Iranian Bar Associations

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* Having Children by Natural and Artificial Means
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* Having Children by Natural and Artificial Means

McCormick Place
2301 S Lake Shore Dr
Chicago, IL 60616
September 17, 2006

International Bar Association Chicago, 2006

Program Papers

Basic Reproductive Biology for Lawyers
Anne Borkowski, MD

Introduction
Human reproduction has always been the object of intense interest. However,
understanding the exciting, new developments in this field requires a basic knowledge of female and male reproductive anatomy and physiology. The female’s reproductive system is located entirely within the pelvis and consists of the vagina, uterus, fallopian tubes and ovaries. The male reproductive system is made of organs located both inside and outside of the pelvis. These are the testicles, the duct system (epididymis and vas deferens), the accessory glands (seminal vesicle and prostate gland), and the penis. Men make millions of sperm cells every day while women are born with their entire complement of eggs, approximately one million. During the reproductive years one egg is ovulated each month. If a woman has intercourse around the time of ovulation, one sperm cell out of millions of sperm that are deposited into the vagina, may fertilize the egg within the fallopian tube. The result is a single-celled organism called a zygote.

The zygote multiplies thousands of times to become a multi-cellular organism called a
blastocyst. The blastocyst burrows itself into the uterine lining and develops into an embryo, the size of an adult thumb. From nine weeks onward the embryo is called a fetus. The fetus continues to grow for the next 31 weeks, until the time of delivery.
Discussion Human reproduction, forever an object of intense interest, has recently become the darling of the media. It is the topic of countless newspaper articles, magazine editorials and television talk shows. With each new medical advancement in fertility the hype intensifies.

From preschool into college we are inundated with information, some fact, some fiction, on menstruation, conception, contraception and menopause. Grasping all of it may seem
impossible. However, a reasonable understanding of the basics of reproductive biology can ease the undertaking.

First let’s review female anatomy. Unlike the male, the female’s reproductive system is
located entirely within her pelvis. The vulva, or “covering” in Latin, is the eternal portion of this system. The female’s internal organs consist of the vagina, the uterus, two fallopian tubes, and two ovaries. The vagina is a hollow tube made of muscular tissue. It measures approximately three to five inches long in the adult woman and extends from the vaginal opening to the uterus.

The vagina connects the uterus at the cervix which is the bottom portion of the uterus. The cervix contains a very small opening into the uterus. The uterus is the shape of an upside-down pear, with thick, muscular walls. In the non-pregnant state the uterus measures approximately three inches long and two inches wide. It enlarges greatly during pregnancy. The fallopian tubes protrude from the upper outer corners of the uterus. They are about four to five inches in length and approximately as wide as a piece of spaghetti.

The hollow opening within each tube is no wider than a sewing needle. The distal end of the fallopian tube is fringed and is called the fimbria. The fimbriae are finger-like projections that wrap around the ovary to pick up an egg at the time of ovulation. The ovaries are two walnut-sized organs that lie on either side of the uterus. They produce, store and release eggs into the fallopian tubes. They also produce sex hormones such as estrogen and progesterone.

Unlike the female, the male has reproductive organs located both inside and outside of
the pelvis. These are the testicles, the duct system (epididymis and vas deferens), the accessory glands (seminal vesicle and prostate gland), and the penis. The adult testicles are oval in shape, measuring about two inches in length and one inch in diameter. They produce and store millions of sperm cells. Once a boy reaches puberty he will produce millions of new sperm cells each day. A mature sperm looks like a tadpole with a head containing genetic material and a tail designed for movement. Each sperm is microscopic in size, measuring only 1/600th of an inch.

The testicles also produce hormones such as testosterone. Alongside the testicles is the
epididymis which is a set of coiled tubes that store and nourish the sperm. The sperm use their tails to travel through the epididymis, a journey that takes approximately four to six weeks. The epididymis connects to a muscular tube called the vas deferens that transports sperm to the seminal vesicles where they are mixed with fluid and stored. With ejaculation, semen is released from the seminal vesicle and travels through the urethra inside of the penis. The base of the urethra is surrounded by the prostate gland which also adds nourishing fluid to the semen on its way out of the body. Each ejaculate contains up to 500 million sperm cells!

A girl is born with 1 to 2 million eggs in her ovaries. Some of these remain inactive, but
many others die during the first decade of life. By the time she reaches puberty about 300,000 eggs are left. At puberty, the pituitary gland, located within the brain, starts making hormones.

