Infertility Research Paper

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Abstract

This research paper addresses ethical aspects of infertility and its management. The research paper discussed infertility definitions, prevalence, classifications, causes, and implications. Treatment of infertility with conventional methods did not create much ethical debate; however, new assisted reproduction techniques brought hope and offered better chances for treatment and, in the same time, created many moral and ethical concerns needing solutions. These new techniques abled couples to procreate and have children without having sex, at any age, even as married or single, and the sex of the child could be determined. The research paper discussed some techniques that are creating more ethical and moral concerns, such as providing futile treatment, as in cases of perimenopausal women; multifetal reduction, in cases of multiple pregnancy; gamete donation; surrogacy and gestational carriers; pregnancy of a single mother or lesbian; treating infertile couple living with HIV/AIDS; posthumous reproduction; and reproductive cloning. The research paper also discussed infertility management in low-resource settings and argued that efforts should be carried aiming at prevention and also providing low-cost techniques.

The research paper argues that in providing these new techniques, one must observe principles of respect for the dignity of the human being, security of human genetics, inviolability of the person, and quality of services. The research paper concludes that by applying these problems, ethical concerns regarding the new modalities of management of infertility could be answered.

Introduction

Infertility, the inability to conceive, is a stressful state of being for couples who suffer from it. However, new techniques for assisted reproduction, in the last few decades, have brought hope and caused a great impact on the infertile couples and improved the quality of life. These new techniques created many ethical concerns and generated moral dilemma that needs to be solved. The new techniques abled couples to procreate and have children without having sex, at any age, even as married or single, and the sex of the child could be determined (Serour 2000).

Consequently, many moral and ethical issues have been raised regarding the management of infertility. It therefore became important to examine ethical aspects that resulted from the new treatment techniques. Theologians, scientists, moralists, philosophers, and ethical experts have contributed to this debate, offering a broad spectrum of options varying from strict conservative views, skeptical of each new advancement in the reproductive technologies, to the most liberal which accept all kinds of innovations. This research paper will give an overview about infertility: its definitions, causes, and management. This will be followed by discussions on the ethical questions and concerns and their answers.

Infertility Definitions

Many definitions of infertility were proposed: clinical, demographic, and epidemiological. Mostly, these definitions set 1 year of stable marital relations, without the wife getting pregnant, as the duration that a couple be considered infertile (WHO 2014). However, there are several situations that raise some ethical considerations: What about a wife aged forty and above? What about if one of the couple has a life-threatening disease? Consequently, the author suggests this definition:

Infertility is diagnosed when a mature couple wishes to be assisted to have children regardless the duration of their infertility, health providers should do their best to fulfill this wish with the best available interventions (the author).

Reproductive Choice And Childless By Choice/Child Free

Reproductive choice is the right of a person to freely choose his/her reproductive performance, including his/her reproductive potentials. For instance, a person can choose to be childless. Although reproductive right is basically a personal decision, it may conflict with the interest of his/her society or country. While the desire to be childless is accepted within the context of societies where the respect of individual liberty is respected, mainly in the west, it is not accepted in communities where an individual is considered a part of the society, such as in eastern countries.

There should be a distinction between infertility and “childless by choice” and “childfree” which are terms given to individuals who desire not to have children. The term includes people who are fertile and intend not to have children, people who chose sterilization without having had children, or women past childbearing age who were fertile but chose not to have children or people who are otherwise infertile but their infertility has no impact on their desire to not have children (Bastern 2009).

Infertility As A Disability

From an ethical point of view, infertility generates disability. Infertility was ranked the fifth highest global disability (WHO 2011); thus access to health care falls under the Convention of Persons with Disability (WHO 2011). However, in many of the developing countries, infertility is being managed outside the primary health-care services, and rarely free treatment is offered.

Global Estimates Of Infertility

The difficulty to address infertility prevalence is coupled with the lack of consistent use of definition and lack of common tools to diagnose, manage, or report infertile individuals and couples worldwide (WHO 2012). WHO (2014) indicated that one in every four couples in developing countries had been found to be affected by infertility.

