of Arts and Sciences and the Universities of Amsterdam and Leuven. No conflict of interest to declare.

Menopausal women requesting egg/embryo donation: examining health screening guidelines for assisted reproductive technology

OBJECTIVE

As more postreproductive women opt to pursue pregnancy with advanced assisted reproductive technologies (ART), the menopausal practitioner will become more involved in counseling, screening, and referral of premenopausal, perimenopausal, and postmenopausal women for these services. This review was conducted with the aim of (1) evaluating ART screening practices as they pertain to postreproductive women, and (2) reviewing the outcomes of ART using oocyte donation in postreproductive women.

METHODS

A total of 950 unique records were found on PubMed, Clinical Key, and Google Scholar. Of these, 252 records were screened for relevance based on their titles and abstracts. With further review of these 252 records, 93 full-text articles were assessed for eligibility, and 63 were excluded based on relevance to our study. Finally, 30 studies were included in our qualitative synthesis.

RESULTS

Despite the increasing use of ART in postreproductive women, there are limited guidelines for determining candidacy with regard to maternal health, the most comprehensive of which are the guidelines from the American Society for Reproductive Medicine (ASRM). Although the American Society for Reproductive Medicine guidelines state that healthy women over 50 who are prepared for parenthood are candidates for ART through oocyte donation, they note that older women should be counseled as to the increased obstetric risk associated with advanced maternal age. With aging, particularly for those women who are menopausal and postmenopausal, the woman and her fetus, however, are at risk of increased morbidity and mortality as compared with younger, healthy pregnant women. Because national trends suggest that women are delaying childbearing, the cohort of postreproductive women looking toward ART using donor oocytes as a fertility option will expand and menopausal practitioners will often participate in the ART counseling of these women.

CONCLUSIONS

Because maternal and fetal morbidity and mortality increase in postmenopausal women who become pregnant through ART, practitioners caring for this cohort should provide input into developing standardized, comprehensive guidelines for this population so that screening is consistent for all older women seeking this intervention and risks are objectively outlined and considered.

"Will they be good enough parents?": Ethical dilemmas, views, and decisions among assisted reproductive technology (ART) providers

BACKGROUND

Many adults may make less-than-ideal parents, but important ethical questions arise concerning whether assisted reproductive technology (ART) providers should thus ever refuse treatment to certain patients, and if so, when, and how to decide.

METHODS

In-depth interviews of approximately 1 hour each were conducted with 27 ART providers (17 physicians, and 10 other health providers).

RESULTS

Clinicians often struggle with whether to attempt to assess and predict patients' potential future parenting abilities, and if so, how, and how to proceed if doubts arise. Providers face profound ethical tensions between adults' rights to reproduce and best interests of the eventual children (i.e., to be born into "stable" homes), and questions about the extent of professional responsibilities toward potential parents versus toward future offspring. Providers generally feel uncomfortable with this role, and hence don't want it, partly since they lack training for it, but also because of inherent empirical and ethical uncertainties. Concerns about discrimination based on the mere presence or history of certain diagnoses or traits (e.g., single marital status or past depression) also arise. Clinicians frequently seek to resolve these tensions through various strategies-for example, referring these decisions to others; hoping that patients drop out of treatment; assessing and increasing social support (e.g., arranging for possible co-parents); assisting the patient psychotherapeutically; or seeking to communicate concerns to patients only indirectly or implicitly. Clinics vary in how they make and approach these decisions-whether they rely on a formal ethics or other committee.

CONCLUSIONS

These data, the first to explore several critical aspects of in vitro fertilization (IVF) providers' views and decision making about assessing the quality of patients' potential future parenting, have critical implications for future practice, education, research, and guidelines. Further empirical and normative scholarship and guidelines are needed to help clarify expectations, processes, and possible approaches to aid providers and patients.

Lesbian, gay, bisexual, transgender content on reproductive endocrinology and infertility clinic websites

OBJECTIVE

To assess geographical distribution and practice characteristics of fertility clinics inclusive of lesbian, gay, bisexual, and transgender (LGBT) patients.

DESIGN

Cross-sectional analysis.

SETTING

Not applicable.