These hormones stimulate the ovaries to produce female sex hormones including estrogen. Estrogen causes secondary sexual characteristics, such as breasts and public hair, to develop.

During the reproductive years, one egg a month matures and is released, a process called
ovulation. Meanwhile, hundreds of immature eggs atrophy and die. The ovulated egg is picked up by one of the fallopian tubes. If the egg is not fertilized by the sperm the uterine lining is shed approximately two weeks later, a process called menstruation.
If the female has intercourse within several days of ovulation, fertilization can occur.
Between 75 and 900 million sperm are deposited into the vagina when the male ejaculates.

These sperm swim through the cervix and uterus and encounter the egg in the fallopian tube. Only one sperm of the millions that are available may fertilize the egg.
Once the egg is fertilized the single-celled organism is called a zygote. The zygote
travels through the fallopian tube for approximately three to four days then drops into the uterus, all the time dividing into a multi-cellular organism. About five days after fertilization the zygote becomes a blastocyst, a hollow ball of cells with fluid-filled cavity inside. The blastocyst burrows itself into the lining of the uterus called the endometrium. The process is known as implantation. As the blastocyst continues to grow, the inner cells form a flattened circular shape which eventually develops into a baby. The outer cells will become the thin membranes surrounding the baby. All the cells multiply thousands of times while moving to new positions.

This mass of cells eventually becomes what is called an embryo. At eight weeks the embryo is about the size of an adult thumb and is fully formed. From nine weeks onward the embryo is called a fetus. The fetus spends the next 31 weeks growing into a baby with an average weight of seven pounds, two ounces at delivery.

References American Society for Reproductive Medicine, Age and Fertility: A Guide for Patients, 2003.
Nelsson, Lennart, A Child is Born. Dell Publishing, 1993.

Infertility: Prevalence, Work-up and Basic Treatment Options
Susan Davies, MD

Introduction
Infertility is a disease which knows no discrimination; it affects females and males, the
rich and the poor, all religious groups and all cultures. Infertility is estimated to affect up to 168 million people world wide. Another way to think about this fact is that 10-15% of couples are touched by this disease.

Infertility is clinically defined as 1 year of unprotected intercourse without conception. If
a female partner is over the age of 35, the time interval can be decreased to 6 months. A fertile couple has a 20-25% chance of achieving conception each month. If conception has not occurred within 1 year, the probability of conception drops to 3% or less per month. Infertility has many contributing factors: greater interest in advanced education and career goals among women, later marriage and more frequent divorce, improvements in contraception and access to family planning services, delayed child bearing, and decreased family size. Fortunately now days, it is much more socially acceptable to discuss infertility and its consequences.

The causes of infertility are many. It is estimated that tubal and pelvic pathology
contribute up to 35% of all cases, male factors 35%, ovulatory dysfunction 15%, unexplained infertility 10% and unusual problems 5%. The evaluation of an infertile couple is not as varied.

The female partner undergoes a history and physical exam, hormonal blood work to asses her fertility potential on cycle day 2 or 3, and a hysterosalpingogram or hysterosonogram to evaluate her uterine anatomy and the patency of the fallopian tubes. The male partner is worked up with a history and a semen analysis. If abnormalities exist, the male partner is usually referred to an urologist.

After completion of the diagnostic work-up, specific problems are addressed. If no
abnormalities exist, treatment can be started to enhance a couple’s fertility potential. Several treatment options exist including ovulation induction with either clomiphene citrate or gonadotropins combined with intrauterine insemination or gonadotropin therapy combined with in vitro fertilization (IVF).

Since the birth of Louise Brown in 1978 via IVF, there have been over 1 million babies
born as a result of assisted reproductive technologies (ART). Medical treatment of infertility has dramatically advanced over the past decade and the best is yet to come. The great advances in fertility treatments have helped to successfully obtain many couples’ goal of achieving or expanding their families.

Discussion
Infertility is a disease which knows no discrimination; it affects females and males, the
rich and the poor, all religious groups and all cultures. Infertility is estimated to affect up to 168 million people world wide. Another way to think about this fact is that 10-15% of couples are touched by this disease.

Infertility is clinically defined as 1 year of unprotected intercourse without conception. If
a female partner is over the age of 35, the time interval can be decreased to 6 months. A fertile couple has a 20-25% chance of achieving conception each month. If conception has not occurred within one year, the probability of conception drops to 3% or less per month. Infertility has many contributing factors: greater interest in advanced education and career goals among women, later marriage and more frequent divorce, improvements in contraception and access to family planning services, delayed childbearing, and decreased family size. Fortunately now days, it is much more socially acceptable to discuss infertility and it consequences.