The overall burden of infertility is significant, is likely underestimated, and has not displayed any decrease over the last 20 years. An analysis of 277 national surveys (WHO 2012) estimated the levels and trends of infertility in 190 countries from 1990 to 2010. The analysis found that in 2010, 1.9 % of women aged 20 years who wanted to have children were unable to have their first live birth (primary infertility) and 10.5 % of women who had previously given birth were unable to have another (secondary infertility) – a total of 48.5 million couples. The report found that the levels of infertility were similar in 1990 and 2010, with only a slight overall decrease in primary infertility (0.1 %) with a more pronounced drop in sub-Saharan Africa and South Asia and a small increase in secondary infertility (0.4 %). The report suggested that the reduction of infertility rate in sub-Saharan Africa might be caused by the reduction in sexually transmitted infection, which can cause infertility if left untreated – as well as improved obstetric care which might have contributed to this fall (WHO 2012).

Classifications Of Infertility

There are many classifications of infertility, among them male or female infertility (when one of the couple has the cause and may be both), idiopathic infertility (when there is no detectable cause), and iatrogenic infertility (when infertility is caused by a medical fault like inducing adhesions that obstruct the fallopian tube during laparotomies). However, the most common classification is into primary and secondary infertility. Primary infertility is infertility in couples who have never had a child, while secondary infertility is failure to conceive following a previous pregnancy.

Infertility Causes

There are many predisposing factors that contribute to inducing infertility; among them is the lack of reproductive and sexual health knowledge and the exposure to sexually transmitted diseases, especially in sub-Saharan Africa. Consequently, it is needed to address these factors especially in low-resource countries in order to establish programs for prevention of infertility.

Congenital anomalies of the reproductive tract and chromosomal abnormalities/genetic factors for female and male partners could be predisposing factors. Female age plays an important role as fertility declines after the age of 35 years (Ethics Committee of Reproductive Medicine 2012). Medical conditions like diabetes and thyroid disease are contributing factors to infertility. In addition, lifestyle, such as smoking, being overweight, and stress, are contributing to inducing infertility. Previous medical history of abdominal operations and radio or chemotherapy for either male or female would affect the reproduction process. Having jobs that expose either partner to radiation or chemical substances could contribute also to inducing infertility. Abortion and obstruction or damage of fallopian tubes, especially in areas where the sexually transmitted diseases are common, are also contributing factors. Tubal damage can cause ectopic pregnancy and previous ectopic pregnancy can cause damage of the fallopian tube.

Ovulatory problems, in females, like polycystic ovarian syndrome (PCOS), endometriosis, and cervical and uterine factors, are also among the causes of infertility.

Azoospermia, low sperm count and quality, occlusion/damage of the vas deferens (congenital or due to inflammation), congenital anomalies like undescended testes, genetic problems, and iatrogenic causes, like during hernia repair surgery, are among causes in men. Male fertility is also sought to decline with age, although to what extent is unclear.

Implications Of Infertility

Although infertility is not a life-threatening condition, it has serious implications for the mental and social well-being of those involved. The inability to procreate is frequently considered a personal tragedy and a threat for the couple, influencing the entire family and even the local community.

Treatment Of Infertility

In order to understand how infertility can be managed, it is important to understand how conception takes place naturally. For a conception to be possible, first, the ovary of the female must release (ovulate) an egg, which must be picked up by the fallopian tube. The sperm must travel through the vagina, into the uterus, and up into the fallopian tube in order to fertilize the egg. Fertilization usually takes place in the fallopian tube. The fertilized egg should develop normally and implant successfully when it arrives at the uterine cavity as an embryo. A problem that develops in any part of this process can lead to infertility.

There are different techniques available for the treatment of fertility for both female and male partners depending on the causes of infertility.

Some of these techniques have been practiced for many years like medical and hormonal therapies, corrective and reconstructive surgery for male or female infertility (Serour 2000), and intrauterine insemination, either by a partner/husband or donor. The general ethical principles, like beneficence, non-maleficence, justice, and autonomy, are applied in such treatment. For instance, informed consent should be obtained before any intervention. However, these techniques did not create much debate as they did not separate the bonding of the sexual act from the process of reproduction (Serour 2000). Reproduction was only possible when both partners practiced the act of sexual intercourse for months or years after undergoing these procedures. However, in the last few decades, many techniques were available to assist couples in achieving their fertility goals. The following subsection will examine these modalities and their ethical concerns.

