Assisted Reproductive Services Research Articles

Strategy for the creation of clinical grade hESC line banks that HLA‐match a target population

Here, we describe a pre-derivation embryo haplotyping strategy that we developed in order to maximize the efficiency and minimize the costs of establishing banks of clinical grade hESC lines in which human leukocyte antigen (HLA) haplotypes match a significant proportion of the population. Using whole genome amplification followed by medium resolution HLA typing using PCR amplification with sequence-specific primers (PCR-SSP), we have typed the parents, embryos and hESC lines from three families as well as our eight clinical grade hESC lines and shown that this technical approach is rapid, reliable and accurate. By employing this pre-derivation strategy where, based on HLA match, embryos are selected for a GMP route on day 3–4 of development, we would have drastically reduced our cGMP laboratory running costs.

Reproductive technology: the effects of context on attitudes

To examine the effect of contextual circumstances on attitudes towards reproductive technology. A multiple-segment factorial vignette was designed to explore the effects that contextual circumstances (i.e. sex of the individual seeking treatment, relationship status, age, source of gametes, and sexual orientation) have on attitudes toward the procurement of assisted reproductive technology services. A probability sample of ROUGHLY 400 Kentucky households was obtained using random-digit dialing that gave every household in the state of Kentucky an equal probability of being contacted. Descriptive statistics, three logistic regression models, three ordinal regression models, and over 1,000 open-ended rationales provided by participants for their closed-ended responses, will be summarized. Preliminary analyses indicate that procurement of assisted reproductive technology services was viewed as more appropriate when sought by older than younger individuals, by single women than couples and by couples than single men, and by lesbians than by gay males. Also, female respondents generally viewed the use of assisted reproductive technology as more acceptable than did male respondents. Attitudes toward reproductive technology vary according to context and it is important to understand the nuances of these differences and the reasons for them to inform medical decision making and policy development.

Blood and other substances: new reproductive technologies and adoption in popular groups in southern Brazil

Based on ethnographic research in a public hospital that offers assisted reproduction services and in low income communities in the city of Porto Alegre, in southern Brazil, this article focuses on cases in which the use of conceptive reproductive technologies for couples is related to the type of relationship established with public health services. The paper also discusses how the fact that people seek medical attention does not invalidate adoption as a way of establishing kinship ties. The aim is to question discourses about the spread of new reproductive technologies, which are generally based on vague definitions of what is called a desire for biological children. In addition, the article reflects on the specific nature of adoption among the working classes in the context of dissemination of such reproductive technologies.

News and social media: Windows into community perspectives on disinvestment

The aim of this study, in the context of disinvestment related health technology assessment, is to examine whether analysis of Web 2.0--commercial media output, blogs, and discussion forums--can provide an understanding of media framing, community perspectives, and the sociopolitical aspects of an entrenched technology. Thematic analysis of relevant data from fifty-nine media articles, thirty-nine discussion forums, thirteen blogs, and three Facebook pages relating to our case study: public funding for assisted reproductive technology services. Mainstream media and community-based social media responses were compared. Media responses were narrow, primarily describing emotive individual narratives or the political nexus of interests. Community (including patient) responses were broader including discussion of opportunity cost and vested interests but mostly reflected the polar ends of the debate, diverging strongly for or against disinvestment from public funding. Web2.0 and media analysis offers an inexpensive method to capture media portrayal, divergent community responses both to that portrayal and independent of it, and insight into the sociopolitical aspects of an entrenched technology undergoing disinvestment debate.

Assisted reproduction services provision in a developing country: time to act?

To conduct a survey in a developing country to gauge the extent of subfertility and the current state of assisted reproductive technology (ART) service provision and explore factors limiting access to ART services. Cross-sectional online survey. The study was co-ordinated at the Aga Khan University Hospital, Nairobi, Kenya. One hundred eighty-eight obstetricians and gynecologists registered with the Kenya Obstetrics and Gynecology Society were invited to complete the survey. None. None. A total of 47 responses (25%) were received after completion of the survey. The overall rate of subfertility was 26.1% among the gynecology consultations, with 50% attributed to tubal factors and 15% due to male factors. Assisted reproductive service provision (IVF/intracytoplasmic sperm injection) was severely limited to only three units, despite the reported high rate of tubal disease. The high cost of treatment, patients' limited finances, and limited local services were almost universally cited as the main barriers to ART services in Kenya. The demand for ART in developing countries is not in doubt. Simplified, less costly, and more accessible ART approaches need to be considered in developing countries, even though the benefits and outcomes of such approaches may not be apparent immediately.