The causes of infertility are many. It is estimated that tubal and pelvic pathology
contribute up to 35% of all cases, male factors 35%, ovulatory dysfunction 15%, unexplained infertility 10% and unusual problems 5%. The evaluation of an infertile couple is not varied.

The female partner undergoes a history and physical exam, hormonal blood work to asses her fertility potential on cycle day 2 or 3, and a hysterosalpingogram or hysterosonogram to evaluate her uterine anatomy and the patency of the fallopian tubes. The male partner is worked up with a history and a semen analysis. If abnormalities exist, the male partner is usually referred to an urologist.

It is estimated that when a female is born, she has roughly 2 million oocytes or eggs in
her ovaries. Out of these 2 million eggs, she will only ovulate 500 during her reproductive lifespan. A day 3 Follicle Stimulating Hormone (FSH) level is used to assess a woman’s fertility potential and thus, indirectly, the quality of her remaining eggs. If a day 3 FSH level is low (below 10 mIU/mL), it can be assumed that a woman’s fertility potential is very good. If the day 3 FSH level is elevated (above 20 mIU/mL), it indicates that her fertility potential is decreased.

It should be noted that FSH levels can vary from cycle to cycle, especially above the age of 35.

An Estradiol (E2) level is also drawn on cycle day 3, as this hormone has feedback control on FSH levels. Thyroid Stimulating Hormone (TSH) and Prolactin levels are also assessed, as these hormones can be associated with cycle irregularity and potentially pregnancy losses.

A hysterosalpingogram (HSG) or hysterosonogram (HSN) can be performed usually
between cycle days 6 through 12. These studies are used to assess uterine anatomy (size and shape) and tubal patency. Congenital anomalies such as unicornuate, septate, bicornuate, and didelphys can be identified along with acquired abnormalities such as submucosal myomas intrauterine adhesions, and endometrial polyps.

A semen analysis is used to assess male fertility potential. A semen analysis should be
collected after a 2 to 3 days period of abstinence. Normal parameters of a semen analysis in clued a volume of 1.5 to 5.0 mL, sperm concentration >20 million/mL, percent motility >50%, and normal morphology >14% by Strict criteria. If a semen analysis is abnormal, it is recommended that the analysis be repeated at a 1 month interval. If still abnormal, a urology consult should be considered.

After completion of the diagnostic work-up, specific problems are addressed. If no
abnormalities exist, treatment can be started to enhance a couple’s fertility potential. Several treatment options exist, including ovulation induction with either clomiphene citrate or gonadotropins combined with intrauterine insemination or gonadotropin therapy combined with in vitro fertilization (IVF).

Clomiphene citrate (Clomid®) is an orally active nonsteroidal agent. It is clinically
indicated for absent or infrequent ovulation and best utilized in women who are under the age of 35. Eighty percent of properly selected patients will ovulate and 40% typically become pregnant. Pregnancy usually occurs within 3 ovulatory cycles. There is a 5% chance of multiples with Clomid® administration (usually twins). Clomid® is also the only currently recognized fertility medication which has been associated with ovarian cancer if utilized long term (longer than 12 months). Clomid® is typically prescribed at 50mg, 100mg or 150 mg per day for 5 days. Once an ovulatory dose is achieved, the dose of Clomid® is maintained for up to 3 cycles. If pregnancy does not occur within 3 ovulatory cycles, more aggressive treatment is pursued. Typical side effects of Clomid® include hot flashes and vaginal dryness.

If Clomid® is not successful in achieving pregnancy or if a female partner is older than 35
years of age, gonadotropin therapy is attempted. Both human and recombinant menopausal gonadotropin therapies are purified preparations of gonadotropins. The injections are administered daily during the follicular phase of the cycle to override the body’s stimulus to make a single oocyte each month.

With multiple oocytes in the system, there is a greater likelihood of achieving pregnancy. Both Clomid® and gonadotropin cycles are typically combined with intrauterine insemination (IUI). The injections can be administered either subcutaneously or intramuscularly and more intense monitoring via ultrasound is needed to follow follicular development. On average, 90% of women ovulate on gonadotropin therapy and cumulative pregnancy rates range between 30 and 60% in Clomid® resistant patients. Typically there is a 25% chance of a multiple pregnancy and a 1% incidence of ovarian hyperstimulation syndrome (OHSS). OHSS is exemplified by massive ovarian enlargement, progressive weight gain, severe abdominal pain, intractable nausea and vomiting, gross ascites, and oliguria in its severe form.

