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Assisted reproductive technology (ART) is a general term referring to methods used to achieve pregnancy by artificial or partially artificial means. It is reproductive technology used primarily in infertility treatments. Some forms of ART are also used in fertile couples for genetic reasons. ART is also used in couples who are discordant for certain communicable diseases, i.e. Aids, to reduce the risk of infection when a pregnancy is desired. The term also includes any reproductive technique involving a third party e.g. a sperm donor. There is yet no strict definition of the term.

Contents

Definitions

While there is no consensus on the definition, generally the process of intercourse is bypassed either by insemination (example IUI) or fertilization of the oocytes in the laboratory environment (i.e. in IVF).

  • The Centers for Disease Control and Prevention(CDC) -- which is required as a result of the 1992 Fertility Clinic Success Rate and Certification Act to publish the annual ART success rates at U.S. fertility clinics—defines ART to include "all fertility treatments in which both eggs and sperm are handled. In general, ART procedures involve surgically removing eggs from a woman’s ovaries, combining them with sperm in the laboratory, and returning them to the woman’s body or donating them to another woman." According to CDC, "they do not include treatments in which only sperm are handled (i.e., intrauterine—or artificial—insemination) or procedures in which a woman takes medicine only to stimulate egg production without the intention of having eggs retrieved."

Procedures

Procedures are mainly fertility medication, as well as ART techniques that use more substantial and forceful interventions, of which in vitro fertilisation (IVF) and expansions of it (e.g. OCR, AZH, ICSI, ZIFT) are the most prevalent. However, there are also other manual ART, not necessarily dependent on IVF (e.g. PGD, GIFT, SSR).

Medication

Most fertility medication are agents that stimulate the development of follicles in the ovary. Examples are gonadotropins and gonadotropin releasing hormone.

In vitro fertilisation

In vitro fertilisation (IVF) is the technique of letting fertilisation of the male and female gametes (sperm and egg) occur outside the female body.

Embryo transfer is the step in the process whereby one or several embryos are placed into the uterus of the female with the intent to establish a pregnancy.

Expansions of IVF

The following are techniques involved in, or requiring, in vitro fertilisation. In vitro fertilization does not necessarily involve each technique.

  • Transvaginal ovum retrieval (OCR) is the process whereby a small needle is inserted through the back of the vagina and guided via ultrasound into the ovarian follicles to collect the fluid that contains the eggs.
  • Assisted zona hatching (AZH) is performed shortly before the embryo is transferred to the uterus. A small opening is made in the outer layer surrounding the egg in order to help the embryo hatch out and aid in the implantation process of the growing embryo.
  • Intracytoplasmic Sperm Injection (ICSI)
    Intracytoplasmic sperm injection (ICSI) is beneficial in the case of male factor infertility where sperm counts are very low or failed fertilization occurred with previous IVF attempt(s). The ICSI procedure involves a single sperm carefully injected into the center of an egg using a microneedle. This method is also sometimes employed when donor sperm is used.
  • Autologous endometrial coculture is a possible treatment for patients who have failed previous IVF attempts or who have poor embryo quality. The patient’s fertilized eggs are placed on top of a layer of cells from the patient’s own uterine lining, creating a more natural environment for embryo development.
  • In zygote intrafallopian transfer (ZIFT), egg cells are removed from the woman's ovaries and fertilized in the laboratory; the resulting zygote is then placed into the fallopian tube.
  • Cytoplasmic transfer is the technique in which the contents of a fertile egg from a donor are injected into the infertile egg of the patient along with the sperm.
  • Egg donors are resources for women with no eggs due to surgery, chemotherapy, or genetic causes; or with poor egg quality, previously unsuccessful IVF cycles or advanced maternal age. In the egg donor process, eggs are retrieved from a donor’s ovaries, fertilized in the laboratory with the sperm from the recipient’s partner, and the resulting healthy embryos are returned to the recipient’s uterus.
  • A gestational carrier is an option when a patient’s medical condition prevents a safe pregnancy, when a patient has ovaries but no uterus due to congenital absence or previous surgical removal, and where a patient has no ovaries and is also unable to carry a pregnancy to full term.
  • Preimplantation genetic diagnosis (PGD) involves the use of genetic screening mechanisms such as Fluorescent In Situ Hybridization (FISH) or Comparative Genomic Hybridization (CGH) to help identify genetically abnormal embryos and improve healthy outcomes.