Assisted reproduction on treacherous terrain: the legal hazards of cross-border reproductive travel

The growing phenomenon of cross-border reproductive travel has four significant legal dimensions. First, laws that ban or inhibit access to assisted reproductive procedures in one country lead patients and physicians to travel to other countries to acquire, to contribute to or to provide assisted reproductive services. Such laws may include provisions that criminalize those who assist or advise patients to undertake such travel. Second, the law may expressly criminalize crossing borders to obtain, to be a donor for or to perform certain procedures. Third, the law may interfere with the ultimate goal of reproductive travellers by refusing to recognize them as the parents of the child they have crossed borders to conceive. Finally, facilitating cross-border reproductive travel may expose physicians, attorneys and brokers to malpractice or other civil liability. This article explores these legal dimensions of cross-border reproductive care and uses the legal doctrines of proportionality, extraterritoriality and comity to assess the legality and normative validity of governmental efforts to curb or limit assisted reproductive practices. This article explores the four significant legal dimensions of the growing phenomenon of cross-border reproductive travel. It first discusses laws that ban or inhibit access to assisted reproductive procedures to show how restrictive laws in one country often lead patients and physicians to travel to other countries to acquire, to contribute to, or to provide assisted reproductive services. Such laws may include provisions that criminalize those who assist or advise patients to undertake such travel. The article then explores how the law, albeit rarely, may expressly criminalize crossing borders to obtain, to be a donor for, or to perform certain procedures. Turning to the third dimension of cross-border reproductive care, this article shows how the law may interfere with the ultimate goal of reproductive travellers when they meet with refusal by their country’s officials to recognize them as the parents of the child they have crossed borders to conceive. Finally, this article describes how cross-border reproductive travel may expose physicians, attorneys and brokers to malpractice or other civil liability. After discussing all four legal dimensions of cross-border reproductive care, this article analyses the legality and normative validity of governmental efforts to curb or limit assisted reproductive practices.

Urinary trichloroacetic acid levels and semen quality: A hospital-based cross-sectional study in Wuhan, China

Toxicological studies indicate an association between exposure to disinfection by-products (DBPs) and impaired male reproductive health in animals. However, epidemiological evidence in humans is still limited. We conducted a hospital-based cross-sectional study to investigate the effect of exposure to DBPs on semen quality in humans. Between May 2008 and July 2008, we recruited 418 male partners in sub-fertile couples seeking infertility medical instruction or assisted reproduction services from the Tongji Hospital in Wuhan, China. Major semen parameters analyzed included sperm concentration, motility, and morphology. Exposure to DBPs was estimated by their urinary creatinine-adjusted trichloroacetic (TCAA) concentrations that were measured with the gas chromatography/electron capture detection method. We used linear regression to assess the relationship between exposure to DBPs and semen quality. According to the World Health Organization criteria (<20 million/mL for sperm concentration and <50% motile for sperm motility) and threshold value recommended by Guzick (<9% for sperm morphology), there were 265 men with all parameters at or above the reference values, 33 men below the reference sperm concentration, 151 men below the reference sperm motility, and 6 men below the reference sperm morphology. The mean (median) urinary creatinine-adjusted TCAA concentration was 9.2 (5.1) μg/g creatinine. Linear regression analyses indicated no significant association of sperm concentration, sperm count, and sperm morphology with urinary TCAA levels. Compared with those in the lowest quartile of creatinine-adjusted urinary TCAA concentrations, subjects in the second and third quartiles had a decrease of 5.1% (95% CI: 0.6%, 9.7%) and 4.7% (95% CI: 0.2%, 9.2%) in percent motility, respectively. However, these associations were not significant after adjustment for age, abstinence time, and smoking status. The present study provides suggestive but inconclusive evidence of the relationship between decreased sperm motility and increased urinary TCAA levels. The effect of exposure to DBPs on human male reproductive health in Chinese populations still warrants further investigations.

