Social aspects in assisted reproduction.

In-vitro fertilization (IVF) and assisted reproductive techniques have become common practice in many countries today, regulated by established legislation, regulations or by committee-set ethical standards. The rapid evolution and progress of these techniques have revealed certain social issues that have to be addressed. The traditional heterosexual couple, nowadays, is not considered by many as the only 'IVF appropriate patient' since deviations from this pattern (single mother, lesbians) have also gained access to these treatments. Genetic material donation, age limitation, selective embryo reduction, preimplantation genetic diagnosis, surrogacy and cloning are interpreted differently in the various countries, as their definition and application are influenced by social factors, religion and law. Financial and emotional stresses are also often described in infertile couples. Information as deduced from the world literature regarding IVF regulation, as well as about the existing religious, cultural and social behaviours towards these new technologies, is presented in this article in relation to the social aspects of assisted reproduction.     

Surrogacy: the experience of commissioning couples

BACKGROUND: Findings are presented of a study of families with a child created through a surrogacy arrangement. This paper focuses on the commissioning couples' reports of their experiences. METHODS: A total of 42 couples with a 1-year-old child born through surrogacy were assessed using a standardized semi-structured interview. Data were obtained on motivations for surrogacy, details about the surrogate mother, experience of surrogacy during pregnancy and after birth and disclosure of the surrogacy to friends and family. RESULTS: Couples had considered surrogacy only after a long period of infertility or when it was the only option available. Couples retrospectively recalled their levels of anxiety throughout the pregnancy as low, and relationships between the couple and the surrogate mother were found to be generally good. This was the case regardless of whether or not the couple had known the surrogate mother prior to the arrangement. After the birth of the child, positive relations continued with the large majority of couples maintaining some level of contact with the surrogate mother. All couples had told family and friends about the surrogacy and were planning to tell the child. CONCLUSIONS: Commissioning couples generally perceived the surrogacy arrangement as a positive experience.     

British women's attitudes to surrogacy

BACKGROUND: There has been little interest in the research literature onpublic opinions regarding assisted conception and surrogacy,particularly in European countries, despite the growing evidenceshowing that problems in adaptation and coping may be relatedto perceived normative values. This study investigated Britishwomen's attitudes to surrogacy using components of the theoryof planned behaviour (TPB). METHODS: Questionnaires on attitudes to surrogacy and reasons for parenthoodwere completed by 187 women from the general public. RESULTS: Significant socio-demographic differences were found betweenwomen who were possibly willing (n = 76) and those who wereunwilling (n = 111) to become surrogate mothers. General attitudesto surrogacy also differed between groups (P = 0.000). Thisstudy supported the predictive utility of components of theTPB, and differentiated adequately between groups on attitudesto recruitment for surrogacy (P = 0.000), the consequences ofsurrogacy (P = 0.000), factors that induce people to becomesurrogates (P = 0.000), social support (P = 0.000), having personalcontrol (P = 0.002) and reasons for parenthood (P = 0.000).Age (P = 0.000), attitudes to advertising (P = 0.02) and theconsequences of surrogacy (P = 0.05) predicted (un)willingnessto become a potential surrogate mother. CONCLUSIONS: Further research is needed with larger sample sizes of potentialsurrogates to determine whether the predictive attitudes reportedhere translate to actual behaviours. The larger group whichwas not interested in considering becoming a surrogate scoredsignificantly more negatively on all attitudes towards surrogacy.The negative attitudes reported by the ‘unwilling to considerbeing a surrogate’ group may reflect attitudes held bythe majority of the population and are likely to be influencedby reports of stigma associated with surrogacy.     

Uterine transplantation research: laboratory protocols for clinical application

The aim of this review is to summarize the state-of the-art methods that are used in clinical organ transplantation today, as well as the major findings of recent experimental uterus transplantation (UTx) research regarding organ donation/retrieval, ischemic preservation, surgical techniques for anastomosis, immunosuppression and pregnancy. Absolute uterine factor infertility lacks treatment despite the major developments in infertility treatment and assisted reproduction. Concerning uterine factor infertile patients, genetic motherhood is only possible through gestational surrogacy. The latter can pose medical, ethical and legal concerns such as lack of control of life habits during surrogate pregnancy, economic motives for women to become surrogate mothers, medical/psychological pregnancy-related risks of the surrogate mother and uncertainties regarding the mother definition. Thus, surrogacy is non-approved in large parts of the world. Recent advances in the field of solid organ transplantation and experimental UTx provide a favourable and safe background in a scenario in which a human clinical UTx trial can take place. Protocols based on animal research over the last decade are described with a view to providing a scientifically guided approach to human UTx as an experimental procedure in the future.     