Reproductive Choice

Reproductive choice is the right of a person to freely choose his/her reproductive performance, including his/her reproductive potentials. For instance, a person can choose to be childless. Although reproductive right is basically a personal decision, it may conflict with the interest of his/her society or country. While the desire to be childless is accepted within the context of societies where the respect of individual liberty is respected, mainly in the west, it is not accepted in communities where an individual is considered a part of the society, such as in eastern countries.

Assisted Reproductive Techniques (ART)

 Assisted reproductive technology (ART) is a general term referring to methods used to achieve pregnancy by artificial or partially artificial means. Therefore, the couples resort to this method in order to help them in conceiving and ultimately giving birth to a healthy live baby of their own. However, ART separated the act of sexual intercourse from reproduction; it made gametes available to the hands of scientists in the laboratory. This created concerns among the scientists, physicians, sociologists, ethicists, theologians, policy makers, and public at large with different degrees in different countries. This is because the codes of ethics in each country/region are based on the morality, religions, traditions and social background, and education system of such country/region (Serour 2000). Any debate on the social, legal, and ethical issues surrounding ART must consider these new techniques within the general context of health care (Serour 2000). However, in general, there are three moral principles, which provide an ethical basis for ART: the principle of liberty, which guarantees a right to freedom of action; the principle of utility, which defines moral rightness by the greatest good for the greatest number; and the principle of justice, which requires that everyone have equal access to necessary goods and services (Serour 2000). In providing these new techniques, one must observe principles of respect for the dignity of human being, security of human genetic materials, inviolability of the person, inalienability of the persons, and necessary quality of services (Serour 2000). These principles demand a measure of protection for the human embryo that is consonant with culture, religion, tradition, and society.

In The Following, Some Aspects Of Infertility Management And Their Ethical Considerations Are Discussed

In Vitro Fertilization

In vitro fertilization is a technique of assisted reproduction in which the fertilization of an ovum by a sperm is achieved outside the body. Since the first baby born using this technique, in 1980, in vitro fertilization practices have been ethically controversial. Progress was made in the field and many techniques were used until the intracytoplasmic injection of sperm (ICSI) into the ova was discovered. ICSI was rapidly integrated into the routine clinical use of fertility clinics offering assisted reproductive technology throughout the world. Although ICSI was used for cases of severe male factor, it became the most popular and used method for treating infertility of both men and women. The success rate of these techniques varies widely, depending on the quality of care provided, the skills of the providers, and the condition/causes of the fertile couples. Due to the low success rate reported till now, it is a routine, in some centers, to transfer several embryos to the uterus at one time in the hope that one or two will result in pregnancy.

Multiple Embryos

In some cases, multiple pregnancies with a large number of embryos would develop. Consequently, some of these embryos are never transferred to the uterus. These embryos are cryopreserved until couples decide on their disposition. Cryopreservation is used in freezing of semen, freezing of embryos, and oocyte and ovarian tissue cryopreservations. The disposition of leftover embryos can include the following: the couple could decide to transfer them at a later stage; the embryos could be donated to others; they can be disposed of as medical waste; and they can be donated for scientific research.

However, for such embryos and blastocysts, there is a range of ethical considerations regarding their status and whether it is acceptable to donate it for others or for use in scientific research. For ethicists the important question is: When does a human life begin? Is the blastocyst/embryo a person? Different views and theories exist in this regard. At the extreme ends, some believe that this point where human life begins is at birth, and consequently, the embryo/blastocyst is not a person, while others see this point to be at fertilization. In the following subsections, a description on ways to deal with extra embryos and the related ethical concerns are discussed.

Multifetal Reduction

As a result of the increased use of ovulatory drugs in infertility treatment, the incidence of multifetal pregnancies has increased. Furthermore, due to the relative low success rate in certain ART centers, they tend to transfer three to four embryos on the hope of increasing success rate. Carrying multiple fetuses is associated with risks for both the mother and fetuses. Premature deliveries of babies and hypertension of mothers are common in such cases. Researchers suggest that in the case of such pregnancies, the rate of mortality and morbidity of both fetuses and mothers, particularly in cases where four or more are involved, is unacceptably high. In addition, care of such babies is extremely difficult for the mother and very expensive, especially in cases of prematurity (ACOG, Committee of Ethics 2008a).