In vitro fertilization (IVF) represents the most aggressive form of fertility treatment using
one’s own gametes. “In vitro” means “outside of the body” and this where fertilization is
occurring using this technology. IVF utilizes gonadotropin therapy to obtain multiple oocytes.

The oocytes are extracted from the ovary under ultrasound guidance with sedation after a proper stimulation protocol. The oocytes are fertilized either by insemination or intracytoplasmic sperm injection (ICSI) on the day that they are retrieved. The embryos are allowed to grow in culture in the IVF laboratory and are transferred into the female partner’s uterus 3 or 5 days later.

Typically multiple embryos are transferred into the uterus via a transcervical approach. With IVF, pregnancy rates vary largely dependent on maternal age (and thus oocyte quality) and embryo quality. Again with IVF there is a 25% chance of a multiple pregnancy (however, the likelihood of higher order multiples is usually reduced as fewer embryos are transferred into the uterus) and a 1% chance of severe OHSS. Extra embryos which are not transferred and are of good quality can be cryopreserved for future use. Technology also exists to test embryos to check for chromosomal competence (Preimplantation Genetic Diagnosis or PGD).

Since the birth of Louise Brown in 1978 via IVF, there have been over 1 million babies
born as a result of assisted reproductive technologies (ART). Medical treatment of infertility has dramatically advanced over the past decade and the best is yet to come. The great advances in fertility treatments have helped to successfully obtain many couples’ goal of achieving or expanding their families.

Reference:
Speroff, Leon and Fritz, Marc A., Clinical Gynecologic Endocrinology and Infertility.
Lippencott Williams and Wilkins, 2005.

State-of-the-Art – Assisted Reproductive Technology 2006
Charles Miller, MD
In the mid 1980’s an expose in a Chicago newspaper revealed the true ability to deliver a
child via in-vitro fertilization. Every clinic reported rates less than 4%. Now, less than 20 years later, delivery rates in the Chicagoland area are far greater. According to the Society of Assisted Reproductive Technology (SART) statistics in 2003, delivery rates for Miller & Associates were 52.4% in women < 35 years of age; 52% in women 35-37 years of age; 28% in women 38-40 years of age and 25% in women older than 40. In addition, we are now able to routinely treat males with severe sperm concerns via intracytoplasmic sperm injection, where unlike conventional IVF, individual sperm are placed directly into the eggs.

Other common programs involve donor eggs for women with decreased ovarian reserve
or gestational carrier for women whose uterus will not support pregnancy. In 2003 (the latest year of reporting) pregnancy rates for egg donation at Miller and Associates was 66% with a delivery rate of 52%.

Couples who have genetic concerns such as Tay-Sachs disease, Sickle Cell disease,
muscular dystrophy, etc. can have their embryos screened for abnormalities using Preimplantation Genetic Diagnosis (PGD). This technique can also be utilized in couples
experiencing habitual miscarriage or in women in their later reproductive years where risk of genetic-related miscarriage and birth defects are high.

Cryopreservation of the embryos now routinely enables couples to achieve successful
pregnancy when a previous fresh cycle has resulted in pregnancy and delivery or has failed. In 2003, Miller and Associates reported over a 60% delivery rate with thawed embryos in women less than 35 years of age.

The latest technique gaining attention in assisted reproductive technology is egg
cryopreservation. Success in this area ultimately would be of great importance for women
interested in delaying child bearing or women receiving treatment for malignant processes where subsequent ovarian function may be impaired. Unfortunately, egg freezing has not proven to be uniformly successful. In fact, the American Society of Reproductive Medicine has recommended this be performed only as part of an investigative protocol.

PGD - Preimplantation Genetic Diagnosis: One small step for man
Randy Morris
PGD or preimplantation genetic diagnosis is sometimes also referred to as
preimplantation testing. This is probably a more accurate description since we do many other types of testing besides genetic testing.

PGD is made possible through the use of IVF (in vitro fertilization). In short, a woman is
first given fertility drugs to stimulate the development of multiple eggs in her ovaries.

She is monitored during this time with blood tests and ultrasounds. At the appropriate time, the eggs are removed in a process known as an (oocyte) egg retrieval. Once the eggs are removed, they are inspected under the microscope to determine which eggs are mature and normal appearing. Each of these eggs will then have a single sperm injected into them. This process is called ICSI (intracytoplasmic sperm injection).