The social organization of surrogacy: relinquishing a baby and the role of payment in the psychological detachment process

This article presents the 'maternal-foetal detachment' theory providing a framework for understanding how some women relinquish a baby in the context of paid surrogacy. It is postulated that attitude towards payment becomes part of a psychological detachment process in which surrogate mothers emotionally distance themselves from the growing foetus. Important are the subcultural influences engendered by the social organization of surrogacy. Some surrogate mothers appear to learn not to attach to the unborn child or, if feelings emerge, they deal with these by deflecting emotions towards the couple. The discussion considers what can be learned about the concepts of maternal-foetal attachment and maternal instinct. The surrogacy case offers conflicting evidence in favour of, and in opposition to, the concept of maternal instinct.     

Gestational surrogacy

Gestational surrogacy is a treatment option available to women with certain clearly defined medical problems, usually an absent uterus, to help them have their own genetic children. IVF allows the creation of embryos from the gametes of the commissioning couple and subsequent transfer of these embryos to the uterus of a surrogate host. The indications for treatment include absent uterus, recurrent miscarriage, repeated failure of IVF and certain medical conditions. Treatment by gestational surrogacy is straightforward and follows routine IVF procedures for the commissioning mother, with the transfer of fresh or frozen-thawed embryos to the surrogate host. The results of treatment are good, as would be expected from the transfer of embryos derived from young women and transferred to fit, fertile women who are also young. Clinical pregnancy rates achieved in large series are up to 40% per transfer and series have reported 60% of hosts achieving live births. The majority of ethical or legal problems that have arisen out of surrogacy have been from natural or partial surrogacy arrangements. The experience of gestational surrogacy has been largely complication-free and early results of the follow-up of children, commissioning couples and surrogates are reassuring. In conclusion, gestational surrogacy arrangements are carried out in a few European countries and in the USA. The results of treatment are satisfactory and the incidence of major ethical or legal complications has been limited. IVF surrogacy is therefore a successful treatment for a small group of women who would otherwise not be able to have their own genetic children.     

Organizational selection and assessment of women entering a surrogacy agreement in the UK.

In the UK, surrogacy procedures are unregulated and not monitored. Information concerning the selection and assessment of intended (the mother commissioning) and surrogate mothers (the mother carrying and delivering the baby) is therefore not generally available (BMA, 1996). It is important to determine what type of assessment is used, and how selection takes place within the organizations dealing with surrogate motherhood arrangements. The present survey enquired about the incidence, selection and assessment procedures of all registered surrogate and commissioning couples, and aimed to find out what advice and support is given. Eight organizations took part in the survey, six were clinics and two agencies dealing with surrogate arrangements. Two voluntary organizations/helplines were also surveyed, but their data are not relevant to the results presented here. An interview and questionnaire approach was used. Psychosocial assessment was minimally addressed by all organizations, and no fixed procedures for assessment and selection were employed. Despite this, few incidences of controversial cases were reported. Confidence in this practice could be increased in the future if both parties embarking on a surrogacy arrangement knew they were properly selected and assessed. A regulatory body could monitor consistent use of professional evidence-based criteria prior to arrangements.     

Surrogacy: the experiences of surrogate mothers

BACKGROUND: This study examined the motivations, experiences and psychological consequences of surrogacy for surrogate mothers. METHODS: Thirty-four women who had given birth to a surrogate child approximately 1 year previously were interviewed by trained researchers, and the data rated using standardized coding criteria. Information was obtained on: (i) reasons for the woman's decision to become a surrogate mother; (ii) her retrospective view of the relationship with the commissioning couple before the pregnancy, during the pregnancy, and after the birth; (iii) her experiences during and after relinquishing the child; and (iv) how others reacted to her decision to become a surrogate mother. RESULTS: It was found that surrogate mothers do not generally experience major problems in their relationship with the commissioning couple, in handing over the baby, or from the reactions of those around them. The emotional problems experienced by some surrogate mothers in the weeks following the birth appeared to lessen over time. CONCLUSIONS: Surrogate mothers do not appear to experience psychological problems as a result of the surrogacy arrangement.     

