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Multiple pregnancy: Legal and ethical issues
Abstract
Multiple pregnancy is increasingly considered a complication of in vitro fertilization (IVF) and ovarian stimulation for natural fertilization. Harms to fetuses, newborn and older children, mothers, families, and healthcare systems are encouraging single embryo transfer. When patients knowingly accept multiple pregnancy risks from IVF or ovarian stimulation, they are unlikely to succeed in litigation against healthcare providers for wrongful pregnancy or wrongful birth. More challenging are impaired children's claims for "wrongful life." These are unlikely to succeed against parents, but courts are ambivalent to claims against healthcare providers. Historically, courts rejected these claims, under the principle that live birth is not a legal injury. European and other courts, however, have been more sympathetic to these claims. Multiple pregnancy treated by fetal reduction is not usually found to offend abortion laws. This poses ethical concerns, however, of "lifeboat ethics," involving how fetal reduction choices are made.
... Doctors in the business target high success rates and low costs to attract national as well as international clients. Infertile couples undergoing self-financed IVF treatment add to the pressure of achieving a pregnancy in their first attempt (22). Commissioning parents might see multiple pregnancies as a positive indicator and opt for clinics advertising higher success rates (23). ...
... This study illustrated the conflicts of interests between the involved parties in medical decision-making in surrogacy. The profit-driven, self-financed nature of IVF reproductive healthcare added to the pressure of achieving a pregnancy in the first attempt both for the doctors as well as commissioning parents (22). A similar practice of high number of embryos per transfer is reported from Taiwan, an East Asian country that also legalizes surrogacy and low cost medical treatments (29). ...
... High success rates would also attract foreign patients, as it would minimize the number of times they would have to travel to India (as Doctor A said, they would get "two in one shot"). However, a high number of embryos per transfer is unethical and needs regulation (10,22). This practice is similar to the profit-driven healthcare in the USA, which permits more embryos per transfer, in contrast to the partially public-funded IVF health care in Scandinavia, which favors single embryo transfer. ...
Objective
To investigate ethical issues in informed consent for decisions regarding embryo transfer and fetal reduction in commercial gestational surrogacy.DesignMixed methods study employing observations, an interview-guide and semi-structured interviews.SettingFertility clinics and agencies in Delhi, India, between December 2011 and December 2012.SampleDoctors providing conceptive technologies to commissioning couples and carrying out surrogacy procedures; surrogate mothers; agents functioning as links for surrogacy.Methods
Interviews using semi-structured interview guides were carried out among 20 doctors in 18 fertility clinics, five agents from four agencies and 14 surrogate mothers. Surrogate mothers were interviewed both individually and in the presence of doctors and agents. Data on socio-economic context and experiences amongst and between various actors in the surrogacy process were coded to identify categories of ethical concern. Numerical and grounded theory oriented analyses were used.Main outcome measuresInformed consent, number of embryos transferred, fetal reduction, conflict of interest among the involved parties.ResultsNone of the 14 surrogate mothers were able to explain the risks involved in embryo transfer and fetal reduction. The majority of the doctors took unilateral decisions about embryo transfer and fetal reduction. The commissioning parents were usually only indirectly involved. In the qualitative analysis, difficulties in explaining procedures, autonomy, self-payment of fertility treatment and conflicts of interest were the main themes.Conclusions
Clinical procedural decisions were primarily made by the doctors. Surrogate mothers were not adequately informed. There is a need for regulation on decision-making procedures to safeguard the interests of surrogate mothers.This article is protected by copyright. All rights reserved.
... Despite the increased maternal and fetal complications that liveborn multiples entail (3,5,22), many infertility patients actually desire twins or triplets. Given that multifetal reduction procedures involve ethical and legal issues and may not be acceptable to some couples (23)(24)(25), efforts continue in the IVF community to decrease the number of embryos transferred. In our cohort, liveborn multiples accounted for 32.1% of live births among women less than 35 years of age and 18.2% of live births among women 40 years of age and older. ...
... A limitation of our study is the lack of data available on the type of reduction, whether spontaneous or medically induced, that occurred in pregnancies with multiple fetal heartbeats. With current practice patterns in mind, women with quadruplet pregnancies are the most likely to opt for multifetal pregnancy reduction (23), whereas women with twin pregnancies are the least likely (24). ...
... A major strength of this study is the use of a large cohort of all women presenting for their first fresh IVF cycle and followed during more than a decade without exclusion based on ovarian reserve testing, diagnosis, or other prognostic factors, thereby maximizing generalizability. Unlike some studies that excluded frozen ET cycles from the calculation of live birth rates (18,19,24,41,42), we included these cycles to represent a woman's entire treatment experience. Furthermore, we provided an estimate of the cumulative risk of liveborn multiples for a woman entering her first IVF cycle, rather than simply the per cycle PR, thus providing an estimate of the risk of liveborn multiples during the entire course of treatment. ...
Objective:
To estimate the cumulative probability of liveborn multiples after IVF to improve patient counseling regarding this significant morbidity.
Design:
Retrospective cohort study.
Setting:
Large academic-affiliated infertility practice.
Patient(s):
A total of 10,169 women were followed from their first fresh, nondonor IVF cycle through up to six fresh and frozen IVF cycles from 2000-2010.
