Is mandatory elective single embryo transfer ethically justified

In-vitro fertilisation (IVF) is an effective form of fertility treatment that is acknowledged to be associated with a higher rate of obstetric complications and poorer neonatal outcomes compared to natural conception. While some of this increased obstetric risk is intrinsic to the infertile population being treated, the practice of multiple embryo transfer and resultant higher order pregnancy also plays a significant role. As a result, several jurisdictions (Sweden, Belgium, Turkey, and Quebec) have moved to legally mandate elective single embryo transfer (eSET) for young women, while other countries such as Australia and New Zealand have effectively mandated eSET by making it a professional industry standard. However, in the United States the ASRM guidelines merely suggest offering eSET to young favourable prognosis patients, and as a result double embryo transfer (DET) is still the norm, with eSET occurring in only 12.2% of cases. In this paper we outline the financial and social advantages of a flexible approach that allows for DET, while also mounting an argument that mandated eSET is an unethical breach of patient autonomy, with an unclear net benefit. Finally, we highlight the inconsistency of banning DET in young women, while still allowing the practice of ovulation induction and intra-uterine insemination-ovulation induction (IUI-OI), two widely used treatments that also pose a significant risk of multiple pregnancies and resultant poor obstetric outcomes.</p

Is mandatory elective single embryo transfer ethically justified

In-vitro fertilisation (IVF) is an effective form of fertility treatment that is acknowledged to be associated with a higher rate of obstetric complications and poorer neonatal outcomes compared to natural conception. While some of this increased obstetric risk is intrinsic to the infertile population being treated, the practice of multiple embryo transfer and resultant higher order pregnancy also plays a significant role. As a result, several jurisdictions (Sweden, Belgium, Turkey, and Quebec) have moved to legally mandate elective single embryo transfer (eSET) for young women, while other countries such as Australia and New Zealand have effectively mandated eSET by making it a professional industry standard. However, in the United States the ASRM guidelines merely suggest offering eSET to young favourable prognosis patients, and as a result double embryo transfer (DET) is still the norm, with eSET occurring in only 12.2% of cases. In this paper we outline the financial and social advantages of a flexible approach that allows for DET, while also mounting an argument that mandated eSET is an unethical breach of patient autonomy, with an unclear net benefit. Finally, we highlight the inconsistency of banning DET in young women, while still allowing the practice of ovulation induction and intra-uterine insemination-ovulation induction (IUI-OI), two widely used treatments that also pose a significant risk of multiple pregnancies and resultant poor obstetric outcomes.</p

Semen activates the female immune response during early pregnancy in mice

Insemination elicits inflammatory changes in female reproductive tissues, but whether this results in immunological priming to paternal antigens or influences pregnancy outcome is not clear. We have evaluated indices of lymphocyte activation in lymph nodes draining the uterus following allogeneic mating in mice and have investigated the significance of sperm and plasma constituents of semen in the response. At 4 days after mating, there was a 1.7-fold increase in the cellularity of the para-aortic lymph node (PALN) compared with virgin controls. PALN lymphocytes were principally T and B lymphocytes, with smaller populations of CD3(+) B220(lo), NK1.1(+) CD3(–) (NK) and NK1.1(+) CD3(+) (NKT) cells. CD69 expression indicative of activation was increased after mating and was most evident in CD3(+) and NK1.1(+) cells. Synthesis of cytokines including interleukin-2, interleukin-4 and interferon-γ was elevated in CD3(+) PALN cells after exposure to semen, as assessed by intracellular cytokine fluorescence-activated cell sorting, immunohistochemistry and quantitative reverse transcriptase polymerase chain reaction. Matings with vasectomized males indicated that the lymphocyte activation occurs independently of sperm. However, in contrast, males from which seminal vesicle glands were surgically removed failed to stimulate PALN cell proliferation or cytokine synthesis. Adoptive transfer experiments using radiolabelled lymphocytes from mated mice showed that lymphocytes activated at insemination home to embryo implantation sites in the uterus as well as other mucosal tissues and lymph nodes. These findings indicate that activation and expansion of female lymphocyte populations occurs after mating, and is triggered by constituents of seminal plasma derived from the seminal vesicle glands. Moreover, lymphocytes activated at insemination may help mediate maternal tolerance of the conceptus in the implantation site

Increased gonadotrophin stimulation does not improve IVF outcomes in patients with predicted poor ovarian reserve

The original publication can be found at www.springerlink.comPurpose This retrospective study was carried out to evaluate whether increasing the starting dose of FSH stimulation above the standard dose of 150 IU/day in patients with low predicted ovarian reserve can improve IVF outcomes. Method A total of 122 women aged less than 36 years in their first cycle of IVF were identified as having likely low ovarian reserve based on a serum AMH measurement below 14 pmol/l. Thirty five women were administered the standard dose of 150 IU/day FSH, while the remaining 87 received a higher starting dose (200–300 IU/day FSH). There were no significant differences in age, BMI, antral follicle count, serum AMH, FSH or aetiology of infertility between the two dose groups. Results No significant improvement in oocyte and embryo yield or pregnancy rates was observed following an upward adjustment of FSH starting dose. While increasing the dose of FSH above 150 IU/day did not produce any adverse events such as OHSS, it did consume an extra 1,100 IU of FSH per IVF cycle. Conclusion The upward FSH dose adjustment in anticipation of low ovarian reserve can not be advocated as it is both expensive and of no proven clinical value.Dharmawijaya N Lekamge, Michelle Lane, Robert B Gilchrist and Kelton P Tremelle