Using attitudinal indicators to explain the public's intention to have recourse to gamete donation and surrogacy

BACKGROUND: Although the donation and receipt of gametes has become an integral part of infertility management, previous research in the field of social attitudes and intention to use medical technologies is limited. This study aimed to investigate attitudinal indicators and their potential relationship with the public's intention to have recourse to gamete donation and surrogacy. METHODS: A total of 365 individuals of reproductive age (49.3% men and 50.7% women) completed a questionnaire referring to their intention to receive or donate sperm/oocytes and their acceptance of becoming a commissioning couple or surrogate mother, and also to explore their attitudes towards gamete donation and surrogacy. Two attitudinal indicators emerged from the principal component analysis identifying (i). recipients' and donors' choice for anonymity, donors' renunciation of parental obligations and refusal of children's rights to know their biological parents and (ii). favourable attitudes towards legislative and financial measures to be adopted by the Government for the promotion of reproductive technologies. RESULTS: It was found that the indicator of 'Donors Anonymity and Refusal of Children's Rights' (DARCR) and the 'Legislative and Financial Support' (LFS) scale are positively associated with intention to have recourse to Gamete Donation and Surrogacy (GDS) (regression coefficients 0.31 and 1.08 respectively). Moreover, among the other variables used in the analysis only the 'church attendance' variable is negatively related with reported rates of intention to have recourse to GDS (P = 0.029), suggesting that the more religious respondents are less willing to use GDS. CONCLUSION: Social, legislative and financial implications provide a convenient rationale for adopting a favourable intention towards reproductive technologies. The findings of the present research should be given close consideration by policy makers and health education campaigns.     

When genes determine motherhood: problems in gestational surrogacy.

Gestational surrogacy in which a commissioning couple's egg and spermatozoon are united in vitro and the resulting embryo is implanted in a woman's uterus is, of all the new methods for overcoming infertility, the most genetically appealing. This is because the genes are often perceived as determining all aspects of human health, disease and even behaviour. Having a child with the genes of both parents has become far more attractive to most infertile couples than having one who is only genetically related to the father. However, gestational surrogacy has created a situation where one child has two mothers, each one claiming to be the 'true' mother having exclusive parental rights. Surrogacy arrangements also raise the question of the meaning of motherhood.     

Is blood pressure reduction a valid surrogate endpoint for stroke prevention? an analysis incorporating a systematic review of randomised controlled trials, a by-trial weighted errors-in-variables regression, the surrogate threshold effect (STE) and the biomarker-surrogacy (BioSurrogate) evaluation schema (BSES)

Background

Blood pressure is considered to be a leading example of a valid surrogate endpoint. The aims of this study were to (i) formally evaluate systolic and diastolic blood pressure reduction as a surrogate endpoint for stroke prevention and (ii) determine what blood pressure reduction would predict a stroke benefit.

Methods

We identified randomised trials of at least six months duration comparing any pharmacologic anti-hypertensive treatment to placebo or no treatment, and reporting baseline blood pressure, on-trial blood pressure, and fatal and non-fatal stroke. Trials with fewer than five strokes in at least one arm were excluded. Errors-in-variables weighted least squares regression modelled the reduction in stroke as a function of systolic blood pressure reduction and diastolic blood pressure reduction respectively. The lower 95% prediction band was used to determine the minimum systolic blood pressure and diastolic blood pressure difference, the surrogate threshold effect (STE), below which there would be no predicted stroke benefit. The STE was used to generate the surrogate threshold effect proportion (STEP), a surrogacy metric, which with the R-squared trial-level association was used to evaluate blood pressure as a surrogate endpoint for stroke using the Biomarker-Surrogacy Evaluation Schema (BSES3).

