The evolution of legislation in the field of Medically Assisted Reproduction and embryo stem cell research in European union members

Diagnosis and Treatment of Male Infertility-Related Fertilization Failure

Infertility affects approximately 15% of reproductive-aged couples worldwide, of which up to 30% of the cases are caused by male factors alone. The origin of male infertility is mostly attributed to sperm abnormalities, of which many are caused by genetic defects. The development of intracytoplasmic sperm injection (ICSI) has helped to circumvent most male infertility conditions. However, there is still a challenging group of infertile males whose sperm, although having normal sperm parameters, are unable to activate the oocyte, even after ICSI treatment. While ICSI generally allows fertilization rates of 70 to 80%, total fertilization failure (FF) still occurs in 1 to 3% of ICSI cycles. Phospholipase C zeta (PLCζ) has been demonstrated to be a critical sperm oocyte activating factor (SOAF) and the absence, reduced, or altered forms of PLCζ have been shown to cause male infertility-related FF. The purpose of this review is to (i) summarize the current knowledge on PLCζ as the critical sperm factor for successful fertilization, as well as to discuss the existence of alternative sperm-induced oocyte activation mechanisms, (ii) describe the diagnostic tests available to determine the cause of FF, and (iii) summarize the beneficial effect of assisted oocyte activation (AOA) to overcome FF.

Reproductive surrogacy in Ireland - an ethical and legal context

Reproductive surrogacy can be altruistic or commercial, each with complex ethical considerations that are complicated by heterogeneity in governing laws across jurisdictions. Surrogacy in Ireland is relatively new and largely unregulated, so this review aims to elucidate its current regulatory status and associated ethical issues. AIMS: On reproductive surrogacy from an Irish legal perspective, to: 1. Illustrate the lack of established legislation 2. Describe draft statute 3. Demonstrate the inadequacy of current non-statutory regulation 4. Examine European and Irish Constitutional Law 5. Exhibit challenges in case law for parenthood: i. The lack of recognition of intent to conceive compared to non-Irish jurisdictions ii. The lack of recognition of international surrogacy iii. The lack of procedures to transfer legal parenthood iv. The legal/medical/religious/socioeconomic consequences of 5] i, ii, iii On reproductive surrogacy from an Irish ethical perspective, to: 6. Analyse ethical issues in altruistic surrogacy 7. Evaluate ethical issues specific to commercial surrogacy: i. Financial and emotional exploitation ii. Commodification of children and women's bodies iii. Child welfare iv. Healthcare inequality CONCLUSION: Irish reproductive surrogacy exists in a legislative vacuum and is poorly governed by non-statutory regulation. However, Ireland is free to draft laws aligned with modern societal views on reproduction, which is especially relevant given the recent legalisation of same-sex marriage. Ethically, carrying mothers and children are vulnerable, particularly in commercial arrangements, with significant financial disparities between commissioning and surrogate parties. Altruistic arrangements can be a boon to Irish society if supported by public education and appropriate legal frameworks.

Why are multiple pregnancy rates and single embryo transfer rates so different globally, and what do we do about it?

In the early years of in vitro fertilization, overall pregnancy rates were low, and it was considered necessary to transfer more than one embryo to increase the chances of pregnancy. It was not until advances in assisted reproductive technologies resulting in increased pregnancy rates that the concept of transferring just one embryo was considered possible. A consequence of improvements in implantation rates was also an increase in multiple pregnancies when more than one embryo was transferred. Although some countries have reduced the number of embryos transferred, international data show that in many parts of the world high twin and higher order multiple pregnancy rates still exist. Even in developed countries these problems persist depending on clinical practice, funding of health services, and patient demands. Perinatal and other outcomes are significantly worse with twins compared with singleton pregnancies and there is an urgent need to reduce multiple pregnancy rates to at least 10%. This has been achieved in several countries and clinics by introducing single embryo transfer but there are many barriers to the introduction of this technique in most clinics worldwide. We discuss the background to the high multiple rate in assisted reproduction and the factors that contribute to its persistence even in excellent clinics and in high-quality health services. Practices that may promote single embryo transfer are discussed.