Intervention(s):
None.
Main outcome measure(s):
Delivery of a liveborn infant(s).
Result(s):
After three IVF cycles the cumulative live birth rate (CLBR) was 53.2%. The singleton, twin, and triplet CLBRs were 38.0%, 14.5%, and 0.7%. After six IVF cycles the CLBR was 73.8%, with 52.8%, 19.8%, 1.3% for singletons, twins, and triplets. Of the 5,433 live births, 71.4% were singletons, 27.1% were twins, and 1.5% were triplets. Women more than 39 years had the lowest incidence of liveborn multiples with CLBRs of 5.2% after three cycles and 9.5% after six cycles. The twin CLBR doubled from cycles 1 through 3 with the rate of increase slowing from cycles 3 through 6. Although very low in absolute terms, the triplet CLBR also doubled from cycles 1 through 3 and doubled again from cycles 3 through 6. Of the 1,970 pregnancies that began as multifetal on ultrasound, 77.4% resulted in liveborn multiples.
Conclusion(s):
Providers should be aware of the cumulative probability of liveborn multiples to effectively counsel patients on this important issue. With nearly three-quarters of all women having live birth after up to six IVF cycles, it is encouraging to report a low incidence of liveborn multiples.
... The clinics advertise high success rates at lower costs and thus raise expectations of early successful pregnancy amongst patients. Selffinanced fertility treatment heightens the desire of CPs for a successful pregnancy in the first attempt (Dickens and Cook 2008). Therefore, CPs might see multiple pregnancies in a positive light and opt for those clinics that advertise higher success rates (Price 1999). ...
... As a parent, she has the right to decide for her own body and the child, but as a part of the treatment, she loses these rights (Gupta and Richters 2008). However, regardless of how a surrogate is viewed, a high number of embryos per transfer and subsequent fetal reduction is unethical and needs regulation (Dickens and Cook 2008). ...
With breakthroughs in science and reproductive technologies, “natural” birthing has undergone change due to the “assisted” use of conceptive technologies. Bodies and their parts have become commodities, to be sold and purchased in medical markets. In the literature, there have been numerous debates on commercialization and commodification, which have addressed the biopolitical and bioethical aspects of organ, egg and sperm donations, and gestational commercial surrogacy. This paper examines the everyday experiences of surrogates and egg donors, coerced and enticed into selling their reproductive services (for familial and socio-economic reasons), which become commodities for the larger medical markets of India's In Vitro Fertilization (IVF) industry. Based on a qualitative study of 4 IVF clinics and 28 surrogates in a state capital city of a southern state in India, this paper addresses the issue of commodification of women's bodies, where the women from lower socio-economic families are either lured or pushed to respond to the demands of reproductive markets. However, legal gestational commercial surrogacy in India, without clear laws and regulations to guide it, is a complex issue and raises many bioethical concerns. This paper limits itself to addressing the commodification of surrogates’ bodies.
... The clinics advertise high success rates at lower costs and thus raise expectations of early successful pregnancy amongst patients. Selffinanced fertility treatment heightens the desire of CPs for a successful pregnancy in the first attempt (Dickens and Cook 2008). Therefore, CPs might see multiple pregnancies in a positive light and opt for those clinics that advertise higher success rates (Price 1999). ...
... As a parent, she has the right to decide for her own body and the child, but as a part of the treatment, she loses these rights (Gupta and Richters 2008). However, regardless of how a surrogate is viewed, a high number of embryos per transfer and subsequent fetal reduction is unethical and needs regulation (Dickens and Cook 2008). ...
As a neo-liberal economy, India has become one of the new health tourism destinations, with commercial gestational surrogacy as an expanding market. Yet the Indian Assisted Reproductive Technology (ART) Bill has been pending for five years, and the guidelines issued by the Indian Council of Medical Research are somewhat vague and contradictory, resulting in self-regulated practices of fertility clinics. This paper broadly looks at clinical ethics in reproduction in the practice of surrogacy and decision-making in various procedures. Through empirical research in New Delhi, the capital of India, from December 2011 to November 2012, issues of decision-making on embryo transfer, fetal reduction, and mode of delivery were identified. Interviews were carried out with doctors in eighteen ART clinics, agents from four agencies, and fourteen surrogates. In aiming to fulfil the commissioning parents' demands, doctors were willing to go to the greatest extent possible in their medical practice. Autonomy and decision-making regarding choice of the number of embryos to transfer and the mode of delivery lay neither with commissioning parents nor surrogate mothers but mostly with doctors. In order to ensure higher success rates, surrogates faced the risk of multiple pregnancy and fetal reduction with little information regarding the risks involved. In the globalized market of commercial surrogacy in India, and with clinics compromising on ethics, there is an urgent need for formulation of regulative law for the clinical practice and maintenance of principles of reproductive ethics in order to ensure that the interests of surrogate mothers are safeguarded.
... and it is not affordable to common man; (4) It bypasses the natural method of conception [31]; (5) Multiple pregnancies are a major complication of IVF. It may be harmful for foetus, newborn, mothers, families and also health care system [32]. ...