The day after the ICSI is performed; the injected eggs are inspected under the microscope
to determine which have fertilized. We look for two features: two pronuclei and two polar bodies. The polar bodies contain chromosomes that the egg got rid of. At this time we can perform a polar body biopsy. The fertilized eggs are then placed back into the incubator and allowed to develop. Two days later, the embryos are removed and inspected. We hope to see embryos have reached the 8 cell stage. These cells are called blastomeres. Each one contains identical chromosomal information. The next phase of the preimplantation genetic diagnosis process is called a blastomere biopsy.

During this time, the cells that were removed from the developing embryo and
specifically the genetic material inside of the cells can be tested for various abnormalities or characteristics. This information can be used to select which embryos to place into the uterus.

The most common type of preimplantation testing we do is to look at the number of each
type of chromosome present. This is called aneuploidy testing. Any couple that is having in vitro fertilization is a potential candidate for aneuploidy testing. In all women, some percentages of the embryos are going to be abnormal. We can improve the chance for pregnancy and reduce the risk for miscarriage with this type of preimplantation testing.
A small percentage of couples who have a problem with recurrent miscarriage may
themselves have a chromosome abnormality known as a translocation. This is a structural
abnormality that occurs between two chromosomes. Preimplantation testing can also be used to identify embryos with translocations.

There are other types of problems that can be detected in embryos also. We can perform
true preimplantation genetic diagnosis. That is, identify embryos with certain genes or genetic mutations.

One of the more controversial procedures we have performed is testing embryos to
determine whether they are tissue matched to siblings that may be suffering from diseases that could be cured with a bone marrow or stem cell transplant. Another controversial procedure is testing embryos to determine their gender so that a couple can have a child of a particular sex.

This is known as gender selection.

Frequently Asked Questions About PGD
Q) Does performing an embryo biopsy for PGD damage an embryo?
A) No. We have now studied thousands of embryos. Compared to IVF without PGD, embryos that have a polar body biopsy or embryo biopsy develop in a similar way. For example, when we compare the percentage of eggs that achieve normal fertilization, the PGD embryos which had a polar body biopsy had a normal fertilization rate of 78%. The eggs that did not have a PGD biopsy had a normal fertilization rate of 76%. Cleavage rate is a measure of the percentage of fertilized eggs that go on to start dividing. PGD embryos have a cleavage rate of 96%, compared to embryos without PGD which divide 95% of the time. A very important quality measure is how often a fertilized egg will become a blastocyst. PGD embryos will develop into blastocysts about 40% of the time.

Non-PGD embryos become blastocysts slightly more often at 47%, a difference that is not statistically different. Rarely, an embryo can be damaged by the biopsy procedure itself. If this occurs, it can be identified right away by viewing it under a microscope.

Q) I'm under age 35, so my embryos won't have chromosome abnormalities, right?
A) Wrong. We have studied women of different age groups and have found that even younger women have abnormal embryos. We recently looked at women under age 35 and performed PGD for 5 chromosomes. We looked at chromosomes 13, 16, 18, 21 and 22. Abnormalities in the number of copies of these five chromosomes account for the majority of chromosome abnormalities found in embryos. We could identify that in women under 35, 40% of the embryos tested were abnormal for one of these five chromosomes. This does not mean that all women will have 40% of their embryos abnormal. Some might have a higher abnormality rate and some lower. Overall, it averages out to 40% at that age. We have seen some younger women with recurrent IVF failure have abnormality rates over 90%.

Q) What are the chances that an abnormal embryo is going to be missed by PGD?
A) Remember that an embryo can have many different types of abnormalities. Preimplantation genetic diagnosis is only going to test for a specific type of abnormality. For instance, testing to determine if an embryo will produce a baby with Down's syndrome (caused by three copies of chromosome 21) will not rule out the possibility that the embryo also has a gene mutation that would cause the baby to have cystic fibrosis.

Furthermore, when we do chromosome testing, we can only look at a maximum of nine
chromosomes. Since an embryo has 23 pairs of chromosomes, it means that we won't be testing the remaining 14. We choose the nine that we do test very carefully, however. We believe that we can identify about 85-90% of the numeric chromosome abnormalities by testing the nine. In other words, we expect to miss a chromosome abnormality about 10-15% of the time.

Q) What are the chances that an embryo will be diagnosed as abnormal when it is really ok?
A) When an embryo starts dividing, each of the daughter cells is supposed to be identical to the parent cell. Sometimes, however, the embryo can make a mistake. One cell from an eight cell embryo may be slightly different than the remaining seven cells. This is called mosaicism. Mosaicism can affect the results of PGD when blastomere biopsy is performed.