Use of in vitro fertilization-ethical issues

This report is an ethical analysis based on both facts and values. In in vitro fertilization (IVF), there is an intricate interaction between rapid scientific development and changing societal values. In most countries, the ethical discussion is no longer on whether or not IVF in itself is ethically justifiable. Therefore, in this review, I discuss other ethical aspects that have emerged since IVF was first introduced, such as upper age limits, 'ownership' of gametes and embryos, IVF in single women and same-sex couples, preimplantatory genetic testing, social egg freezing, commercialization, public funding, and prioritization of IVF. Despite secularization, since religion still plays an important role in regulation and practices of IVF in many countries, positions on IVF among the world religions are summarized. Decision-making concerning IVF cannot be based only on clinical and economic considerations; these cannot be disentangled from ethical principles. Many concerns regarding the costs, effects, and safety of IVF subtly transcend into more complex questions about what it means to society to bear and give birth to children.

Combined use of medically-assisted reproductive techniques: a new bioethical issue

Background and aim: The studies of Nobel laureate Robert Geoffrey Edwards led to the first in vitro fertilization and embryo transfer in 1978. Since then, reproductive medicine has made huge advances. Methods available to sterile couples now include: purchasing oocytes and sperm, uterus surrogacy, pre-implantation or pre-natal diagnosis, embryo/fetal selection. Here we highlight the fact that combinations of existing technologies could threaten the non-marketability of human life. Methods: We searched PubMed and websites to find articles regarding assisted reproduction techniques. Results: These methods, taken separately, provide support for natural fertilization, but when used together, they may lead to genuine “baby factories”. In poor countries, such “factories” exist and often act illegally. Conclusions: We highlight the need for deeper bioethical studies and better legislation regarding the combined use of medically-assisted reproductive techniques. (www.actabiomedica.it)

CRISPR Ethics: Moral Considerations for Applications of a Powerful Tool

With the emergence of CRISPR technology, targeted editing of a wide variety of genomes is no longer an abstract hypothetical, but occurs regularly. As application areas of CRISPR are exceeding beyond research and biomedical therapies, new and existing ethical concerns abound throughout the global community about the appropriate scope of the systems' use. Here we review fundamental ethical issues including the following: 1) the extent to which CRISPR use should be permitted; 2) access to CRISPR applications; 3) whether a regulatory framework(s) for clinical research involving human subjects might accommodate all types of human genome editing, including editing of the germline; and 4) whether international regulations governing inappropriate CRISPR utilization should be crafted and publicized. We conclude that moral decision making should evolve as the science of genomic engineering advances and hold that it would be reasonable for national and supranational legislatures to consider evidence-based regulation of certain CRISPR applications for the betterment of human health and progress.

Intrafamilial oocyte donation in classic galactosemia: ethical and societal aspects

Classic galactosemia is a rare inherited disorder of galactose metabolism. Primary ovarian insufficiency (POI) with subfertility affects > 80% of female patients and is an important concern for patients and their parents. Healthcare providers are often consulted for subfertility treatment possibilities. An option brought up by the families is intrafamilial oocyte donation (mother-to-daughter or sister-to-sister). In addition to POI, galactosemia patients can also present varying cognitive and neurological impairments, which may not be fully clear at the time when mother-to-daughter oocyte donation is considered. Ethical and societal aspects arise when exploring this option. This study aimed to provide guidance in aspects to consider based on the views of different groups involved in the oocyte donation process. A qualitative study using in-depth semi-structured interviews with > 50 participants (patients, family members, and healthcare providers) was conducted. From these interviews, themes of concern emerged, which are illustrated and reviewed: (1) family relations, (2) medical impact, (3) patients' cognitive level, (4) agreements to be made in advance and organization of counseling, (5) disclosure to the child, and (6) need for follow-up. We conclude that discussing and carrying out intrafamilial oocyte donation in galactosemia patients requires carefully addressing these themes. This study adds value to the already existing recommendations on intrafamilial oocyte donation in general, since it highlights important additional aspects from the perspectives of patients and their families.

3D Bioprinting Technology: Scientific Aspects and Ethical Issues

The scientific development of 3D bioprinting is rapidly advancing. This innovative technology involves many ethical and regulatory issues, including theoretical, source, transplantation and enhancement, animal welfare, economic, safety and information arguments. 3D bioprinting technology requires an adequate bioethical debate in order to develop regulations in the interest both of public health and the development of research. This paper aims to initiate and promote ethical debate. The authors examine scientific aspects of 3D bioprinting technology and explore related ethical issues, with special regard to the protection of individual rights and transparency of research. In common with all new biotechnologies, 3D bioprinting technology involves both opportunities and risks. Consequently, several scientific and ethical issues need to be addressed. A bioethical debate should be carefully increased through a multidisciplinary approach among experts and also among the public.