Posters * Cross-Border Reproductive Care

Introduction:This paper provides an overview of reproductive medical travel in the Asia-Pacific region, and some of the significant anthropological considerations it raises. It aims to contribute to debates on the implications of reproductive travel for reproductive rights. I give a summary of reproductive travel in the region, focusing upon Thailand, India and South Korea, which have developed a sophisticated and profitable reproductive trade. While the services in these countries cater for their own populations, they also provide assisted reproductive services for wealthy patients from the region seeking services not available in their home countries, and for patients from other wealthy countries seeking to avoid the costs, waits, limitations or regulatory boundaries in their home countries. I explore the consequences through case studies and the policy and regulatory frameworks that exist to regulate this trade within the region.Methods:The paper is a qualitative review of issues raised by anthropological work on this issue in the Asian region combined with preliminary case studies conducted with 6 patients travelling for IVF services to a clinic in Thailand.Results:The growth of travel for reproductive medical services generates some important policy questions such as equity in access to services, protection of vulnerable populations and appropriate regulatory mechanisms versus reproductive autonomy. A comprehensive examination of the challenges raised by medical travel must include consideration of the socio-cultural and political impacts for those involved in the trade. Reproductive travel involves the intensification of stratification and commodification of the body and is riven with issues pertaining to race and class. Choices of clinic, ova and sperm donors and embryos carry considerations of race, ‘whiteness’, sex, class and eugenic potential determined by market forces. Countries in the Asia region struggle to meet the regulatory challenges the trade poses.Conclusions:A major obstacle to developing policies, monitoring and evaluation of cross-border reproductive care is the lack of reliable and comparable data on the extent and practice of reproductive travel. Although reliable quantitative data is urgently required, qualitative data (i.e., ethnographic accounts) also has a useful role to play, particularly in monitoring the actual practice of clinics and experiences of patients on the ground, and in understanding the effects of differences in cultural, religious and social norms and grounded bioethical decision-making. Copyright © 2011 European Society of Human Reproduction and Embryology

Reproductive Tourism in the Age of Globalization

Although reproduction involves deeply private choices among individuals, state actors have long intervened in shaping their citizens' procreative choices through regulations, incentives, technologies, and services. Reproductive tourism has emerged as a phenomenon in which people go abroad for assisted reproductive technology services, demonstrating the globalization of procreation and childbearing. While some people engage in reproductive tourism to access cheaper, more efficient, or a wider range of services, others do so to bypass regulations and laws in their home countries. This paper examines the tensions between national regulations and the global marketplace for assisted fertility services, paying attention to the patchwork of national policies regarding reproductive technologies in the face of multilateral trade agreements, regional confederations, technological development, the forces of global capital, and consumer desire. A pesar de que la reproducción implica profundas preferencias privadas entre los individuos, los actores estatales han intervenido desde hace tiempo en perfilar las preferencias procreativas de sus ciudadanos a través de normas, incentivos, tecnologías y servicios. El turismo de reproducción ha emergido como un fenómeno en el que la gente va al extranjero para recibir servicios de tecnología reproductiva, demostrando la globalización de la procreación y la maternidad. Mientras algunas personas emplean el turismo de reproducción para tener acceso a un rango de servicios más eficiente o más amplio, otras lo hacen para saltarse las normas y leyes en sus países de origen. Este artículo examina las tensiones entre los reglamentos nacionales y el mercado global para los servicios de ayuda a la fertilidad, prestando atención a la tela de retazos de las políticas nacionales referentes a las tecnologías reproductivas contra los acuerdos multilaterales de comercio, confederaciones regionales, desarrollo tecnológico, las fuerzas del capital global y el deseo del consumidor.

Direct health services costs of providing assisted reproduction services in older women

To assess the total health service costs incurred for each live birth achieved by older women undergoing IVF compared with costs in younger women. Retrospective cross-sectional analysis. In vitro fertilization unit and maternity hospital in a tertiary care setting. Women who underwent their first cycle of IVF between 1997 and 2006. Bottom-up costs were calculated for all interventions in the IVF cycle. Early pregnancy and antenatal care costs were obtained from National Health Service reference costs, Information Services Division Scotland, and local departmental costs. Cost per live birth. The mean cost per live birth (95% confidence interval [CI]) in women undergoing IVF at the age of > or =40 years was pound 40,320 (pound 27,105- pound 65,036), which is >2.5 times higher than those aged 35-39 years (pound 17,096 [pound 15,635- pound 18,937]). The cost per ongoing pregnancy was almost three times in women aged > or =40 (pound 31,642 [pound 21,241- pound 58,979]) compared with women 35-39 years of age (pound 11,300 [pound 10,006- pound 12,938]). The cost of a live birth after IVF rises significantly at the age of 40 years owing to lower success rates. Most of the extra cost is due to the low success of IVF treatment, but some of it is due to higher rates of early pregnancy loss.