In vitro fertilization (IVF) is one of the assisted reproductive technologies in the field of medical sciences. Fusion of collected egg from female and sperm from male done in a culture media under aseptic condition in laboratory is called as IVF. This technique is one of the gifts of science towards the human society and mainly those who are facing problem in reproduction due to having either male or female defective reproductive systems. In this present study, factors to consider during IVF, steps followed in this technology, need of IVF are discussed. Risk of multiple birth and phenotypic changes to the newborn due to IVF are also well reviewed. And different types of instruments used during this process are focused. Few ethical and legal issues arising during this IVF process are shown as well. We also emphasize that part of IVF. © 2018 Asian Pacific Journal of Reproduction Produced by Wolters Kluwer-Medknow.
... At the same time however, it has been argued that continuing medico-technical progress has led to an increased medicalisation of pregnancy [8]. Its use has also raised many ethical challenges, especially in relation to non-medical provision [9], and its role in the practice of sex-selective abortions [10,11], and fetal reduction in multiple pregnancies [12]. ...
Background
Obstetric ultrasound has come to play a significant role in obstetrics since its introduction in clinical care. Today, most pregnant women in the developed world are exposed to obstetric ultrasound examinations, and there is no doubt that the advantages of obstetric ultrasound technique have led to improvements in pregnancy outcomes. However, at the same time, the increasing use has also raised many ethical challenges. This study aimed to explore obstetricians' experiences of the significance of obstetric ultrasound for clinical management of complicated pregnancy and their perceptions of expectant parents' experiences.
Methods
A qualitative study was undertaken in November 2012 as part of the CROss-Country Ultrasound Study (CROCUS). Semi-structured individual interviews were held with 14 obstetricians working at two large hospitals in Victoria, Australia. Transcribed data underwent qualitative content analysis.
Results
An overall theme emerged during the analyses, 'Obstetric ultrasound - a third eye', reflecting the significance and meaning of ultrasound in pregnancy, and the importance of the additional information that ultrasound offers clinicians managing the surveillance of a pregnant woman and her fetus. This theme was built on four categories: I:'Everyday-tool' for pregnancy surveillance, II: Significance for managing complicated pregnancy, III: Differing perspectives on obstetric ultrasound, and IV: Counselling as a balancing act. In summary, the obstetricians viewed obstetric ultrasound as an invaluable tool in their everyday practice. More importantly however, the findings emphasise some of the clinical dilemmas that occur due to its use: the obstetricians' and expectant parents' differing perspectives and expectations of obstetric ultrasound examinations, the challenges of uncertain ultrasound findings, and how this information was conveyed and balanced by obstetricians in counselling expectant parents.
Conclusions
This study highlights a range of previously rarely acknowledged clinical dilemmas that obstetricians face in relation to the use of obstetric ultrasound. Despite being a tool of considerable significance in the surveillance of pregnancy, there are limitations and uncertainties that arise with its use that make counselling expectant parents challenging. Research is needed which further investigates the effects and experiences of the continuing worldwide rapid technical advances in surveillance of pregnancies.
... It is interesting that this point has been discussed within the fetal reduction context. There, one seems to choose on the basis of a combination of ethical and practical considerations (less developed fetuses, the most easily accessible, least risk and so one) (Dickens and Cook, 2008; Rochon and Stone, 2003 ...
Analogical reasoning is a basic method in bioethics. Its main purpose is to transfer the rule from an existing or known situation to a new and problematic situation. This commentary applies the lifeboat analogy to the context of selective termination and fetal reduction. It turns out that the analogy is only partially helpful as the main principle in the case of selective termination is the procreative beneficence principle. However, the wide person-affecting form of this principle doubly justifies selective termination: i.e. one prevents the harm caused by the birth of an affected child and one increases the life chances of the remaining fetuses. I conclude, however, that all analogies are basically flawed since they assume that fetuses as such have interests. I argue that fetuses only have interests to the extent that they are potential future persons.
... Following the breakthrough, the new technique rapidly spread throughout the world. Nowadays the number of children born by IVF worldwide is estimated to exceed 3 million (Dickens and Cook, 2008). Currently, European registrations indicate that the proportion of infants born by assisted reproduction in 16 European countries comes to 3.9% of all live-born children (Andersen et al., 2009). ...
The aim of this research was to ascertain how the opportunities now open by the Greek legislation regarding assisted reproduction fits with Greek society and how it compares with the wider EU legal framework. A revision of the Greek legislation took place a few years ago, with two new Acts. The different issues that arise from the two Acts and the relevant statements are examined. Issues such as the legal state of the newborn, involvement of a third party in the reproduction process, surrogacy, post-mortem fertilization and cryopreserved embryos are analytically presented. A pragmatic orientation seems to unfold, which is characterized by the prevalence of the benefits that can be obtained from the resources of reproductive technologies. The reality is that Greek society is still quite traditional, therefore specific parts of this new legislation do not fit with the current picture. A comparison with the other national legislative systems in existence within the EU has revealed specific differences. The creation of a common legislative framework covering most of the points raised through the implementation of assisted reproduction could provide guidance for any future legislative reforms or updates within a EU state, including Greece.