Sperm DNA fragmentation in donors and normozoospermic patients attending for a first spermiogram: Static and dynamic assessment

Static assessment of sperm DNA Fragmentation (SDF at the time of ejaculation or sperm thawing when cryopreserved) and the dynamic assessment of SDF (SDF assessed after T2 hr, T6 hr and T24 hr of sperm thawing) were used to establish cut-off values associated with sperm donors when compared with closely related normozoospermic patients. Cryopreserved samples from donors revealed SDF levels two times lower in comparison with the patients. Donor sperm DNA exhibited a 2.5 times higher longevity when compared with the patients. Static values of SDF after thawing of approximately 11% identify the donors with a 71% of sensitivity and 84% specificity. With respect to the dynamic assessment, SDF increases of 2.3 per hr during the first 2 hr of incubation identify the donors with 70% of sensitivity and 66% of specificity. Creating the Rate of Combined Damage (RCD) defined as the product of SDF-T0 by the increase in the damage registered during the first 2 hr of incubation (r-SDF-T0-2 ), an index of RCD = 22.2 units has an identification capacity of donors with a 78% sensitivity and 77% specificity. Such cut-off values could be used to characterise donors with high chromatin resistance to damage when meeting the above-established criteria.

A 50% reduction in multiple live birth rate is associated with a 13% cost saving: a real-life retrospective cost analysis

Belgian legislation limiting the number of embryos for transfer has been shown to result in a 50% reduction of the multiple live birth rate (MLBR) per cycle without having a negative impact on the cumulative delivery rate per patient within six cycles or 36 months. The objective of the current study was to evaluate the cost saving associated with a 50% reduction in MLBR. A retrospective cost analysis was performed of 213 couples, who became pregnant and had a live birth after one or more assisted reproductive technology treatment cycles, and their 254 children. The mean cost of a singleton (n = 172) and multiple (n = 41) birth was calculated based on individual hospital invoices. The cost analysis showed a significantly higher total cost (assisted reproductive technology treatment, pregnancy follow-up, delivery, child cost until the age of 2 years) for multiple births (both children: mean €43,397) than for singleton births (mean: €17,866) (Wilcoxon-Mann-Whitney P < 0.0001). A 50% reduction in MLBR resulted in a significant cost reduction related to hospital care of 13%.

Human embryo research in Belgium: an overview

OBJECTIVE

To present an overview of the numbers and types of human embryos used in research projects in Belgium from 2007 to 2015.

DESIGN

Analysis of all research proposals approved by the Federal Commission for Medical and Scientific Research on Embryos In Vitro.

SETTING

Not applicable.

PATIENT(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Number of embryos used for research, number of embryos created for research, and areas of embryo research.

RESULT(S)

Since 2007, 15,811 embryos were used for 36 research projects. In total, 10,492 (66%) fresh supernumerary embryos (unfit for transfer or freezing) were used, 4,083 (26%) frozen supernumerary embryos (donated by parents whose child wish was completed or abandoned), and 1,236 (8%) embryos created for research. Most projects focused on research into embryo development. Fresh supernumerary embryos were mainly used for human embryonic stem cell (hESC) research. Frozen supernumerary embryos were almost exclusively used for research into embryo development and for hESC research. Embryos created for research were used for research into embryo development, oocyte research, research into cryopreservation of oocytes, and hESC research.

CONCLUSION(S)

Having concrete data on embryo research is crucial for an informed debate. Moreover, these data are necessary to find out trends in research such as the numbers of embryos needed and the areas of research. Data collection requires a sufficiently clear definition of "research" and "embryo." These conceptual questions frequently reveal lack of clarity in legislation.

Attitudes Toward Parenthood, Partnership, and Social Rights for Diverse Families: Evidence From a Pilot Study in Five Countries

Attitudes toward the civil and social citizenship rights of individuals in diverse family forms are underresearched. We use cross-national data from a pilot study among students in Denmark, Spain, Croatia, Italy, and the Netherlands to explore cross-country differences in beliefs about partnership, parenthood, and social rights of same-sex couples vs. heterosexual couples or married vs. cohabiting couples. The results suggest a polarization in students' attitudes between countries that appear more traditional (i.e., Italy and Croatia) and less traditional (Spain and the Netherlands), where the rights of married heterosexual couples are privileged over other family forms more so than in nontraditional countries. Moreover, equality in social rights is generally more widely accepted than equality in civil rights, particularly in relationship to parenthood rights and in more traditional countries. We discuss the implications of these findings and the implications for further research in this underexplored area of attitudinal research.