Results

In 18 qualifying trials representing all pharmacologic drug classes of antihypertensives, assuming a reliability coefficient of 0.9, the surrogate threshold effect for a stroke benefit was 7.1 mmHg for systolic blood pressure and 2.4 mmHg for diastolic blood pressure. The trial-level association was 0.41 and 0.64 and the STEP was 66% and 78% for systolic and diastolic blood pressure respectively. The STE and STEP were more robust to measurement error in the independent variable than R-squared trial-level associations. Using the BSES3, assuming a reliability coefficient of 0.9, systolic blood pressure was a B + grade and diastolic blood pressure was an A grade surrogate endpoint for stroke prevention. In comparison, using the same stroke data sets, no STEs could be estimated for cardiovascular (CV) mortality or all-cause mortality reduction, although the STE for CV mortality approached 25 mmHg for systolic blood pressure.

Conclusions

In this report we provide the first surrogate threshold effect (STE) values for systolic and diastolic blood pressure. We suggest the STEs have face and content validity, evidenced by the inclusivity of trial populations, subject populations and pharmacologic intervention populations in their calculation. We propose that the STE and STEP metrics offer another method of evaluating the evidence supporting surrogate endpoints. We demonstrate how surrogacy evaluations are strengthened if formally evaluated within specific-context evaluation frameworks using the Biomarker- Surrogate Evaluation Schema (BSES3), and we discuss the implications of our evaluation of blood pressure on other biomarkers and patient-reported instruments in relation to surrogacy metrics and trial design.     

The importance of a genetic link in mothers commissioning a surrogate baby in the UK

Reproductive technologies have enabled genetic and gestational links between parents and children to become separate from social relationships and inter-personal ties within families. The meaning of family is discussed, by drawing on research with infertile women who become parents as the result of surrogacy. The complexities of family are highlighted by addressing the consequences of babies carried and delivered by women who are not the biological parents of the child, or by women who are the biological mother of the child but who relinquish their genetic material to another woman. In all, 29 women completed a questionnaire on various aspects of their infertility, surrogacy, and the importance of a genetic link. The study identified some characteristics of women who have become mothers as a result of surrogacy, and some of their reactions to this way of creating families. In general, women who could use their own genetic material tended to believe a genetic link was important. Those who could not use their own genetic material were less uniform in their beliefs about the importance of a genetic link. The cognitive dissonance observed in this population has implications for the future of reproductive technology assisting couples in becoming a family with or without genetic relatedness.     

Behavioral and hormonal responses to separation in infant rhesus monkeys and mothers

Effects of social stimuli on behavioral and physiological responses were examined in infant rhesus monkeys at 4 and 9 months of age. Infants and mothers were removed from the social group and housed as dyads. Following this period, infants were removed and separated under four counterbalanced conditions: (a) totally isolated--placed in a holding cage for 24 hr; (b) mother present, no contact--housed in a single cage in view of their mother, no contact; (c) mother present, contact--similar to above, with mother in proximity to the infant; and (d) peer present--separated but in proximity to a peer. In the first experiment, the infants rarely vocalized when totally isolated but showed high rates of vocalization in the presence of the mother, both with and without contact. In the mother-present conditions, they failed to show a plasma cortisol response. In contrast, totally isolated infants showed a significant elevation in plasma cortisol. At 9 months of age, these infants were separated for 3 days under two different conditions: mother present and totally isolated. Once again, the infants that were totally isolated showed little vocalization but significant elevations in plasma cortisol. In contrast, infants separated in the presence of their mothers showed high vocalization rates but no cortisol response. The concepts of protest and despair are discussed as they relate to behavioral and physiological differences observed following different separation paradigms.     

A relationship between traditionally motivated patterns and gamete donation and surrogacy in urban areas of Greece

BACKGROUND: Although gamete receipt or donation has become an integral part of infertility management, previous research in the field of social attitudes and intention to use medical technologies is limited. The aim of this paper was to investigate people's intentions to receive or donate sperm, oocyte or uterus (surrogacy) and to identify possible motivational patterns explaining this intention. METHODS: Personal interviews were conducted with 365 men and women of reproductive age (18-45 years). Stratified random sampling was performed to select the men and women for interview. The content of the instrument used was derived from in-depth qualitative interviews with physicians experienced in assisted reproductive technologies, as well as from people who had recourse to gamete donation and surrogacy. RESULTS: The results obtained highlighted the following major aspects: (i) approximately 50% of the survey's participants would be prepared to receive/donate sperm and oocyte; (ii) the results from multiple regression analysis suggest that the 'traditional gender roles' pattern is positively associated with 'intention to use gamete donation and surrogacy'. On the contrary, 'confidence in emotional relationship' is negatively associated with 'intention to use gamete donation and surrogacy, and (iii) men are more likely than women to report 'intention to use gamete donation and surrogacy'. CONCLUSION: These data suggest that specific motivational patterns of the population need to be thoroughly analysed and taken into consideration, in order that appropriate counselling be addressed to individuals and couples.     