Seguimiento del neurodesarrollo de niños nacidos por técnicas de reproducción asistida

In recent years a number of publications have reported a higher incidence of congenital defects or chromosome abnormalities linked to conventional in vitro fertilisation (IVF), and some other publications have suggested that intracytoplasmic sperm injection (ICSI) may have a negative influence on neurodevelopment. AIM. To determine whether there were any differences in the medical development and the neurodevelopment of children conceived using conventional IVF techniques and those conceived using ICSI techniques. Our sample consisted of 17 babies born after IVF (nine males and eight females) and 40 infants born after ICSI (23 males and 17 females). All of them were the result of pregnancies induced by IVF and ICSI achieved in the assisted reproduction service at our hospital and followed up by the same team of obstetricians and specialists in maternal-foetal medicine. At the chronological age of 24 months all the patients were submitted to a paediatric examination and a neuropsychological examination. The examination was performed in one single session. Neurodevelopment was evaluated specifically by means of the Bayley scales of infant development. The health and neurodevelopment of infants from conventional IVF and from ICSI in our study were similar to those of the general population at the age of two years. ICSI proved to be as safe as conventional IVF as regards the children's medical and cognitive progression.

The direct health services costs of providing assisted reproduction services in overweight or obese women: a retrospective cross-sectional analysis

Prevalence of overweight and obesity is rising. Hence, it is likely that a higher proportion of women undergoing assisted reproduction treatment are overweight or obese. In a retrospective cross-sectional analysis using routinely collected data of an IVF Unit and maternity hospital in a tertiary care setting in the UK, direct costs were assessed for all weight classes. Costs for underweight, overweight and obese were compared with those for women with normal body mass index (BMI). Of 1756 women, who underwent their first cycle of IVF between 1997 and 2006, 43 (2.4%) were underweight; 988 (56.3%) had normal BMI; 491 (28.0%) were overweight; 148 (8.4%) were obese (class I) and 86 (4.9%) were obese (class II). The mean (95% CI) cost of each live birth resulting from IVF was pound 18,747 (13 864-27 361) in underweight group; pound 16,497 (15 374-17 817) in women with normal BMI; pound 18,575 (16,648-21,081) in overweight women; pound 18,805 (15 397-23 554) in obese class I; pound 20,282 (15 288-28 424) in obese class II or over. The cost of a live birth resulting from IVF is not different in underweight, overweight and obese class I when compared with women with normal BMI. However, due to increased obstetric complications weight loss should still be recommended prior to commencing IVF even in overweight or obese (class I) women.

Australian sperm donors: Public image and private motives of gay, bisexual and heterosexual donors

This paper contributes to debate in Australia about sexuality-based restrictions on access to Assisted Reproduction Services, particularly sperm donation by gay and bisexual men. It utilises content analysis of print-media and reveals that the public image of sperm donation is saturated with concern about risk, particularly risk to heterosexual donors and their property, from claims made by recipient women and their children. In contrast, a detailed analysis of the profiles of men who register to donate sperm through the Australian Sperm Donor Registry reveals that most donors are open to identity disclosure. However a marked difference is evident between heterosexual and gay/bisexual donors with the latter being significantly more likely to desire contact with children born of their donations. It appears sperm donation offers gay and bi/sexual men an opportunity for family formation and parenting which is denied by Australian laws and clinical practices that exclude them from Assisted Reproduction Services and adoption.

Affordable ART services in Africa: synthesis and adaptation of laboratory services

The aim of this paper is to provide information, opinions and suggestions on affordable laboratory-orientated fertility screening and treatment. Resource management to provide such services in developing countries, basic and advanced assisted reproductive services and assisted reproduction treatment (ART) of patients with sexually transmitted infections are addressed. Alternative viewpoints and parallel thinking should be encouraged to synthesize and adapt first-world ART guidelines and recommendations into safe and workable directives for developing regions. Affordable African ART programmes, devoid of commercialism, can provide essential sexual health screening services en route to safe fertility services for human immunodeficiency virus type-1 (HIV-1) serodiscordant couples (male HIV-positive), who wish to have their own biological child.

Economics may not explain Hispanic underutilization of assisted reproductive technology services

In a lower cost, equal-access-to-care setting, Hispanic use of assisted reproductive technology was less than half of what would have been expected based on patient demographics. Despite this use disparity, there were no significant differences between Hispanic and Caucasian women with regard to infertility diagnoses, assisted reproductive technology cycle parameters, clinical pregnancy rates, live birth rates, spontaneous abortion rates, and implantation rates.