Remember, during a blastomere biopsy, one cell in an eight cell embryo is removed and
tested. It is assumed that this cell is going to be representative of the entire embryo. If it is not, then a misdiagnosis can result. For this reason, PGD for chromosome abnormalities should always be performed using both polar body biopsy and blastomere biopsy. This will reduce the chances of an error due to mosaicism.

Q) Will PGD increase my chances of having a baby?
A) In many cases, the answer is yes. Preimplantation genetic diagnosis has been shown in our studies and in studies from other medical groups to increase the chance for pregnancy and reduce the risk of miscarriage in women who are 37 or older. Ordinarily, older women have a lower pregnancy rate and a higher miscarriage rate. This is true even when performing fertility treatments such as IVF. With each year, the pregnancy rate declines and miscarriage rate rises.

Both problems are primarily due to the higher rate of abnormal embryos that occur in older women. By finding and placing the normal embryos into the uterus, the chances are better that a delivery will occur.

It is possible that younger women may also benefit from PGD but since they have a lower
percentage of abnormal embryos, the benefit is likely to be smaller. Therefore, a much larger number of women need to be studied in order to statistically prove an effect.

This also does not mean that every older women will benefit. In many cases, older women
are found to have all of their embryos abnormal and therefore they do not have an embryo transfer and thus no opportunity for pregnancy on that particular IVF cycle.

Q) Is it likely that my insurance will cover the cost of PGD?
A) It is very unlikely that PGD will be covered by your insurance. Most insurance companies still consider PGD to be experimental even though we have been doing PGD for more than ten years. Don't look for this to change any time soon. Although we have a law in Illinois which requires most employers to cover infertility, it took a great deal of effort to get that law passed.

Even then, it was passed with some major loopholes that allow some employers to deny coverage to infertile couples.

PGD is a much more controversial technology than IVF. It can be used for things such
as gender selection and selection of embryos for tissue typing. Many people do not believe that these technologies should be allowed. Because of this, there are not likely to be politicians that are going to be willing to back a measure that will require employers to cover PGD.

Family Building Through Egg and Sperm Donation
Nancy Block
Help make a dream come True...
The greatest gift one can offer another is the gift of life. Egg donation provides infertile couples an opportunity they would not otherwise have.

Facts About Egg Donation...
Egg donation is the process of taking healthy eggs from a fertile woman and using them
to help another woman conceive, who is infertile. Taking eggs from a donor is possible because young, fertile women produce dozens of eggs every month that are never used.

To the best of medical knowledge, these eggs can be safely donated without affecting the woman's ability to conceive in the future.

Each physician has his/her own protocol, but to produce 15-20 eggs at a retrieval, the
donor is put on medications to stimulate her ovaries to produce many eggs. These medications need to be taken as instructed and donors must attend every scheduled medical appointment. The success of the cycle depends on this. The egg retrieval is an out-patient procedure.

Donors Wanted ...
Women wishing to become egg donors must be between the ages of 20 and 30. Interested
women must:

• Be physically and emotionally healthy.
• Have no history of infertility or endometriosis.
• Have both ovaries.
• Be drug free and a non-smoker.
• Be single or in a stable relationship.

In addition to the above requirements, eligible donors must complete an application
providing personal information on her health history, education, and personality as well as information regarding her family. We also request that each donor supply 7-12 different color photographs of herself to help in the selection by our egg recipients. No identifying information is released and remains strictly confidential.
Once a donor is matched with a recipient, meetings will be arranged with a genetic counselor and a licensed psychologist or licensed social worker and an attorney. These fees are covered by the intended parents. After these meetings, the medical process begins. Each donor is compensated for the time and effort she puts into helping our recipients reach their goal of becoming parents.

Once a recipient match is made, the donor’s doctor visits are coordinated. Center for Egg
Options acts as a liaison between the donor, recipient, and doctor's office, providing the recipient with continuous updates throughout the entire egg donation cycle.

Practical and Psychological Aspects of Embryo Donation and Surrogacy
Marie A. Davidson, Ph.D.

Introduction
Both embryo donation and surrogacy have grown modestly in popularity in the United
States over the past ten years. With hundreds of thousands of frozen embryos in storage that may never be used by the genetic parents, and a subset of fertility patients who are in need of both eggs and sperm, embryo donation is a desirable solution for meeting the needs of some people using assisted reproductive technology to build families and for families who are unable to use embryos previously frozen for their own use.