... In April 2009, the Constitutional Court of Italy modified the law on assisted reproduction [18], ruling that an embryo can be transferred only if this would not endanger the woman's health. Nevertheless, the limit on embryo creation requires infertile or subfertile women to receive hormonal ovarian stimulation in preparation for each cycle of treatment, adding to their discomfort, health burden, and expenses, and the requirement of transfer of all embryos created in a treatment cycle imposes the risks, to women and fetuses, of multiple pregnancy [19]. Many Italian couples find relief from this doctrinally-driven, dysfunctional legislation by seeking services in other countries [20]. ...
Judicial approaches to stored (cryopreserved) human embryos, in western jurisprudence, tend not to reflect approaches within systems of moral ordering or particular religious traditions, which differ among themselves. The emerging judicial approach is pragmatic, protecting individuals' rights of control and their interests in parenthood. Embryos are approached instrumentally, not by reference to any inherent characteristics that may be attributed to them outside the law. Political legislatures may adopt religious approaches, such as by prohibiting embryo preservation and limiting how many may be created in an IVF treatment cycle. Legislatures may alternatively set time limits on embryo preservation, however, on expiry of which they must be left to natural degeneration. In treating human embryos as property, courts recognize owners' powers of voluntary disposition, for instance by gift, but have held back from making financial assessments of their value, for instance on loss, consistently with legislation prohibiting their exchange for payment.
Background:
Medically assisted reproduction (MAR) is a challenging application area for health economic evaluations, entailing a broad range of costs and outcomes, stretching out long-term and accruing to several parties.
Purpose:
To systematically review which costs and outcomes are included in published economic evaluations of MAR and to compare these with health technology assessment (HTA) prescriptions about which cost and outcomes should be considered for different evaluation objectives.
Data sources:
HTA guidelines and systematic searches of PubMed Central, Embase, WOS CC, CINAHL, Cochrane (CENTRAL), HTA, and NHS EED.
Study selection:
All economic evaluations of MAR published from 2010 to 2022.
Data extraction:
A predetermined data collection form summarized study characteristics. Essential costs and outcomes of MAR were listed based on HTA and treatment guidelines for different evaluation objectives. For each study, included costs and outcomes were reviewed.
Data synthesis:
The review identified 93 cost-effectiveness estimates, of which 57% were expressed as cost-per-(healthy)-live-birth, 19% as cost-per-pregnancy, and 47% adopted a clinic perspective. Few adopted societal perspectives and only 2% used quality-adjusted life-years (QALYs). Broader evaluations omitted various relevant costs and outcomes related to MAR. There are several cost and outcome categories for which available HTA guidelines do not provide conclusive directions regarding inclusion or exclusion.
Limitations:
Studies published before 2010 and of interventions not clearly labeled as MAR were excluded. We focus on methods rather than which MAR treatments are cost-effective.
Conclusions:
Economic evaluations of MAR typically calculate a short-term cost-per-live-birth from a clinic perspective. Broader analyses, using cost-per-QALY or BCRs from societal perspectives, considering the full scope of reproduction-related costs and outcomes, are scarce and often incomplete. We provide a summary of costs and outcomes for future research guidance and identify areas requiring HTA methodological development.
Highlights:
The cost-effectiveness of MAR procedures can be exceptionally complex to estimate as there is a broad range of costs and outcomes involved, in principle stretching out over multiple generations and over many stakeholders.We list 21 key areas of costs and outcomes of MAR. Which of these needs to be accounted for alters for different evaluation objectives (determined by the type of economic evaluation, time horizon considered, and perspective).Published studies mostly investigate cost-effectiveness in the very short-term, from a clinic perspective, expressed as cost-per-live-birth. There is a lack of comprehensive economic evaluations that adopt a broader perspective with a longer time horizon. The broader the evaluation objective, the more relevant costs and outcomes were excluded.For several costs and outcomes, particularly those relevant for broader, societal evaluations of MAR, the inclusion or exclusion is theoretically ambiguous, and HTA guidelines do not offer sufficient guidance.
Approximately five million children have been born worldwide as a result of assisted reproductive technology (ART). These techniques are now practised independently in most of the world's nations. Although the vast majority of ART parents and children are healthy following the procedures involved, there is an imperative to maintain a high standard of practice and monitor outcomes carefully. Interpretation of outcome data is difficult for a variety of reasons. As ART technologies evolve and new variants are established, the need for robust assessment of outcomes increases. This book gives a thorough review of potential complications of ART, with detailed analysis of outcome data for the various conditions described. A worldwide perspective is given throughout, with an international team of chapter authors.
This chapter includes clinical cases, background, evidence‐based practical management options, preventive measures, key‐point summaries of multifetal pregnancy reduction (MFPR) after IVF and answers to questions patients ask. With the increased use of assisted reproductive technology (ART), utilizing gonadotropin controlled ovarian stimulation and multiple embryo transfer, the incidence and order of multiple pregnancies have dramatically increased. The increased incidence of multiple pregnancies and their associated higher risks have led to the introduction of guidelines to reduce the number of embryos transferred at ART and the utilization of MFPR as a strategy to try and improve outcomes. When first introduced in the 1980s, MFPR was performed in early pregnancy using transcervical and transabdominal techniques. ART clinicians and patients should be aware of the significantly increased maternal and fetal complications of multiple pregnancies, particularly the higher‐order ones.