Others

The following Assisted Reproduction techniques don't necessarily involve IVF.

Risks

The majority of IVF-conceived infants do not have birth defects.[1] However, some studies have suggested that assisted reproductive technology is associated with an increased risk of birth defects.[2][3] In the largest U.S. study, which used data from a statewide registry of birth defects,[4] 6.2% of IVF-conceived children had major defects, as compared with 4.4% of naturally conceived children matched for maternal age and other factors (odds ratio, 1.3; 95% confidence interval, 1.00 to 1.67).[1]

The main risks are:

Other risk factors are:

Sperm donation is an exception, with a birth defect rate of almost a fifth compared to the general population.[7] It may be explained by that sperm banks accept only people with high sperm count.

Usage

Assisted reproductive technology procedures performed in the U.S. has more than doubled since 10 years ago, with 140.000 procedures in 2006[8], resulting in 55.000 infants born.[8]

In Australia, 3.1 percent of babies now born are a result of ART.[9]

Costs

United States of America

Not everyone in the U.S. has insurance coverage for fertility investigations and treatments. Many states are starting to mandate coverage, and the rate of utilization is 277% higher in states with complete coverage.[10]

There are some health insurance companies that cover diagnosis of infertility but frequently once diagnosed will not cover any treatment costs.

2005 approximate treatment/diagnosis costs (United States, costs in US$):

  • Initial workup: hysteroscopy, hysterosalpingogram, blood tests ~$2,000
  • Intrauterine Insemination (IUI) fka Artificial insemination ~ $200– 900 per. trial
  • Sonohysterogram (SHG) ~ $600 – 1,000
  • Clomiphene citrate cycle ~ $ 200 - 500
  • IVF cycle ~ $10,000 -30,000
  • Use of a surrogate mother to carry the child - dependent on arrangements

Another way to look at costs is to determine the cost of establishing a pregnancy. Thus if a clomiphene treatment has a chance to establish a pregnancy in 8% of cycles and costs $500, it will cost ~ $6,000 to establish a pregnancy, compared to an IVF cycle (cycle fecundity 40%) with a corresponding cost of ($12,000/40%) $30,000

For the community as a whole, the cost of IVF on average pays back by 700% by tax from future employment by the conceived human being.[11]

United Kingdom

In the UK all patients have the right to preliminary testing, provided free of charge by the National Health Service. However, treatment is not widely available on the NHS and there can be long waiting lists. Many patients therefore pay for immediate treatment within the NHS or seek help from private clinics[12].

Sweden

In Sweden, official fertility clinics provide most necessary treatments and initial workup, but there are long waiting lists, especially for egg donations, since the donor gets just as low reward as the receiving couple are charged. However, there are private fertility clinics.

Canada

Some treatments are covered by OHIP (public health insurance) in Ontario and others are not. If you are undergoing artificial insemination or if you have bilaterally blocked fallopian tubes and are under 40, the treatment is covered but you are still required to pay lab fees which are around $3,000-4,000. Coverage would vary in other provinces. Most other patients are required to pay for treatments themselves.[13]

Israel

Israel's National Health Insurance, which is mandatory for all Israeli citizens, covers nearly all fertility treatments. In-Vitro-Fertilization costs are fully subsidized up to the birth of two children for all Israeli women, including single women and lesbian couples. Embryo transfers for purposes of gestational surrogacy are also covered.[14]

Ethics

Some couples find it difficult to stop treatment despite very bad prognosis, resulting in futile therapies, and may put ART providers a hard choice whether to continue or refuse treatment.[15]

For treatment-specific ethical considerations, see entries individual articles, e.g. In vitro fertilisation#Ethics, Surrogacy#Ethical issues and Sperm donation#Ethical considerations

Fictional representation

Films and other fiction depicting emotional struggles of assisted reproductive technology have had an upswing first in the latter part of the 2000s decade, although the techniques have been available for decades.[16] Yet, the amount of people that can relate to it by personal experience in one way or another is ever growing, and the variety of trials and struggles are huge.[16]

Any individual examples are referred to individual subarticles, e.g. surrogacy and sperm donation.