Surrogacy is the answer for people who are unable to carry a pregnancy but who have
healthy eggs and sperm (gestational surrogacy) or need both a host uterus and eggs (traditional
surrogacy.)

Both of these forms of family building utilizing assisted reproduction are relatively
uncommon and they are not without controversy, usually on religious or ethical grounds.
Embryo donation is questioned as being another but problematic way to adopt, in the preimplantation period. That objection is countered with the argument that embryo donation is a way for embryos that would otherwise be discarded to have a chance to develop into living children.

Surrogacy raises concerns about the issue of “womb for hire” and the possible conflict
between intended parents and surrogates over pregnancy decisions and custody of a child.

In addition, surrogacy is often quite costly.

There is no stopping some individuals, who are highly motivated to have a genetically
linked child (surrogacy) or to experience pregnancy (embryo donation). It is of crucial
importance that these avenues to family building be assisted with great thoughtfulness and attention to existing medical guidelines, legal considerations, and the psychological impact that they may have on participants and the children that they will raise.
Embryo Donation Who are the people who want to donate their embryos to other people? What are their other options? Who are the people who seek to receive donated embryos? Is this a common arrangement? Why is it controversial?

How do the donors and recipients find each other? The available means to a match will
be discussed. How important is the internet? Anonymous and known matches will be
addressed.

Medical guidelines (ASRM, FDA) and psychological guidelines for screening both
donors and recipients will be presented, as well as expected success rates of this form of ART.

Legal considerations. The important distinction between embryo donation and adoption
will be described. The need for written agreements and legal counsel will be discussed.
What about the children? Issues of disclosure to children and future planning for reunion
of offspring with genetic family will be discussed.

Possible psychological ramifications for all participants in embryo donation arrangements
will be presented. How might this be like/unlike being an adoptee after birth?
Surrogacy
Definitions of the two types of surrogacy (gestational and traditional) will be offered.
Why is surrogacy controversial? “Rent-a womb” mentality? What really motivates
surrogates? What are their personal attributes?

When is it medically appropriate to consider surrogacy? What are the guidelines? (not
as defined as for donor gametes.) What are the best estimates of success with this form of ART?

How do intended parents (IP’s) and surrogates find each other? What is the process, medical, psychological, and legal? What are the costs financially? How do the participants plan to talk to their children about this? It is “out in the open”,
so telling is the obvious choice. But how to do it best? What do we know so far?

Informing Children About Their Donor Conception
Marie A. Davidson, Ph.D.
As the use of donated gametes and donated embryos increases in frequency and
popularity, more families are faced with making important decisions about how they will handle the information about donor conception with their children. In my role of staff psychologist for a large reproductive medicine practice, I have interviewed several thousand couples (or individual) who are planning to conceive with donor gametes.

Donor embryos are a much less common choice, but the disclosure issues with that form of collaborative reproduction are at least as prominent in the mind of potential parents.
The American Society of Reproductive Medicine’s Ethics Committee (Fertility and
Sterility, March 2004) has addressed this topic, and concluded that “counseling and informed consent about disclosure are essential for donors and recipients”, and further stated that, “disclosure to offspring...is encouraged.”

Collaborative reproduction with donor embryos or gametes can be very private. A child
is born to a couple and, to the outside world, there is usually no reason to think that the child is not genetically connected to both parents. So why tell? Any decision to tell or not tell is up to the parents, and it is typically a complex decision involving feelings about privacy, health concerns, family dynamics, and broader social issues. There are four main reasons why parents say they plan to tell their child about donor conception:

1) The child has a right to know their genetic health history.
2) The parents want to avoid having this information discovered later on and be a shock
to the child.

3) It feels like too heavy a burden to keep such a secret.
4) The parents have already told family and friends about their conception plan.

A less-often expressed reason is to avoid consanguinity, having their child unknowingly marry their own sibling.

There are some situations in which telling a child seems to be out of the question. One
example is when the use of donated gametes or embryos is expressly forbidden by the family’s religious background. Another is when the parents have good reason to believe that their child might be rejected or treated poorly by extended family if the donor aspect were known.

A review of the small number of available studies suggests that people using egg
donation are more inclined to tell children than those using a sperm donor. We have almost no organized information about how people plan to handle information about embryo donation.
Anecdotally, some donor embryo families and their recipient families have a high level of
interest in exchanging information so that children who are genetic full siblings may later have a chance to meet. Embryo donation is breaking new ground in the way families handle talking to their children about how they came to be in the family. The trend toward openness in adoption has had an impact on collaborative reproduction, with the emphasis on what is in a child’s best interest rather than maintaining privacy at all costs.