Fetal reductions seem to be an acceptable method of improving maternal and fetal outcome in high-order multiple pregnancies despite the many unresolved medical and ethical dilemmas. It is allowed if the prospect of carrying the pregnancy to viability is very small, and it is allowed if the life or health of the mother is in jeopardy (ACOG, Committee of Ethics 2008a).

Single embryo transfer is the simplest and safest and most obvious way of avoiding multiple pregnancies. Choosing the best quality embryo to be transferred gives better chances.

Gamete Donation

Sperm and ovum donations are increasingly used. Oocyte donation would involve fertilizing the oocyte donor with the husband’s sperm and transferring the resultant embryo into the infertile female partner. Embryo donation involves transferring an embryo generated using anonymous oocyte and sperm donors into the female partner (American Society of Reproductive Medicine 2009). Indications for OD are women with ovarian failure, women who are carriers of recessive autosomal disorders, and women who have attained menopause, while indications for ED are primary germ cell failure and inheritable genetic disorder (American Society of Reproductive Medicine 2009).

This raises some ethical questions: Is it ethical to sell or buy a human life or potential life? What are the emotional effects to children who are conceived in that way when they know that they were purchased?

In certain cultures, gamete donation is not acceptable, and where it is acceptable, several ethical considerations exist: rights of both donors and recipients and criteria by which they are collected.

The rights of donors and recipients are based on the principles of medical ethics including informed consent and are not mandated by law. Among sperm donor rights, on one hand, the identity of the donor shall remain anonymous. The clients have no right to know the identity of the donor. The donor shall also be free from any responsibility to the biological offspring produced by the sperm. On the other hand, the clients have the right to be informed of the limitations and potential complications. Sperm donation is not always successful and multiple treatments might have to be performed. The client also must understand that she/he is fully responsible for the offspring conceived by the use of the donated sperms. In some clinics, genetic testing and screening techniques are offered. Although these techniques are advanced and sensitive, they are not foolproof (American Society of Reproductive Medicine 2009). Informed consent is an essential step which ensures that the client and donor understand their rights and the steps of the process including potential complications.

Choosing sperm is ethically controversial. Some banks are “ultra-selective,” in which certain criteria of the donors are mandatory; others are from “normal” population. This raises an ethical question, which needs an answer: Is only providing a selected sperm a form of eugenics? Since sperm banks/clinics adhere to proper standard and respect of informed consent, they can provide any type of sperm they wish (American Society of Reproductive Medicine 2009).

Surrogacy And Gestational Carriers

A surrogate mother, on one hand, is defined as a woman who agrees to carry a pregnancy using her own oocyte but with the sperm of another man, and then after birth, she gives the child to this couple. A gestational carrier, on the other hand, is a woman who carries the pregnancy till birth from a couple who undergoes ART with their genetic gametes and then places the resultant embryo in her uterus. Then she gives the child to this couple. This creates some ethical questions regarding parenthood (ACOG Committee on Ethics 2008b). Who are the parents? Are they the biological or the genetic one? After birth, in some cases, the biological mother develops an emotional bond to the child and, in some cases, refuses to give the child to the couple.

Pregnancy Of A Single Mother Or Lesbian

Artificial insemination using donor sperms (AID) has been known as a treatment for heterosexual couples where the husband has been found to be infertile. However, recently it has been used by lesbians or single women who wish to have children, without having to have sexual relations with a male (Baetens and Brewaeys 2001). Both lack the father figure. However, single women carry the responsibility of raising the child alone, whereas in lesbian couples, partners share this responsibility. The concern regarding the quality of life of the child that is born from these procedures is of ethical importance.

Futile Treatment: Infertility Treatment In Perimenopausal/Postmenopausal Women

There are many questions and concerns when the treatment is futile. Age is a major factor that affects the chance of pregnancy and some ART centers set limits of age for a woman to be treated. Among women in their twenties, pregnancy and live birth rates are relatively stable and decline steadily from the mid-thirties onward (Ethics Committee for the American Society of Reproductive Medicine 2012).