DOI: 10.1007/s13132-012-0138-z. The objectives of this study were (1) to elucidate ethical priorities in reproductive health in studies published between 1986 and 2012, and (2) to address the place of clinical ethics in reproductive health knowledge economy through comparative analysis of country-based ethical vignettes and practices. A total of 101 studies are identified through the PubMed portal. Recruited studies are inclusive for their focus and level of evidence (I, II-1, 2, 3). Pooled prevalence of the ethical problems, their approximate determinants, and outcomes are modeled as measurable outcomes. Ethical debates are correlated with the extrapolated maternal and perinatal mortality rates. Calculations use cases as units of analysis. This meta-study prioritizes the following ethical issues: patient’s autonomy, adolescent pregnancy, fetal surgery, cross-border reproduction, health insurance constraints, surrogacy, stem cell registry, and reproductive health in mentally ill. Clinical pregnancy rate from the transferred embryos is 17–22 %. Sixty percent of couples consent for posthumous reproduction, and 47 % consent for fetal surgeries for the nonlethal conditions; 48.2 % of pregnant adolescents choose to continue their pregnancy, 45 % opt to terminate, and 6 % miscarry. Abortion debates take pro-choice (66.7%), pro-life (6.7 %), and balanced (26.7 %) arguments. No correlations are found between presented ethical problems, maternal and perinatal mortality ratios per country (r 2 = 0.117–0.209). Structurally too, the cost of prime knowledge products, like reproductive health education—has tripled adjusted for inflation. Nevertheless, the relative power of the costs for the malpractices and adverse outcomes against knowledge products remains assuredly higher. An accurate definition of the ethical norms is essential and may impact on the reproductive health knowledge economy on both system and case levels. At the system level, it promotes a moral foundation to maximize wellfare; at the case level, it assists physicians in identifying and resolving ethical issues to minimize legal aid expenses. LINK: https://link.springer.com/article/10.1007/s13132-012-0138-z
Reproductive biology has witnessed substantial technological developments to cure infertility, which is a major concern worldwide affecting more than 10% of the couples. The combined effort of basic and applied medical research led to the development of a technique popularly known as in vitro fertilization (IVF) to alleviate infertility. It is a technique by which an egg is fertilized by a sperm in in vitro conditions. It has emerged as a safe and effective technique that overcomes the limitation of other methods. In general, damage of fallopian tubes is the major reason for female infertility as it obstructs the contact between the egg and the sperm, whereas male infertility is mainly due to impaired sperm quality and quantity. In 1978 the technique of IVF was successfully adopted by Dr. Edwards and Dr. Steptoe resulting in a normal, healthy, and fit baby from a human oocyte. The technique is performed by collecting the contents of female fallopian tube after natural ovulation and mixing it with sperm followed by implantation. The ovarian hyperstimulation, transvaginal oocyte retrieval from ovary, egg and sperm preparation, and selection of resulting embryos before implantation are important considerations for IVF. By the application of applied reproductive technologies, the IVF success rate is now substantially improved. There are many potential factors that might influence the success or failure of pregnancy rate through IVF. Although IVF has proved to be a boon for many couples suffering from infertility, it poses serious moral, ethical, social, and religious controversies.
The aim is to achieve a transgenerational view of single motherhood in Spain, to look at which contexts it arises in, how it changes with the introduction of assisted reproduction, and how the role of religion in Spanish society permeates medical practice and affects the lives of women patients. I examine single motherhood and investigate two interconnected themes: a) being a mother and being mothered are both permeated with socio-cultural, political, religious, economic and psychological significance; b) Spain led Europe in multiple births due to assisted reproduction, thus ethical conflicts and patient rights are analysed.
A paper considering the use of terminology in relation to clinical procedures related to multiple pregnancy.
Multi-fetal pregnancy reduction (MFPR) is an ethically acceptable procedure aimed to increase survival and well-being of the remaining fetuses from high-order multiple gestations. In most cases we offer the procedure to triplets or quadruplets and opt to preserve twins; lately, the option to maintain a single fetus was suggested. We examined the outcomes of 140 pregnancies that underwent MFPR in our center and were followed to delivery - 105 were reduced to twins and 35 to singletons. The rate of procedure-related pregnancy loss was identical (2.9%). Leaving only one fetus was associated with a higher gestational age at delivery (35.4±2.4 weeks vs. 37.7±2.1 weeks, P<0.0001), with heavier neonates (2222 g vs. 3017 g, P<0.0001) and with a reduction in the cesarean section (CS) rate (76% in twins vs. 51.4% in singletons, P=0.02). Six pregnancies reduced to twins (5.8%) ended before 32 weeks as compared to one pregnancy reduced to a singleton. We conclude that reduction of triplets to singletons is medically and ethically acceptable, after thorough counseling of patients. However, considering the pregnancy loss risk of MFPR and the relatively good outcome of twin gestations, reduction of twins to singletons is ethically acceptable only in extraordinary maternal or fetal conditions.