PATIENT(S)

None.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Prevalence and geographical distribution of fertility clinic websites with LGBT-specific content, indicated by keywords and home page cues specific to the LGBT patient population. Assessment of relationship between LGBT-specific content and clinic characteristics, including U.S. region, clinic size, private versus academic setting, and state-mandated fertility insurance coverage.

RESULT(S)

Of 379 websites analyzed, 201 (53%) contained LGBT content. Clinics with the highest proportion of LGBT website content were in the Northeast (59/82, 72%) and West (63/96, 66%), while the lowest proportion was in the Midwest (29/74, 39%) and South (50/127, 39%). Most frequently used terms included lesbian (72%), LGBT/LGBTQ (69%), and gay (68%), while less used terms included trans/transgender (32%) and bisexual (15%). Larger clinic size was associated with LGBT-specific website content (odds ratio, 4.42; 95% confidence interval, 2.07-9.67). Practice type and state-mandated fertility insurance coverage were not associated with a clinic website having LGBT content.

CONCLUSION(S)

Over half of Society for Assisted Reproductive Technology member fertility clinics included LGBT content on their websites, yet those in the Midwest and South were significantly less likely to do so. Predictive factors for having LGBT website content included location in northeastern and western regions and increasing clinic size. Further studies are needed to evaluate whether inclusion of LGBT content on clinic websites impacts use of reproductive services by the LGBT patient population.

Unconventional combinations of prospective parents: ethical challenges faced by IVF providers

Background

Professional guidelines have addressed ethical dilemmas posed by a few types of nontraditional procreative arrangements (e.g., gamete donations between family members), but many questions arise regarding how providers view and make decisions about these and other such arrangements.

Methods

Thirty-seven ART providers and 10 patients were interviewed in-depth for approximately 1 h each. Interviews were systematically analyzed.

Results

Providers faced a range of challenges and ethical dilemmas concerning both the content and the process of decisions about requests for unconventional interfamilial and other reproductive combinations. Providers vary in how they respond — what they decide, who exactly decides (e.g., an ethics committee or not), and how — often undergoing complex decision-making processes. These combinations can involve creating or raising the child, and can shift over time — from initial ART treatment through to the child’s birth. Patients’ requests can vary from fully established to mere possibilities. Arrangements may also be unstable, fluid, or unexpected, posing challenges. Difficulties emerge concerning not only familial but social, combinations (e.g., between friends). These arrangements can involve blurry and confusing roles, questions about the welfare of the unborn child, and unanticipated and unfamiliar questions about how to weigh competing moral and scientific concerns — e.g., the autonomy of the individuals involved, and the potential risks and benefits. Clinicians may feel that these requests do not “smell right”; and at first respond with feelings of “yuck,” and only later, carefully and explicitly consider the ethical principles involved. Proposed arrangements may, for instance, initially be felt to involve consanguineous individuals, but not in fact do so. Obtaining and verifying full and appropriate informed consent can be difficult, given implicit familial and/or cultural expectations and senses of duty. Social attitudes are changing, yet patients’ views of these issues may also vary, based on their cultural backgrounds.

Conclusions

These data, the first to examine how clinicians make decisions about unconventional reproductive arrangements, highlight several critical ethical questions and ambiguities, and variations in clinicians’ responses. While several professional guidelines exist, the current data highlight additional challenges, and have vital implications for improving future guidelines, practice, education and research.

Trial registration

Not applicable.

Health Care Providers' Implicit and Explicit Attitudes Toward Lesbian Women and Gay Men

OBJECTIVES

We examined providers' implicit and explicit attitudes toward lesbian and gay people by provider gender, sexual identity, and race/ethnicity.

METHODS

We examined attitudes toward heterosexual people versus lesbian and gay people in Implicit Association Test takers: 2338 medical doctors, 5379 nurses, 8531 mental health providers, 2735 other treatment providers, and 214,110 nonproviders in the United States and internationally between May 2006 and December 2012. We characterized the sample with descriptive statistics and calculated Cohen d, a standardized effect size measure, with 95% confidence intervals.

