SOCIAL AND ETHICAL ISSUES

J Indian Med Assoc 2002 Jun;100(6):391-2, 394
Infertility: planning a prototype action plan in the existing health care system. Gupta N.
Division of Reproductive Health & Nutrition, Indian Council of Medical Research, New Delhi. Infertility is considered as a social stigma in our country and has been incorporated in reproductive and child health programme. Research areas emphasised are (a) A database; (b) Management in primary, secondary and tertiary levels of health care services; (c) Training of doctors and health care workers; (d) Costing. Infertility is to be prioritised as an important public health problem as it affects human being's mental, social, physical and reproductive health.

Eur J Hum Genet 2002 May;10(5):303-12
Guidelines for the appropriate use of genetic tests in infertile couples. Foresta C, Ferlin A, Gianaroli L, Dallapiccola B.
University of Padova, Department of Medical and Surgical Sciences, Clinica Medica 3, Via Ospedale 105, 35128 Padova, Italy. forestac@protec.it
Research on genetic causes of male and female infertility rapidly expanded in the last years, following the development of in vitro fertilising techniques. Genetic tests are now available to explore the cause of the infertility and assess the risk of a given couple to transmit its genetic characteristics. This allows at-risk couples to take an informed decision when electing for a medically assisted reproduction. It also allows the professionals to offer a prenatal diagnosis when appropriate. Thus, the genetic work-up of the infertile couple has become good practice for an appropriate diagnosis, treatment and prognostic assessment. The lack of national or international rules for the genetic approach to the infertile couple, prompted the Italian community of professionals in the field of reproductive medicine to join and set up guidelines for the genetic diagnosis of male and female infertility. The group of clinical and research experts is representative of 12 national scientific societies and was supported by external experts from four international societies. We examine the clinically relevant genetic causes of male and female infertility and suggest the category of patients for which each genetic test is recommended or optional, both for an accurate diagnosis and prior to ART. (236)

Saudi Med J 2000 Mar;21(3):294-6
Quadruplet pregnancy following a single course of clomiphene citrate. An expensive success. Abotalb Z.
Department of Obstetrics and Gynecology, King Khalid University Hospital, PO Box 7805, Riyadh 11472, Kingdom of Saudi Arabia.
Prescribing clomiphene citrate for infertility patients has been taken very lightly. High order pregnancy can happen with this treatment. In addition to high perinatal mortality and morbidity of multiple pregnancy, the economic and social strains on the national health system and the family is great. The case presented showed that although the outcome of pregnancy was successful but the cost to the national health was tremendous. It is therefore recommended that measures should be taken to avoid high order births. Moreover, delaying the delivery, if possible, will be cost effective.

Int J Fertil Womens Med 2001 May-Jun;46(3):169-83
The new genetic era in reproductive medicine: possibilities, probabilities and problems. Greene RA, Jenkins TM, Wapner RJ.
Department of Obstetrics and Gynecology, Thomas Jefferson University Hospital,Philadelphia, Pennsylvania 19107, USA.
The "New Genetic Era" will be a period of enormous exponential growth in our knowledge of the structure and function of the basic information blocks of life. The Human Genome Project will soon provide a complete and accurate sequence of the human genome. This will give us an abundance of basic genetic knowledge and provide a molecular understanding of disease, allowing for improved diagnosis and more sensitive and specific screening for disease. This will, we hope, lead to better treatments, prevention and cures through gene therapy, patient-specific drug design, and earlier and more specific behavioral interventions to prevent disease. With this information comes a complexity of legal, ethical and social concerns about potential use and abuse. The public has expressed its concerns about the potential for genetic discrimination. However, genetic information is enhancing our knowledge as to the causes of infertility, allowing diagnosis of more diseases in the prenatal period, and may aid our identification of patients at increased risk for breast and ovarian cancer. Doctors involved in reproductive medicine must become knowledgeable about the new genetic era so as to offer our patients the most appropriate and informed care.