Research on human embryos has advanced at a tremendous pace during the last three decades. The main argument over using embryos for research is about the value of human life at its beginning. Therefore, its wide application in several parts of the world is a cause of great concern in many societies, including Muslim countries, due to the absence of adequate ethical, social and legal implications. This paper considers the Islamic views that surrounded the conduct of destructive research, e.g. human embryonic stem cell research, on surplus in vitro fertilisation embryos that are not wanted. This will also be devoted to an explanation of the scientific and moral-religious position of human embryo research and stem cell science in Iran, which has taken the lead among Muslim countries since 2003.
The optimal outcome after IVF is a live, healthy, singleton term baby. This can be achieved by transferring a single embryo, but at the possible expense of reducing pregnancy rates. Recent studies suggest that delaying transfer of embryos to the blastocyst stage (day 4/5), rather than the more traditional cleavage stage (day 2-3), allows for better selection of the best embryo, maximising pregnancy rates from a single embryo transfer (SET). The aim of this study was to assess pregnancy outcomes in relation to changing embryo transfer practices.
A retrospective analysis of pregnancy outcomes was made between IVF cycles conducted in 2007 when blastocyst SET became standard practice, with IVF cycles in 2003 when double cleavage-stage embryo transfer was the norm.
The implementation of a blastocyst SET policy resulted in a significant decrease in multiple birth rates, while maintaining live birth delivery rate comparable to double cleavage-stage transfer (27.2% versus 24.8%, respectively, N.S.).
Improvements in culturing protocols have facilitated extended culture, increasing embryo selection capability. These results indicate that it is now possible to maintain excellent pregnancy rates with SET blastocyst culture, while decreasing complications related to multiple births.
To report a genetically proved superfecundation of quintuplets after transfer of two embryos in IVF procedure and successful completion of the pregnancy after fetal reduction.
Case report.
Academic reproductive medicine center.
A 31-year-old woman, gravida 0, who underwent her second IVF cycle after three IUIs.
After 5 years of primary infertility, three IUIs, and one IVF, the patient underwent her second IVF cycle with transfer of two fresh embryos on day 2.
Development of five separate embryonic sacs. Fetal reduction to twins at 12 weeks of gestation. Successful pregnancy and delivery. Deoxyribonucleic acid analysis of the three reduced embryos, the live-born twins, and their parents.
Analysis of the seven DNA samples, because all were different, confirmed the superfecundation and disproved the zygote's division after transfer. Fetal growth restriction motivated preterm delivery by cesarean section. Both twins were in good health.
Superfecundation can explain high-order multiple pregnancy and can be proved by DNA analysis. Couples must be informed because of the implications of fetal reduction for ethical issues, risks of pregnancy loss, fetal growth restriction, preterm delivery, and its consequences.
This article concerns the issue of multifetal reduction performed in some cases of higher order multiple gestation in order to decrease the possibility of adverse pregnancy outcomes and increase the chances of survival in the remaining fetuses. If multifetal pregnancy reduction is considered as a treatment option, it is usually performed in the first or early second trimester. The decision to reduce one or more fetuses is extremely complicated, and numerous factors must be considered, since the procedure has risks, such as loss of the entire pregnancy or preterm labor and birth of the remaining fetuses. In addition, there are also psychological risks for the mother. Typically women faced with this decision have struggled for years with infertility and now they are asked to consider terminating one or more of the fetuses to prevent morbidity and/or mortality in others. Nurses who work with infertile women may be able to assist in minimizing the need for multifetal pregnancy reduction by educating women about the risks associated with assisted reproductive technologies and higher order multifetal pregnancy before decisions are made about multiple embryo transfers or intrauterine insemination after ovulation induction.
Advances in perinatal care have increased the number of premature babies who survive. There are concerns, however, about the ability of these children to cope with the demands of adulthood.
We linked compulsory national registries in Norway to identify children of different gestational-age categories who were born between 1967 and 1983 and to follow them through 2003 in order to document medical disabilities and outcomes reflecting social performance.
The study included 903,402 infants who were born alive and without congenital anomalies (1822 born at 23 to 27 weeks of gestation, 2805 at 28 to 30 weeks, 7424 at 31 to 33 weeks, 32,945 at 34 to 36 weeks, and 858,406 at 37 weeks or later). The proportions of infants who survived and were followed to adult life were 17.8%, 57.3%, 85.7%, 94.6%, and 96.5%, respectively. Among the survivors, the prevalence of having cerebral palsy was 0.1% for those born at term versus 9.1% for those born at 23 to 27 weeks of gestation (relative risk for birth at 23 to 27 weeks of gestation, 78.9; 95% confidence interval [CI], 56.5 to 110.0); the prevalence of having mental retardation, 0.4% versus 4.4% (relative risk, 10.3; 95% CI, 6.2 to 17.2); and the prevalence of receiving a disability pension, 1.7% versus 10.6% (relative risk, 7.5; 95% CI, 5.5 to 10.0). Among those who did not have medical disabilities, the gestational age at birth was associated with the education level attained, income, receipt of Social Security benefits, and the establishment of a family, but not with rates of unemployment or criminal activity.
In this cohort of people in Norway who were born between 1967 and 1983, the risks of medical and social disabilities in adulthood increased with decreasing gestational age at birth.