RESULTS

Among heterosexual providers, implicit preferences always favored heterosexual people over lesbian and gay people. Implicit preferences for heterosexual women were weaker than implicit preferences for heterosexual men. Heterosexual nurses held the strongest implicit preference for heterosexual men over gay men (Cohen d = 1.30; 95% confidence interval = 1.28, 1.32 among female nurses; Cohen d = 1.38; 95% confidence interval = 1.32, 1.44 among male nurses). Among all groups, explicit preferences for heterosexual versus lesbian and gay people were weaker than implicit preferences.

CONCLUSIONS

Implicit preferences for heterosexual people versus lesbian and gay people are pervasive among heterosexual health care providers. Future research should investigate how implicit sexual prejudice affects care.

How statewide LGB policies go from ‘‘under our skin’’ to ‘‘into our hearts’’: fatherhood aspirations and psychological well-being among emerging adult sexual minority men

Researchers have noted increasingly the public health importance of addressing discriminatory policies towards lesbian, gay, and bisexual (LGB) populations. At present, however, we know little about the mechanisms through which policies affect LGB populations’ psychological well-being; in other words, how do policies get under our skin? Using data from a study of sexual minority young men (N = 1,487; M = 20.80 (SD = 1.93); 65% White; 92% gay), we examined whether statewide bans (e.g., same-sex marriage, adoption) moderated the relationship between fatherhood aspirations and psychological well-being. Fatherhood aspirations were associated with lower depressive symptoms and higher self-esteem scores among participants living in states without discriminatory policies. In states with marriage equality bans, fatherhood aspirations were associated with higher depressive symptoms and lower self-esteem scores, respectively. Fatherhood aspirations were associated negatively with self-esteem in states banning same-sex and second parent adoptions, respectively. Our findings underscore the importance of recognizing how anti-equality LGB policies may influence the psychosocial development of sexual minority men.

Vida reprodutiva de pessoas vivendo com HIV/AIDS: revisando a literatura

No contexto atual da epidemia de HIV/AIDS, temáticas como a reprodução e a transmissão materno-infantil tornaram-se frequentes e têm suscitado diversos posicionamentos por parte de pessoas portadoras e das equipes de saúde. O presente artigo teve por objetivo examinar o impacto da infecção por HIV/AIDS na vida reprodutiva de pessoas portadoras, considerando o direito à maternidade e à paternidade. Foi realizada uma revisão da literatura acerca de aspectos biológicos, psíquicos e sociais que compõem o cenário da assistência em saúde reprodutiva. Constatou-se que a prevalência da lógica biomédica e o impacto social da epidemia restringem o exercício do direito à maternidade e à paternidade dos indivíduos portadores de HIV/AIDS. Diante disso, entende se que as políticas públicas e as ações em saúde devem ser direcionadas pelo respeito ao princípio da integralidade e pelo respeito à autonomia individual, dentro de um contexto de apoio e orientação psicossocial.

Interests, obligations, and rights of the donor in gamete donation

This Ethics Committee report outlines the interests, obligations, and rights of both male and female donors who choose to provide gametes for use by others.

When do involuntarily infertile couples choose to seek medical help?

OBJECTIVE

To estimate the probability of medical consultation for infertility during the course of a pregnancy attempt and to study its determinants.

DESIGN

Pregnancy-based retrospective telephone survey analyzed with a discrete time Cox model.

SETTING

Two rural counties in Brittany and Normandy, France.

PATIENT(S)

A random sample of 901 women from the general population aged 18-60 years reporting 1,460 pregnancy attempts resulting in a live birth between 1985 and 2000 (participation rate, 73%).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Probability of medical consultation for involuntary infertility cumulated over time.

RESULT(S)

The cumulative probability of medical consultation for involuntary infertility among nulligravid women was 45% after 12 months of involuntary infertility and 75% after 24 months. The probability of medical consultation at any time was half that for parous women (odds ratio 0.4, 95% confidence interval 0.2-0.6). More highly educated women were more likely to have sought medical help for infertility. Only 45% of women who had sought medical advice received infertility treatment.

CONCLUSION(S)

Our survival approach provides a description of infertility service use during the course of a pregnancy attempt, and confirms that parity and educational level are strong predictors of medical help-seeking behaviors.