Physiological correlates of maternal separation in surrogate-reared infants: a study in altered attachment bonds.

Three pigtail infant monkeys (Macaca nemestrina) were separated from their mothers shortly after birth and raised in social isolation on cloth surrogates. At about 24 weeks of age they were surgically implanted with multichannel biotelemetry systems. Following the collection of baseline behavioral and physiological data, the cloth surrogates were removed for 4 days, then returned. The behavioral and physiological (heart rate, body temperature, sleep patterns) reaction to separation from the surrogate was much less intense than is the case in group-living pigtail infants that are separated from their mothers, suggesting that the attachment bond to a cloth surrogate may be different than the bond to a living mother in a social group. Heart rate mean values and variability were similar in surrogate-reared and mother-reared infants, suggesting a degree of environmental independence in heart rate regulation.     

Non-genetic surrogacy: no cure but problems for infertility?

Non-genetic surrogacy characterizes a situation where the gestational mother is not the genetic mother. It further widens a circle that started with the introduction of in-vitro fertilization (IVF) and creates problems in defining motherhood and identifying at birth the mother who will have the rights and responsibilities of rearing the child.     

Assisted reproduction practice in Europe: legal and ethical aspects

This report describes the ethical and legal aspects of assistedreproductive technologies (ART) that have been instituted inEuropean countries. The data were collected from questionnairescirculated to fertility centres in 39 countries in Europe. Ninetysix ART centres were located in 30 of these countries. Ninecountries do not offer ART services. According to the survey,there are approximately 516 centres in Europe, which representapproximately 60% of the world ART centres. The survey includedinformation regarding regulation of ART services, access tothese services, attitude toward genetic material donation, cryopreservationof pre-embryos, surrogacy, manipulation of gametes and pre-embryos,research on pre-embryos and multiple fetal pregnancy reduction.At present, the majority of countries in Europe do not haveestablished legislation pertaining to the various aspects ofART practice. The study reviews the ethical and legal aspectsof ART practice in Europe.     

Nocturnal sleep in isolation-reared monkeys: evidence for enviromental independence.

Thirteen all-night recordings were obtained from 3 infant pigtailed (Macaca nemestrina) monkeys raised on a cloth surrogate mother and under conditions of social isolation. Totally implantable biotelemetry systems were used to record the sleep physiology from the unrestrained animals. Sleep stages and night-to-night variability were virtually identical to values previously found in 8 mother-reared group-living infants. Sustained alterations in the early rearing enviroment, even though considerably modifying the organism's development, did not appear to result in differences in sleep organization.     

ESHRE Task Force on Ethics and Law 10: surrogacy

This 10th statement of the Task Force on Ethics and Law considers ethical questions specific to varied surrogacy arrangements. Surrogacy is especially complex as the interests of the intended parents, the surrogate, and the future child may differ. It is concluded that surrogacy is an acceptable method of assisted reproductive technology of the last resort for specific medical indications, for which only reimbursement of reasonable expenses is allowed.     

Experience with gestational surrogacy as a treatment for sterility resulting from hysterectomy

A retrospective study was carried out to assess the potential of 16 hysterectomized women to achieve surrogate pregnancies. A total of 11 patients completed 16 cycles of assisted conception treatment incorporating in-vitro fertilization and gestational surrogacy. Three other women failed to respond to ovulation induction while two more patients produced few oocytes which also failed to fertilize. Six host mothers became pregnant thereby giving a pregnancy rate of 37.5% (6/16) per patient and embryo transfer and 27.3% (6/22) per cycle of treatment commenced. Two women later miscarried, three have given birth to twins and the remaining host has delivered a male infant. The commissioning mother's age was closely related to occurrence and continuation of pregnancy in the host. Hysterectomized women demonstrate varying patterns of response to assisted conception treatment but gestational surrogacy generally appears to be a feasible option especially in younger patients.