A long latency period between an environmental trigger and the onset of subsequent disease is widely recognized in the etiology of certain cancers, yet this phenomenon is not generally considered in the etiology of other conditions such as cardiovascular disease, metabolic disease, or osteoporosis. However, many lines of evidence, including epidemiologic data and data from extensive clinical and experimental studies, indicate that early life events play a powerful role in influencing later susceptibility to certain chronic diseases.
This classic textbook has provided students of medical law and ethics with a framework for exploring this fascinating subject for over 25 years. Providing coverage of all of the topics found on medical law courses, it gives an overview of the inter-relationship between ethical medical practice and the law. The authors, both hugely experienced and influential in the field, offer their own opinions on current debates and controversies, and thereby encourage readers to formulate their own views and arguments.
As a still-developing discipline, medical law is significantly shaped by the courts, and as such this book provides extensive coverage of recent judicial decisions as well as statutory developments. This edition continues to take a comparative approach, with particular importance attached to the shift in influence from transatlantic jurisdictions to those of the EU.
This book has continually evolved to reflect changes in the law and shifting ethical opinions - this ninth edition continues to fulfil this remit and is essential reading for any serious medical law student or practitioner, as well as being of interest to all those involved in the delivery and control of modern healthcare.
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In-vitro fertilisation has been done for nearly 30 years; in developed countries at least 1% of births are from assisted reproductive therapies (ART). These children now represent a substantial proportion of the population but little is known about their health. Some of the morbidity associated with ART does not result from the techniques but from the underlying health risks of being subfertile. Much of the amplified risk associated with ART is related to high birth order. However, risk of intrauterine and subsequent perinatal complications is enhanced after ART, and urogenital malformations can be present in boys, even in singleton infants. No increase in discord or other difficulties within families has been recorded. Long-term follow-up of children born after ART to reproductive age and beyond is necessary.
Offering the first comprehensive theoretical engagement with actions for wrongful conception and birth, The Harm Paradox provides readers with an insightful critique into the concepts of choice, responsibility and personhood. Raising fundamental questions relating to birth, abortion, family planning and disability, Priaulx challenges the law's response that enforced parenthood is a harmless outcome and examines the concept of autonomy, gender and women's reproductive freedom. It explores a wealth of questions, including: Can a healthy child resulting from negligence in family planning procedures constitute 'harm' sounding in damages, when so many see its birth as a blessing? Can a pregnancy constitute an 'injury' when many women choose that very event? Are parents really harmed, when they choose to keep their much loved but 'unwanted child'? Why don't women seek an abortion if the consequences of pregnancy are seen as harmful? An exciting and original contribution to the fields of medical law and ethics, tort law and feminist jurisprudence, this is an excellent resource for both students and practitioners.
In vitro fertilization is associated with a high risk of multiple births, which is a direct consequence of the number of embryos transferred. However, other factors that contribute to the risk are not well defined.
Using the data base established by the Human Fertilization and Embryology Authority in the United Kingdom, we studied the factors associated with an increased risk of multiple births in 44,236 cycles in 25,240 women. The factors included the woman's age, the cause and duration of infertility, previous attempts at in vitro fertilization, previous live births, number of eggs fertilized, and number of embryos transferred.
Older age, tubal infertility, longer duration of infertility, and a higher number of previous attempts at in vitro fertilization were all associated with a significantly decreased chance of a birth and of multiple births. Previous live birth was associated with an increased chance of a birth but not of multiple births. The higher the number of eggs fertilized, the higher the likelihood of a live birth. When more than four eggs were fertilized, there was no increase in the birth rate for women receiving three transferred embryos as compared with those receiving two, but there was a considerable increase in the rate of multiple births when three were transferred (odds ratio, 1.6; 95 percent confidence interval, 1.5 to 1.8).
Among women undergoing in vitro fertilization, the chances of a live birth are related to the number of eggs fertilized, presumably because of the greater selection of embryos for transfer. When more than four eggs are fertilized and available for transfer, the woman's chance of a birth is not diminished by transferring only two embryos. Transferring more embryos increases the risk of multiple births.
Principles of religious freedom protect physicians, nurses and others who refuse participation in medical procedures to which they hold conscientious objections. However, they cannot decline participation in procedures to save life or continuing health. Physicians who refuse to perform procedures on religious grounds must refer their patients to non-objecting practitioners. When physicians refuse to accept applicants as patients for procedures to which they object, governmental healthcare administrators must ensure that non-objecting providers are reasonably accessible. Nurses' conscientious objections to participate directly in procedures they find religiously offensive should be accommodated, but nurses cannot object to giving patients indirect aid. Medical and nursing students cannot object to be educated about procedures in which they would not participate, but may object to having to perform them under supervision. Hospitals cannot usually claim an institutional conscientious objection, nor discriminate against potential staff applicants who would not object to participation in particular procedures.
The birth of 'Siamese' twins in August 2000 whose parents refused to consent to surgery for separation required English courts to decide whether the twins could lawfully be separated despite that refusal when one twin would certainly die as a direct surgical result. The Court of Appeal unanimously upheld the trial judge's decision to authorize surgery, taking account of principles of family law, criminal law and human rights law. Parental duties to the viable twin were found consistent with the justification of allowing, without intending, natural death of the non-viable twin. The right to human dignity of both twins supported the justification of separation surgery. The decision did not elevate physicians' choices over parents', but subjected both to the law. The hospital was found entitled to bring the case to court, but not obliged; it could have declined surgery in conformity with the parents' wishes.
