Jean Cohen

Infertility therapy associated-multiple pregnancies (births): an ongoing epidemic

Multiple gestation is now recognized as a major problem associated with both assisted reproductive technologies (ART) and also with ovulation induction therapies. Although some countries are beginning to adopt measures to address this issue, either through legislation or the development of clinical guidelines, there is a clear need to ensure recognition and a consistent approach to this problem worldwide. In particular, there is a need to educate both healthcare professionals and the lay population that multiple gestations are not a desirable outcome for the infertile couple.

IFFS surveillance 01

Abstract Statement of general purpose: Internationally, there is a wide divergence of views on the methods and the content of surveillance of assisted reproductive technologies. This was clearly brought out by a December 3, 1997 survey that was published in Fertility and Sterility (1999;71[Suppl 2]) entitled IFFS Surveillance 98. These 1998 data were presented to the national delegates who had participated in the 1998 survey at the International Federation of Fertility Societies meeting in San Francisco, California, in October 1998 in the hope that at least some of the discrepancies brought out by the survey could be resolved. This effort had limited success, as the delegates were concerned that they were not empowered to authorize a deviation from the situation as revealed by the survey. Thus, consensus on the various issues remains elusive. The divergence of views on various issues makes it seem likely that the exact purpose of surveillance is uncertain. Historically, surveillance was initiated in response to public concern about a new technology that dealt with the mysterious origin of a human being. Thus, the details may be unimportant as long as the public feels that surveillance of some type is in place. However, the scientific community should strive for a higher goal. Indeed, the current discussions about multiple pregnancies and the number to transfer is evidence of this scientific aspiration. The purpose of this survey, IFFS Surveillance 01, is to document the current status of the various issues in the hope that it is a further step along the road to a scientifically based consensus. Preface: The development of IVF and its subsequent variations and extensions, all now included under the umbrella of assisted reproductive technology (ART), seems to have generated more interest and concern among religious leaders, bioethicists, and the general public than any other medical procedure. This widespread interest and concern attracted the attention of, or was called to the attention of, the political process, not only by ethicists and moral theologians but by consumer groups, some members of which expressed dissatisfaction with one or another aspect of their treatment or lack of access thereto. As a result of these events, many committees and commissions, some governmental, some not, have examined the ethical, legal, religious, medical, and public policy aspects of ART, resulting in the establishments of guidelines and/or government regulations in many sovereign states practicing ART. For the purpose of this discussion, the word guidelines will be used to designate sets of rules to be followed voluntarily and the word regulations will be used to designate sets of rules adopted by legislative action, with assigned penalties for violations. Such guidelines/regulations have taken various forms and have often expressed not only a particular medical perspective but sometimes reflected the social and religious mores of the particular sovereign state. Some of the guidelines/regulations have been formulated to accommodate special interest groups. Furthermore, surveillance of compliance with guidelines/regulations has taken forms from none at all to the issuance of a license by a governmental licensing body, after fulfilling designated requirements, and often including follow-up periodic inspections. The specific purposes of this project are: 1.Tabulation of the practice of sovereign nations or political subdivisions thereof with respect to the adoption of guidelines/regulations.2.Tabulation of the methods of surveillance, if any, of such guidelines/regulations.3.Tabulation of the similarities and differences of the guidelines/regulations themselves concerning the various procedures under the umbrella of ART and especially to identify within the guidelines/regulations any that may be medically naive or contradictory, or not supportive of the best interest of the patients, their families, and society in general.4.Highlighting of the changes between this survey and the previous one, i.e., IFFS Surveillance 98.Materials and methods: A survey form was developed (see Appendix), and one or more individuals from the principal sovereign nations known to be practicing ART were invited to fill out the questionnaire. The response has been very satisfactory. Completed questionnaires were codified by the coordinator, Dr. Jacques Maas, and the situation as of December 31, 2000, was tabulated under several subheadings of the questionnaire.Results from 39 countries were tabulated. In some situations, Australia was tabulated four times because three states (South, Victoria, and West) have regulations, while the remaining states operate under guidelines. Over 2,000 individual centers were represented in the survey (Table A). The analysis of the survey, the discussion, and the summaries were prepared by the editors.