Gay male couples and assisted reproduction: should we assist?

Gay male couples seeking fatherhood through assisted reproduction deserve the same attention to care that other couples, lesbian and heterosexual, receive at fertility centers throughout the country.

Debate: do upper age limits need to be imposed on women receiving assisted reproduction treatment?

The inability of local National Health Service trusts to uniformly provide assisted reproduction technology (ART) services has resulted in what has come to be known as a 'postcode lottery'. Older women and those with responsibility for children at home, often have to fund their own treatment. Recently, with the birth of babies to much older women, the mass media have debated whether those past menopausal age should be helped to achieve a pregnancy in this way. We argue that the time is right for interested professionals to enter the debate, especially in view of proposed revisions to the Human Fertilisation & Embryology Authority's code of conduct which requires clinics providing ART to consider the 'welfare of the child'. With that change in mind, we set out the case for imposing upper age limits on those receiving ART in the United Kingdom.

Explaining disparities in treatment seeking: the case of infertility

OBJECTIVE

To present an integrated model of help-seeking, review empirical work in its support, and show its application to the explanation of racial and ethnic disparities in infertility help-seeking.

DESIGN

Review.

SETTING

None.

PATIENT(S)

None.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

None.

RESULT(S)

None.

CONCLUSION(S)

A help-seeking model provides a plausible explanation of observed disparities in infertility help-seeking. In addition to being related to income, race and ethnicity is related to prior experience with doctors, marital status, parity, knowledge and attitudes toward reproductive technology, and attitudes supporting spiritual rather than technological solutions to health problems.

PGD patients' and providers' attitudes to the use and regulation of preimplantation genetic diagnosis

Preimplantation genetic diagnosis (PGD) providers and patients have a vested interest in policy related to the use and regulation of PGD. To understand their experiences and attitudes, 32 in-depth interviews were conducted. Participants included 13 people at risk of transmitting a single-gene alteration to their children (10/13 had actually used PGD to try to have an unaffected child) and 19 PGD service providers (four nurses, five genetic counsellors, two reproductive endocrinologists, two geneticists, two physician-geneticists, two embryologists, and two laboratory directors). Virtually all participants supported the use of PGD to avoid severe, life-threatening genetic illness or to select embryos that are a tissue match for a sick sibling, but their attitudes varied significantly over the appropriateness of using PGD to avoid adult-onset genetic disease, to select for sex, or to select for other non-medical characteristics. There was disagreement within the PGD provider community about whether or not PGD is experimental. Participants were more concerned about overzealous government regulation of PGD creating barriers to access than potential abuses of the technology, and expected the PGD provider community to take the lead in ensuring that PGD is used for ethically appropriate purposes.

Do variations in assisted reproductive technology programs' screening practices indicate a need for national guidelines? Another perspective

Some see an "alarming inconsistency" in candidate-screening practices of assisted reproductive technology (ART) programs and call for common guidelines. However, reasonable people can disagree about who should be prevented from having children and why.

Prevention of triplets and higher order multiples: trends in reproductive medicine

In the United States and throughout the world, today's healthcare providers are challenged by the risks of multiple gestation pregnancy. Assisted reproductive technologies (ARTs) often used to treat infertility raise ethical issues including informed consent, veracity, and nonmalificence. In the United States, there is the need to improve maternal and fetal/neonatal mortality and morbidity by proposing legislation regulating ART and supporting single embryo transfers with no more than 2 such transfers. Beginning with the diagnosis of infertility, providers have a responsibility to educate, inform, and treat infertile couples. From the moment pregnancy with multiples is confirmed, these families are faced with incredible stressors including decision making on multifetal or selective reduction. Full disclosure of risks involved throughout the course of care should be discussed and documented in the record and plan of care. Currently in the United States, legislation does not regulate ART, including ovulation induction/enhancement and in vitro fertilization. Although the United States does have self-regulation via limited reporting through their professional organization and the Centers for Disease Control and Prevention, an unlimited number of embryos may be transferred. Unfortunately, many healthcare providers have not recognized the responsibility and burden placed on families and society as a whole. Lack of regulation means women may become pregnant with high order multiples, which raises serious moral and ethical issues.