What‘s new in the other journals?

What‘s new in the other journals?

Lesbian and bisexual women’s recommendations for improving the provision of assisted reproductive technology services

Qualitative focus groups were conducted with lesbian and bisexual women who were themselves or whose partners were in the process of trying to conceive (n = 6); who were biological parents of young children (n = 7); and who were nonbiological parents of young children or whose partners were currently pregnant (n = 10) to explore their donor insemination service needs and to provide recommendations for improved or additional services. The 10 recommendations generated by participants included providing cues that the service is lesbian and bisexual positive; offering lesbian- and bisexual-specific infertility support; providing opportunities for women to make informed choices about use of interventions consistent with their known or presumed fertility; and offering accessible services to known sperm donors, including gay men.

The science of disinfection in ARTS (assisted reproductive technology services)

ISSUE: Vaginal probes are used in our assisted reproductive technology services (ARTS) during transvaginal sonagraphy. Disposable single-use condom probe covers are used to cover the transvaginal ultrasound transducer head to reduce transmission of bloodborne pathogens. After each use, the probe requires cleaning and high-level disinfection to avoid pathogenic spread from one patient to another. The use of disinfectant wipes and alcohol pads are not adequate to provide high-level disinfection. Because of concerns regarding the potentially harmful effects of the disinfectant used on developing embryos, we began a search for a safer high-level disinfectant. PROJECT: The infection control staff worked closely with the ARTS staff and the probe manufacturer to review available disinfectant products to ensure high-level disinfection for transvaginal probes that was safe for embryos. RESULTS: We found a disinfectant that provided adequate high-level disinfection and was embryo safe for use in ARTS. LESSONS LEARNED: Using a multidisciplinary team approach, close scrutiny, and meticulous examination of our current disinfection process revealed opportunities to improve embryo safety in our choice of disinfectant. We identified a disinfectant that provided embryo-safe high-level disinfection. Working with the probe manufacturer, we received their written permission to use the selected disinfectant on the probe. This was necessary because the disinfectant chosen was not on the list of disinfectants approved for use by the manufacturer for high-level probe disinfection. The use of a disinfectant that has not been approved by the probe manufacturer can void the probe warranty. The identified improvements also included updating policies and procedures, designing a staff competency checklist, and creating quality-control forms for recording the testing of new boxes of test vials and for solution use. We improved our high-level disinfection of transvaginal probes using an embryo safe high-level disinfectant that was approved for use by the probe manufacturer and improved patient safety and quality of care.

Influence of multiple transrectal electroejaculations on semen parameters and intracytoplasmic sperm injection outcome

Objective To compare semen parameters and intracytoplasmic sperm injection (ICSI) outcome in spinal cord–injured subjects who underwent single (group 1) or multiple (group 2) electroejaculations before ICSI. Design Prospective, randomized, controlled study. Setting Department of gynecology, obstetrics, and pediatric science in a reproductive medicine unit at a major Italian university. Patient(s) Thirty-four healthy women with a male partner with SCI who were seeking assisted reproduction services. Intervention(s) Transrectal electroejaculation, controlled ovarian hyperstimulation, and ICSI. Main outcome measure(s) Sperm concentration, morphology, and motility and fertilization and pregnancy rates after ICSI. Result(s) Sperm was successfully retrieved in 94.1% of cases. In male subjects who underwent multiple electroejaculations, statistically significant improvements in sperm concentration and total sperm motility rate were observed. The overall fertilization rate was 63.6%. The number of oocytes retrieved and injected was comparable between the two groups. A total of nine clinical pregnancies were achieved. The pregnancy rate was statistically significantly higher in group 2 (n = 6/16; 37.5%) than in group 1 (n = 3/16; 18.75%). Conclusion(s) These data suggest that multiple electroejaculation has a positive effect on semen parameters and ICSI outcome.

High order multiple gestation rates with IVF: effects of competition among fertility centers

Background: The use of assisted reproductive technology services is associated with an increased risk of multi-fetal pregnancy with attendant adverse fetal outcomes, maternal complications, and associated health care costs. We hypothesized that demand for services and competition among fertility centers would impact practice and, as a consequence, pregnancy rates and high order multiple (HOM) gestation rates.