Incidence and complications of multiple gestation in Canada: proceedings of an expert meeting

This paper reports the proceedings of a consensus meeting on the incidence and complications of multiple gestation in Canada. In addition to background presentations about current and possible future practice in Canada, the expert panel also developed a set of consensus points. The need for infertility to be understood, and funded, as a healthcare problem was emphasized, along with recognition of the emotional impact of infertility. It was agreed that the goal of assisted reproduction treatment is the delivery of a single healthy infant and that even though many positive outcomes have resulted from twin or even triplet pregnancies, the potential risks associated with multiple pregnancy require that every effort be made to achieve this goal. The evidence shows that treatments other than IVF (such as superovulation and clomiphene citrate) contribute significantly to the incidence of multiple pregnancy. There is an urgent need for studies to understand better the usage and application of these other fertility technologies within Canada, as well as the non-financial barriers to treatment. The final consensus of the expert panel was that with adequate funding and good access to treatment, it will be possible to achieve the goal of reducing IVF-related multiple pregnancy rates in Canada by 50%.

Procreative tourism and reproductive freedom

In many societies, the use of assisted reproduction technology has produced a desire to control and regulate this form of treatment. Politicians have taken most decisions. These regulations hold important implications for patients, and there are no two countries with the same regulations. These important differences have led to a traffic of infertile couples across legislative borders to seek a solution to their problem. Would harmonization of laws have positive effects? It seems that it would lead to a minimal common legislation. Procreative tourism is actually a safety valve for many European couples.

A short review of ovarian stimulation in assisted reproductive techniques

Ovarian stimulation during assisted human reproduction is currently a standard procedure in assisted reproductive techniques (ART). Its objective is to stimulate the growth of several follicles by injections of FSH-containing compounds, most recently recombinant FSH (rFSH). An injection of human chorionic gonadotrophin (HCG), or a luteinizing hormone-releasing hormone agonist to discharge pituitary LH is then given to invoke follicle and oocyte maturation. Various other medications are also used in addition to specific drugs such as human menopausal gonadotrophin, rFSH, HCG and rLH. Non-specific drugs include clomiphene citrate, other anti-oestrogens, bromoergocryptine, and gonadotrophin-releasing hormone (GnRH) agonists and antagonists. Numerous protocols have been utilized with these agents, the most common being clomiphene citrate and various regimens of gonadotrophins, including step-up, step-down and continuous. The regimens are used with or without GnRH agonists, and with or without GnRH antagonists. In this brief review, the advantages and disadvantages of each protocol are presented.

Infertile couples, assisted reproduction and increased risks to the children

Among possible causes of increased risks of health problems in babies resulting from assisted reproduction treatment, the main one is infertility itself. Epidemiological investigations aimed at assessing assisted reproduction and child health are difficult ones. Large multicentric international studies are necessary.

A new 'publication bias': the mode of publication.

The editor of a medical journal may influence the opinion of his readers by a publication bias. This can be through the choice of an editorial at the front of the journal, tutoring the article, the choice of an author from the Editorial Board and the organization of a press conference accompanying the publication. The publicity from which certain studies benefited in recent years has had a negative effect on doctors prescriptions and comprehension of the published studies.

Raoul Palmer: a maker of fate

The privilege of old age is to possess a synthetic view over the past and to appreciate the evolution of decisive and determinative episodes in various clinical fields. In my lifetime as a gynaecologist and obstetrician, I have witnessed wide changes in contraception, epidural anaesthesia in obstetrics, IVF, and so on ... Each time, these revolutions were sustained by men and women of exceptional stature. One such revolution concerned the introduction of laparoscopy into clinical practice. To this end, I wish to tell the story of one of my professors who was a determined pioneer in its development.

Consequences of Bertarelli Foundation actions

Since 1999, the Bertarelli Foundation has worked to educate professionals, patients and governmental bodies regarding the burden and problems associated with multiple births resulting from assisted reproductive technology. It has done this by supporting meetings, funding research, and through the personal efforts of board members.

How fashions change in gynaecology and infertility.

In medicine the changes in therapies are the evidence of the progress in knowledge. But many examples concerning the treatment of early spontaneous abortion, late abortion, menopause, contraception and infertility show that gynaecologists and obstetricians change their treatments just as fashion designers change their styles. My Corner on this occasion is an appeal for caution and humility.