There are many ethical questions regarding infertility treatment in the perimenopausal women. They argued that since the treatment in these cases could be of poor prognosis or futile, if a woman can afford that it is associated with less than 5 % chance of success, should it be offered? Does a patient’s desire and request for treatment oblige a physician to provide care? Does a patient’s right to autonomy guarantee the right to futile treatment? What processes and procedures are necessary to address for ineffective, futile, or inappropriate medical care?

Medically assisted conception allows postmenopausal women to become pregnant and have children of their own. Pregnancy in post-menopause involves, at present, egg donation; however, there is increased maternal risk, increased congenital anomalies of the offspring, and problems with rearing of the child. Pregnancy in the postmenopausal woman using a couple’s frozen embryos is associated with increased maternal risk and needs further evaluation (Ethics Committee for the American Society of Reproductive Medicine 2012).

From the ethical point of view and based on the principle of justice, since older men have always been able to have children, having children for the postmenopausal women is just, but is it just for the child? The child will not have the adequate love and care that he/she would have from a young and healthy mother who has a much longer life expectancy.

Considering the principle of non-maleficence, what about the health outcome for a postmenopausal mother? What about the increased risk of congenital anomalies of children born from postmenopausal women?

Treating Infertile Couple Who Are Living with HIV/AIDS

Increasingly, HIV seropositive individuals (people living with HIV/AIDS) are living active and positive lives as a result of a highly effective therapy (HAART). Many of the people living with HIV/AIDS are of reproductive age and would desire to have children. There are, currently, techniques of ART to enable these couples to have children free from HIV infection (Umeora, and Chukwuneke 2013).

Various techniques have been suggested as a preventive measure of avoiding infection in HIVSerodiscordant couples intent on having children. ICSI requires only the in vitro contact of a single sperm and oocyte and should dramatically reduce the risk of transmitting viral particles that are often present in the seminal fluid (Anderson 1999).

The idea of ART to HIV-serodiscordant couples generates concerns and raises questions such as: What is an acceptable level of risk to offspring? And should couples who want this assistance be subject to selection criteria? Should they undergo scrutiny about their suitability as parents when those who are able to conceive naturally face no such scrutiny and people with other illnesses are given access to ART?

The commonly accepted principles of healthcare ethics include considerations of respect of autonomy, non-maleficence, beneficence, and justice. Each of these principles is essential in order to consider treatment. Informed and rational decision-making must be taken in every case of intervention. A proper counseling should precede the treatment, and alternatives, like adoption and childless living, should be discussed. They need to understand that none of the procedures which will be conducted are risk-free.

It might be safe to argue that offering ART to HIV-serodiscordant couples, after proper counseling and having informed consent, is likely to produce more benefits than harm.

Posthumous Reproduction

When one of the couple is going for chemotherapy, frozen gamete can be obtained and used later, even after death. In case of brain death, techniques such as stimulated ejaculations, microsurgical sperm aspiration (MESA), or testicular extraction (TSE) can be employed to procure sperm from a dead or brain-dead individual. Cryopreservation of the ova is also possible. There is not much ethical debate on cases of cryopreservation of gametes for those who are going for chemotherapy. However, for procedures to bring a child of a dead body or brain-dead person, ethical concerns would arise. The Ethics Committee of the American Society for Reproductive Medicine (2013) recommended that posthumous gamete (sperm or oocyte) procurement and reproduction are ethically justifiable if written documentation from the deceased authorizing the procedure is available.

Treatment Of Infertility With Stem Cells

Until recently, men with nonobstructive azoospermia cannot have their own biological children. The treatment is micro dissection testicular sperm extraction, but the success rate is very low and new approaches for male infertility are needed. Stem cells have the potential to differentiate into different functional cell types, and their discovery has given rise to the field of regenerative medicine. Stem-cell research has great potential for clinical application, including treatment of anovulation.

Currently, there are many millions of blastocysts that exist, for which the most likely fate is disposal as a medical waste. Using these blastocyst/embryos in research is a more acceptable choice. Research on human embryos has advanced in the last few decades. This created many debates and ethical concerns. Some understand the blastocyst as genetically unique, and this establishes its worth as a human being. Others argue that the blastocyst exists before the stage wherein the embryo could split to form twins or other multiples. Some objected arguing that the embryo has the potential to grow into a complete human being. The counterargument is that every cell of the body, if cloned, has the theoretical potential to grow into a human being (Serour 2006).