In addition, reproduction and pregnancy in speculative fiction has been present for many decades.

See also

References

  1. ^ a b Van Voorhis BJ (2007). "Clinical practice. In vitro fertilization". N Engl J Med 356 (4): 379–86. doi:10.1056/NEJMcp065743. PMID 17251534.  
  2. ^ Kurinczuk JJ, Hansen M, Bower C (2004). "The risk of birth defects in children born after assisted reproductive technologies". Curr Opin Obstet Gynecol 16 (3): 201–9. doi:10.1097/00001703-200406000-00002. PMID 15129049.  
  3. ^ Hansen M, Bower C, Milne E, de Klerk N, Kurinczuk JJ (2005). "Assisted reproductive technologies and the risk of birth defects--a systematic review". Hum Reprod 20 (2): 328–38. doi:10.1093/humrep/deh593. PMID 15567881. http://humrep.oxfordjournals.org/cgi/reprint/20/2/328.pdf.  
  4. ^ Olson CK, Keppler-Noreuil KM, Romitti PA, Budelier WT, Ryan G, Sparks AE, Van Voorhis BJ (2005). "In vitro fertilization is associated with an increase in major birth defects". Fertil Steril 84 (5): 1308–15. doi:10.1016/j.fertnstert.2005.03.086. PMID 16275219.  
  5. ^ a b c Zhang Y, Zhang YL, Feng C, et al. (September 2008). "Comparative proteomic analysis of human placenta derived from assisted reproductive technology". Proteomics 8: 4344. doi:10.1002/pmic.200800294. PMID 18792929.  
  6. ^ Hvidtjørn D, Schieve L, Schendel D, Jacobsson B, Sværke C, Thorsen P (2009). "Cerebral palsy, autism spectrum disorders, and developmental delay in children born after assisted conception: a systematic review and meta-analysis". Arch Pediatr Adolesc Med 163 (1): 72–83. doi:10.1001/archpediatrics.2008.507. PMID 19124707. http://archpedi.ama-assn.org/cgi/content/full/163/1/72.  
  7. ^ motherearthnews.com - THE SPERM CRISIS
  8. ^ a b chicagotribune.com Infertility by the numbers Colleen Mastony. June 21, 2009
  9. ^ 'More IVF babies but less multiple births' THE AUSTRALIAN. September 24, 2009
  10. ^ Jain T, Harlow BL, Hornstein MD. "Insurance coverage and outcome of in vitro fertilization." New England Journal of Medicine. 347(9):661-6.
  11. ^ Long-term Economic Benefits Attributed to IVF-conceived Children: A Lifetime Tax Calculation by Mark P. Connolly, MHE; Michael S. Pollard, PhD; Stijn Hoorens, MSc; Brian R. Kaplan, MD; Selwyn P. Oskowitz, MD; and Sherman J. Silber, MD
  12. ^ Infertility Treatment, NHS Direct Online (NHS Direct Online Health Enyclopaedia)
  13. ^ IVF Canada
  14. ^ Teman, Elly. 2010. Birthing a Mother: the Surrogate Body and the Pregnant Self. Berkeley: University of California Press
  15. ^ Fertility treatment when the prognosis is very poor or futile. Fertil Steril. 2009 Aug 31. PMID: 19726040
  16. ^ a b chicagotribune.com --> Heartache of infertility shared on stage, screen By Colleen Mastony, Tribune reporter. June 21, 2009

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