Twinning has fascinated human beings over the centuries. New technologies and large study groups have led to improved documentation of frequency and complications in twin pregnancies and long-term outcomes. Artificial reproductive technologies have led to a pronounced rise in numbers of dizygotic and monozygotic twins. Although spontaneous dizygotic twinning is clearly associated with increased concentration of follicle-stimulating hormone and ovulation of more than one egg, causes of monozygotic twinning remain illusive. Twin studies are used increasingly to study complex traits and disorders: however, caution is suggested, since twins might not be representative of a typical singleton pregnancy. Monozygotic twinning seems to represent an anomaly in itself, with an increased number of spontaneous abortions and structural congenital anomalies. Both monozygotic and dizygotic twins have growth rates that slow at 30 weeks in utero and might be programmed both developmentally and biochemically earlier in pregnancy to have different responses at birth and after birth compared with singletons.
Assisted reproductive technologies (ARTs) aim to increase a woman's chances of becoming pregnant by bringing many female and male gametes into close proximity. Techniques to achieve this objective include ovarian hyperstimulation by maturation of several oocytes, intrauterine insemination (IUI) of concentrated sperm, or in-vitro fertilisation (IVF) by bringing gametes together outside the female body. The very nature of ovarian hyperstimulation--with or without IUI--enhances the risk of multiple pregnancy (eg, two or more babies). In most IVF cycles, more than one embryo is transferred, again resulting in an increased chance of multiple pregnancy. Developed societies have witnessed a large rise in prevalence of twin, triplet, and higher order multiple births, mainly resulting from ARTs. The primary aim of this Review is to increase awareness of the many implications of the present iatrogenic epidemic of multiple births. The background of ovarian hyperstimulation, trends supporting current practice, and strategies to reduce the chance of multiple pregnancy are highlighted.
Where legal systems allow therapeutic abortion to preserve women's mental health, practitioners often lack access to mental health professionals for making critical diagnoses or prognoses that pregnancy or childcare endangers patients' mental health. Practitioners themselves must then make clinical assessments of the impact on their patients of continued pregnancy or childcare. The law requires only that practitioners make assessments in good faith, and by credible criteria. Mental disorder includes psychological distress or mental suffering due to unwanted pregnancy and responsibility for childcare, or, for instance, anticipated serious fetal impairment. Account should be taken of factors that make patients vulnerable to distress, such as personal or family mental health history, factors that may precipitate mental distress, such as loss of personal relationships, and factors that may maintain distress, such as poor education and marginal social status. Some characteristics of patients may operate as both precipitating and maintaining factors, such as poverty and lack of social support.
In-vitro fertilisation has been done for nearly 30 years; in developed countries at least 1% of births are from assisted reproductive therapies (ART). These children now represent a substantial proportion of the population but little is known about their health. Some of the morbidity associated with ART does not result from the techniques but from the underlying health risks of being subfertile. Much of the amplified risk associated with ART is related to high birth order. However, risk of intrauterine and subsequent perinatal complications is enhanced after ART, and urogenital malformations can be present in boys, even in singleton infants. No increase in discord or other difficulties within families has been recorded. Long-term follow-up of children born after ART to reproductive age and beyond is necessary.
In the UK, about one in 200 infants is stillborn, and rates of stillbirth have recently slightly increased. This recent rise might reflect increasing frequency of some important maternal risk factors for stillbirth, including nulliparity, advanced age, and obesity. Most stillbirths are related to placental dysfunction, which in many women is evident from the first half of pregnancy and is associated with fetal growth restriction. There is no effective screening test that has clearly shown a reduction in stillbirth rates in the general population. However, assessments of novel screening methods have generally failed to distinguish between effective identification of high-risk women and successful intervention for such women. Future research into stillbirth will probably focus on understanding the pathophysiology of impaired placentation to establish screening tests for stillbirth, and assessment of interventions to prevent stillbirth in women who screen positive.
This paper is the first in a three-part series on preterm birth, which is the leading cause of perinatal morbidity and mortality in developed countries. Infants are born preterm at less than 37 weeks' gestational age after: (1) spontaneous labour with intact membranes, (2) preterm premature rupture of the membranes (PPROM), and (3) labour induction or caesarean delivery for maternal or fetal indications. The frequency of preterm births is about 12-13% in the USA and 5-9% in many other developed countries; however, the rate of preterm birth has increased in many locations, predominantly because of increasing indicated preterm births and preterm delivery of artificially conceived multiple pregnancies. Common reasons for indicated preterm births include pre-eclampsia or eclampsia, and intrauterine growth restriction. Births that follow spontaneous preterm labour and PPROM-together called spontaneous preterm births-are regarded as a syndrome resulting from multiple causes, including infection or inflammation, vascular disease, and uterine overdistension. Risk factors for spontaneous preterm births include a previous preterm birth, black race, periodontal disease, and low maternal body-mass index. A short cervical length and a raised cervical-vaginal fetal fibronectin concentration are the strongest predictors of spontaneous preterm birth.
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