Reproductive Cloning

Cloning means to make multiple copies of something; rats, goats, cats, horses, and donkeys have been cloned. Since 1998, there have been various reports claiming the creation by South Korean scientists whose laboratory was eventually closed down by their government. Other trials were mentioned and claimed in the literatures.

The main argument in favor of reproductive cloning is expansion of opportunities for infertile couple. Infertile individuals or couples could have a child that is genetically related to them. Furthermore, individuals, same-sex couples, or couples who cannot together produce an embryo would not need donor gametes to have a child. Using cloning to help infertile couple have a genetically related child has been defended on the grounds of human well-being, personal autonomy, and the satisfaction of the natural inclination to produce offspring. Using cloning technology to offer individuals or couples the possibility to reproduce is consistent with the right to reproductive freedom (Devolder 2013).

A possible use of reproductive cloning is to create a child that is a tissue match for sick siblings. The stem cells from the umbilical cord blood or from the bone marrow of the cloned child could be used to treat the diseased sibling (Devolder 2013).

However, many ethicists, religious scholars, and international organizations expressed their concerns; while there was a consensus on accepting therapeutic cloning, there was a strong opposition to reproductive cloning. The cloned individual may have a shorter life span, may suffer from aging, and may have a greater susceptibility to cancer. There is also a concern about whether they would be fertile or not and if so, whether they or their offspring would suffer from genetic abnormalities. In addition, the cost of the procedure is expensive (Serour 2006). Serour (2006) argued that in the near future, if safety and efficiency would be improved, societies and ethicists would approve it.

Infertility Management In Resource-Poor Countries

In most of the developing countries, the health system is weak. Infertility management had progressed recently and the cost of providing the new ART techniques increased much. Since, in developing countries, the value of children is high, the demand for infertility treatment is high also (Shahin 2007). In many developing countries, infertile women have low status. Once a newly married woman gets pregnant and has children, especially sons, her status increases and her marriage becomes more stable. Health providers in developing countries receive women after 3 or 4 months of marriage complaining of infertility.

In countries with limited resources, the cost of ART created a major problem. ART is an expensive procedure and is mainly available in most countries on a private basis. This situation seriously violated the principles of equity and distributive justice. The rich could have access to services while they are denied for the poor.

Pennings (2008) examined ethical concerns regarding infertility management in developing countries and indicated that there are five issues that should be considered:

– Overpopulation

– Prioritization of the limited resources

– Prevention rather than cure

– Justice and equal access

– Risk of abuse

He affirmed that efforts should be made to enable people to determine how many children to have due to the importance of a person’s autonomy which is applied to developing countries also. However, due to the difficulties of resource-poor countries to provide even basic services, he argued that the contribution by society should be directed mostly at prevention. Many programs are suggested for the reduction of cost. Providing low-cost procedures has been tried and progress has been made; however, the procedure is still relatively unaffordable by many infertile couples in developing countries.

Conclusion

Infertility, the inability to conceive, is a stressful state of being for couples who suffer from it. New assisted reproduction techniques brought hope and offered better chances for treatment; however, at the same time, it created many moral and ethical concerns needing solutions. The recent advances in the last few decades helped many people that were considered sterile. These new techniques abled couples to procreate and have children without having sex, at any age, even as married or single, and the sex of the child could be determined. However, in providing these new techniques, one must observe principles of respect for the dignity of the human being, security of human genetics, inviolability of the person, and quality of services.

Certain techniques are creating more ethical and moral concerns, such as: providing futile treatment, as in cases of perimenopausal women; multifetal reduction, in cases of multiple pregnancy; gamete donation; surrogacy and gestational carriers; pregnancy of a single mother or lesbian; treating infertile couple living with HIV/AIDS; posthumous reproduction; and reproductive cloning.

In general, there are three moral principles, which provide an ethical basis for ART: the principle of liberty, which guarantees a right to freedom of action; the principle of utility, which defines moral rightness by the greatest good for the greatest number; and the principle of justice, which requires everyone to have equal access to necessary goods and services. By applying these problems, ethical concerns regarding the new modalities of management of infertility could be answered. Within the context of high cost of the new modalities for treatment of infertility, there is a need for research with greater emphasis on innovative, safe, and cost-effective solutions especially for developed countries.

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