Ethics in ART: You be the Judge
Nanette R. Elster, JD, MPH
The momentum behind biotechnology, particularly those technologies related to
reproduction, is a force to be reckoned with, yet as a society we have not determined where it is taking us or more importantly, where we want it to take us. Are we striving to improve upon our society, or are we creating something more akin to Huxley’s frightening vision of utopia?

Biotechnology has enabled us to move rapidly from developing and using technologies to
sustain life (e.g. organ transplantation) to developing and using technologies to create life. Since the 1978 birth of the first test tube baby, Louise Brown, assisted reproductive technologies (ARTs) have greatly expanded the range of choices available for building families as well as the configurations of families – in vitro fertilization, egg donation, surrogacy, cytoplasmic transfer, intracytoplasmic sperm injection, preimplantation genetic diagnosis, sex selection, posthumous reproduction . . . cloning. Each development raises new ethical and legal questions such as who should have access to these technologies, under what circumstances should they be available, who is the parent of a child created? Who should pay for such technologies? Most importantly, who is has the authority to answer these questions? Should it be the couple or individual seeking
to reproduce? Peers? State governments? The Federal government? Additionally, new
challenges arise with regard to defining core social constructs such as reproductive freedom, procreative liberty, family, and individuality.

There has long been a body of medical ethics addressing life-sustaining/enhancing
technologies, which is continues to evolve with advancements in medical and scientific
technology. New technologies, however, have also created the need to develop a framework for the life-creating role of assisted reproductive and emerging at the intersection of ART and genetics. This presentation will examine how existing ethical standards apply to ART and
whether a new or amended ethical framework is necessary.
The presentation will explore a range of issues including preimplantation genetic
diagnosis (PGD) to screen for disease as well as to provide a genetic match for an existing, ill child; genetic enhancement and gender selection; the high cost of ART which limits its accessibility, issues of disclosure and donor anonymity in the area of collaborative reproduction; posthumous reproduction; post-menopausal maternity; alternative families; and providing ART to assist HIV serodiscordant couples in conceiving a child.

For example, the possibilities of the genetic revolution for improving health and wellbeing are astounding, but the benefits come with serious risks as well. Every member of society has a stake in the proliferation of genetic manipulation. Currently, the technology available to accomplish PGD is very expensive and therefore available to a very small segment of the population raising questions of access, leading to the possibility for discrimination and even the possibility of creating a “genetic underclass”. Additionally, we have no societal mechanism for reaching consensus as to what traits should and should not be screened for. Questions about the appropriateness of using PGD to conceive a child who will have the genetic makeup to provide bone marrow to an existing ill child need to be considered as well as whether PGD should be used to screen for late-onset genetic predispositions such as breast cancer or Alzheimer’s or
should the technology only be used for immediate, serious conditions such as Tay-Sachs disease?

What about trait selection such as height, eye color, or hair color? In addition to the ethical issues raised by PGD, a number of ethical issues are presented regarding collaborative reproduction including the impact that such arrangements may have on
the children created through ART. As more and more children of sperm and now egg donation come of age, their concerns and interests must be explored and addressed. For example, what information is made available to the child’s pediatrician when a family history is provided? Not all children are told of the role of a third party in their conception and the impact of learning or not learning this information is just now being explored in empirical studies. One mechanism which may assist in exploring these issues further is the development of a gamete donor registry, which has been an approach adopted in several countries outside the United Sates. Nevertheless, such an endeavor poses a host of ethical and legal quandaries that must be addressed and will be
discussed in this presentation.

An analysis of the ethical implications of PGD and collaborative reproductive arrangements are only two of the issues that this presentation will address. Discussion of the ethical dilemmas raised by the family building approaches made possible by ART will help to inform the ongoing societal debate on these oftentimes controversial issues and may also help to guide the development of law and policy in this burgeoning field of scientific and medical advancement. Although law and ethics are quite distinct, this is one area where ethical guidelines and debate are influential in the enactment of law and policy.

Today’s presentations will illustrate that there are many ways to analyze the ethical
dimensions of ART, and a range of factors may be considered which change the analysis; each case will turn on its own facts and circumstances. Nevertheless, it is important to remember that just because a particular course of action is ethical, does not necessarily mean that such activity is legal, nor is a legal action necessarily ethical.
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