Changing direction: the struggle of regulating assisted reproductive technology in Austria

From 1992 until 2015, Austria had a very restrictive Reproductive Medicine Law (FMedG, 1992) that prohibited a number of treatments such as egg donation, preimplantation genetic diagnosis (PGD), heterologous sperm donation for IVF/intracytoplasmic sperm injection (ICSI) as well as general access to assisted reproductive technology for same-sex couples. As one consequence of this rather prohibitive law, Austrian physicians active in the area of assisted reproductive technology co-operated with, or had daughter institutes in, countries with less restrictive legislation such as the Czech Republic and Slovakia, which are only a few hours' drive away. For a long time, liberalisation of the Reproductive Medicine Law was blocked by the fierce and seemingly unresolvable struggle between the restrictive conservative party (ÖVP) and the permissive social democrats' party (SPÖ). In 2014 the impasse, which had lasted for decades, was finally resolved in favour of a more liberal Reproductive Medicine Law that permits egg donation, PGD in some cases and heterologous sperm donation for IVF/ICSI and lesbian couples. Assisted reproductive technology treatments for single women and surrogate motherhood remain prohibited. The new Reproductive Medicine Law was heavily opposed by the Catholic Church, by some conservatives and by disability associations. By applying the concept of political culture, this paper explains why a liberalisation of the Reproductive Medicine Law was blocked for decades, and how the sudden policy change came about.

Enduring politics: the culture of obstacles in legislating for assisted reproduction technologies in Ireland

Assisted reproductive technology has become a normalized part of reproductive medicine in many countries around the world. Access, however, is uneven and inconsistent, facilitated and restricted by such factors as affordability, social and moral acceptance or refusal and local cultures of medical practice. In Ireland, assisted reproductive technology has been available since 1987 but remains unregulated by legislation. This creates an uncertain and untenable legal circumstance given the contested issues related to constitutional protection of the right to life of the unborn and the indeterminate legal status of embryos in vitro. This paper examines the impact of an enduring political impasse. It explores how clinical assisted reproductive technology services in Ireland operate both inside and outside dominant institutional frameworks, meeting a pronatalist and pro-family social and political agenda, while sometimes contradicting the pro-life politics that has continued to shape women's reproductive lives. The medical approaches to infertility thus intersect with the ongoing debates around abortion, the failure of the government to regulate, and notions of embodied motherhood and responsibility within changing meanings of family and kinship. At the same time women and their partners seek assisted reproductive technology treatment in other countries throughout the European Union where laws differ and availability of services varies. A decade has passed since the Commission on Assisted Human Reproduction in Ireland released its recommendations; the enduring legislative vacuum leaves women, families and practitioners in potential legal limbo.

SIAMS survey on sexological screening during the assisted reproductive technologies in Italy

PURPOSE

The assessment of sexual function is fundamental to the Assisted Reproductive Technology (ART). Nevertheless, it is still not a common clinical routine among infertility centres. The aim of this survey is to describe the main aspects of sexological screening that are considered in Italian centres of ART.

METHODS

After the consensus of the Italian Society of Andrology and Sexual Medicine (SIAMS), a mailing list of reproductive medicine centres was created. Then, we sent a questionnaire concerning the essential characteristics of sexological screening. The respondents to compilers of the questionnaire sent back the information from their centres, and an analysis of absolute frequencies and percentages was performed.

RESULTS

First, 16 centres completed and returned the questionnaire, while 5 ignored the invitation. The main findings concerned the wide use consideration of vardenafil 10 mg (68.7%; 11/16) for the treatment of erectile dysfunction in comorbidity with reproductive problems, the diffuse administration of International Index of Erectile Function (68.2%; 11/16) and Structured Interview for the Erectile Dysfunction (50%; 8/16) as psychometric tools and lesser use of Female Sexual Function Index (31.2%; 5/16) for the evaluation of female sexuality in the infertile couple.

CONCLUSIONS

To conclude, we noticed a major focus on male sexuality and the eventual treatment or evaluation of sexual dysfunction compared to female sexuality. This aspect highlights an important issue for clinical practice to strongly consider and eventually reinforce. In this regard, improvement of the assessment and treatment of possible female sexual problems in reproductive medicine seems necessary.