Information for Medical Professionals

Ethics in Assisted Reproductive Technologies

Infertility is a domain of medical science that is subject to significant changes in Science and Technology. In view of this there are a range of ethical issues that require consideration. Organizations, like the American Society for Reproductive Medicine (ASRM) have formed an Ethics Committee to deliberate on issues in infertility treatments, which pose medical and ethical dilemmas.

Similar initiatives have been lacking in South Africa. The government's current focus on primary health care makes it incumbent on medical professionals to engage official representatives on the range of ethical issues that arise in Assisted Reproductive Technologies (ART). Legislation needs to keep abreast of rapid advances and take cognisance of the medico-legal problems that could arise.

Some of the issues that require consideration are:

  • The commercialisation of ART.
  • The moral and legal status of pre-embryos.
  • The use of donor sperm.
  • The use of donor oocytes.
  • The use of donor pre-embryos.
  • Cryopreservation of oocytes. and pre-embryos.
  • Pre-implantation of genetic diagnosis.
  • HIV testing and ART.
  • Surrogacy.

There is also clear need for the establishment of a national database where records are accessible. These records should reflect the following:

  • Details of patients who have been on infertility cycles.
  • Detailed records of donors and recipients.
  • Registration of ART centres and accreditation of medical professionals.
  • Publication of the number of cycles performed, together with success rates.

Another area of major concern is the reluctance of medical aids to recognize infertility as a DISEASE OF THE REPRODUCTIVE SYSTEM.


IVM - In Vitro Maturation of Oocytes

IVF treatment without long term hormone treatment and maturation of oocytes. in the laboratory.

Standard IVM Treatment

A normal contemporary hormone treatment of women to produce mature oocytes for IVF involves GnRH agonist down regulation followed by follicle stimulating hormone (FSH) stimulation of the ovary, and finally an injection of human chorionic gonadotrophin (hCG) to introduce ovulation. The treatment course usually runs over a period of 4-5 weeks of daily medication that can also be accompanied by unpleasant side effects. Additionally, a serious consequence of hormone therapy can be over stimulation syndrome where it is women with suffering from PCO syndrome who are at the highest risk.

IVM Treatment

An alternative to this standard approach is to collect immature oocytes from medium sized follicles during midcycle and to then mature the ova in the laboratory (IVM). In this system the oocytes are exposed to culture medium containing the same hormones (FSH and hCG) that would otherwise be administered to the woman in order to stimulate the final oocyte maturation. Recent experimental work in this field in Denmark has shown IVM techniques to be relative efficacious as well as safe. This approach has a number of potential advantages:

  1. No hormone stimulation is required and the risk of over stimulation syndrome is obliviated.
  2. The cost of treatment can be reduced due to lower medication requirements and fewer ultrasound scannings are required to monitor follicular development.
  3. The speed of treatment can be faster due to no need for GnRH down regulation and the re-entry into treatment in the event of a cancelled or failed cycle can occur with the next menstrual cycle.

With standard hormone stimulated cycles a few months pause is advised before the next stimulation cycle in order for the women's hormone status to return to a normal rhythm.

Results from IVM in other Countries

In 1991 Cha from Korea was the first report of a child born using IVM of immature oocytes recovered after open surgery. Later in Australia researchers developed a technique for ultrasound guided needle aspiration on immature oocytes that simplifies egg collection. Further improvement of IVM techniques came from the U.S.A. where protocols to enhance uterine receptivity were developed. All of these groups have been successful in maturing and fertilizing oocytes and all have reported pregnancies and the births of normal babies. However, the pregnancy rates reported have been quite low and the number of babies born to date is around 20.

Our own experience with IVM

After having received permission from the Ethical Committee we have performed IVM on both PCO women and women scheduled for ICSI due to their partners poor sperm quality. In a preliminary trail of 14 PCO patients we obtained poor maturation and fertilization results. After a protocol change 2 out of 9 (22%) PCO patients achieved clinical pregnancies. Likewise, of the first 12 male factor patients a single one became clinically pregnant and after a protocol change 5 of 20 (25%) became clinically pregnant. These latest results are approaching the lower range for conventional IVF treatments and we are currently conducting IVM on a larger group of patients to confirm this.
We hope and believe that in the future that IVM will be available as an alternative to conventional IVF treatments employing controlled ovarian hyper stimulation. The potential advantages of IVM are significant, especially in eliminating the risk of hyper stimulation syndrome in PCO patients and in reducing the medication use by patients and by speeding the treatment time required for an IVF cycle. Our Preliminary results give us optimism for the future of IVM as a normal practice in the treatment of fertility. At the present IVM is an experimental procedure under development that is offered to patients that are enrolled for IVF treatments. Patients that volunteer to be a part of the project and that do not become pregnant may proceed to the clinics conventional IVF treatments with no reduction in the normally offered three transfer cycles.

The project is being conducted by Anne Lis Mikkelson MD.and Steven Smith DVM. Ph.D.



Progress with PGD for Sickle Cell prevention
Studies in Denmark and Belgium.

Good IVF success rates after single embryo transfers
Transferring one IVF embryo, followed by a second, is almost as likely to result in a pregnancy as transferring two at a time.

IUI workshop
At University of Maiduguri Teaching Hospital

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