Comment in:
Hum Reprod. 2001 May;16(5):1051-3.
Investigation of the infertile couple: investigation of the infertile couple in the era of assisted reproductive technology: a time for reappraisal. Balasch J.
Institut Clinic of Gynecology, Obstetrics and Neonatology, Faculty of Medicine-University of Barcelona, Spain. jbalasch@medicina.ub.es
At present, several of the elements in widespread use in basic infertility testing are in dispute, marked variability exists in the work-up among specialists, and practice patterns are influenced both by modern assisted reproductive technologies (ART) and the increasing age of couples seeking help for infertility. This article is intended to stimulate the debate on a possible (lack of) usefulness of conventional methods of infertility evaluation in relation to both the modern techniques of assisted reproduction and the woman's age.

Obstet Gynecol Clin North Am 2000 Sep;27(3):473-86
Infertility. Contemporary office-based evaluation and treatment. Penzias AS.
Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts, USA.
Infertility is a common condition that is highly treatable. Couples can help themselves by recognizing that they have a problem, and practitioners can help patients by recognizing who requires an infertility investigation and when they need it. Instituting a clear and comprehensive evaluation will enable patients who need treatment to achieve their goals.

J Assist Reprod Genet 2002 Sep;19(9):400-10
Gender selection: cultural and religious perspectives. Schenker JG.
Department Obstetrics and Gynecology, Hebrew University Hadassah Medical Center, Jerusalem, Israel.
OBJECTIVE: To review the current developments in the field of preconceptual sex selection and to discuss the cultural and religious perspectives as that accompany the scientific progress. CONCLUSION: The requirement for a man to procreate by having a minimum of two children-a boy and a girl-is obligatory according to Jewish law. According to both schools, Beit Shamai and Beit Hillel, in order to fulfill the obligation of procreation at least one son is required. Therefore the application of sex preselection for nonmedical indications may by of practical importance using the method of sperm separation or sex selection of pre-embryo by PGD. According to Christian view, especially the one of the Catholic Church, gender preselection even for medical indications is forbidden. Islamic legal viewpoint is that fetal sex selection is lawful when it is practiced on an individual basis, to fulfill the wish of a married couple to have a boy or a girl through available medical means.

J Obstet Gynaecol Can 2002 Feb;24(2):159-63
Human embryonic stem cell lines: the ethics of derivation. Baylis F.
Dalhousie University, Halifax, NS, Canada.
In Canada it is permissible to proceed with stem cell research using human embryos created by in vitro fertilization (IVF) provided: these were originally created for infertility treatment; they are no longer required for such treatment; and there is an appropriate consent for their research use. As such, IVF human embryos in excess of clinical need are a valuable resource for embryonic stem cell researchers. A point often overlooked, however, is that these excess IVF human embryos are also a scarce resource. Their scarcity suggests the need to develop sound policies and procedures, in a timely and coordinated fashion, to ensure that the few human embryos available for embryonic stem cell research are not used in less important research endeavours or used when other biological materials are appropriate. Injudicious use of the few human embryos available for research use may risk the following consequences: no ongoing research in Canada to derive human embryonic stem cell lines; a reliance on the importation of stem cell lines from other countries for any research on the use of embryonic stem cells; and pressure from Canadian researchers to remove the prohibition on the purposeful creation of human embryos for research use.

Br Med Bull 2000;56(3):650-71
Genetic basis of male fertility.
Hargreave TB.
Fertility Problem Clinic, Department of Urology, Western General Hospital, Edinburgh EH4 2XU, UK. We are in the age of genetic discovery. Now the human genome has been completely sequenced, there will be increasing understanding and ability to manipulate biochemical pathways downstream of genes. At the same time, further development of in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) will enable procreation in situations that were formerly impossible and when there may be an increased possibility of genetic abnormality. Furthermore, preimplantation diagnosis will enable defects to be diagnosed and will give the opportunity for the couple to decide whether to continue with treatment towards a pregnancy or not. Thus, there is a need for clinicians to have a good knowledge of the gentics and hereditary aspects of male (and indeed female) infertility and for couples to have access to correct information and expert counselling. Also, there are ethical implications of these scientific and clinical advances for the future child, the individual, the couple and society. There is increasing public unease about this new science of reproduction and, in the UK, there is regulation by law; thus, there is a need for clinicians and scientists to give accurate information in everday language to the public.