Ethics of In Vitro Fertilization

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Ethics of In Vitro Fertilization

morning to everyone I’m Mary installed slightly and then I’m Contino plant ecology for women the a terrific Mike Ruiz the school which is this beautiful building deck review I’m going to speak about the school briefly a little bit later but now I would like to keep off the conference and get us started and it’s my real pleasure to introduce dr Alan peevish who is the president of Turell ecology university system for while he’s a man who needs no introduction I just want you to know how important he is to us the things he’s done to fool the college forward to introduce new perspectives on what we do and to constantly be innovative and creative so that students across the board at our undergraduate and graduate institutions are capable of competing for the best Natalia we are very very fortunate to have dr. conditions are either I think tonight is kinda and think about what leadership means and it’s hard for me to think of a better leader I dedicated knows I’m always analogizing him to different figures today at you who’ve done want copies and just in the ability to see the future to understand what we need and in complex times to really navigate us in the roles and the opportunities that are there for us and to see that we can meet those challenges and now it’s my pleasure to introduce dr. cage thank you Mary I’m not even sure how to get to respond to that introduction so I’ll just welcome you all to the conference the conference on Jewish perspective on reproductive medicine will hopefully deal with a number of current issues that are important for the basic precept that is of course the first Mitzvah will be fruitful and multiplying challenges reproduction and challenges that can be addressed through modern technology are more common than people who haven’t thought about it think if you include reproductive challenges as well as challenges with genetic diseases and mutations you’re probably talking about twenty-five or thirty percent of all families and that’s a challenge which scientific advances have created the opportunity to address in looking at the field broadly I think there are three different kinds of questions we have to answer one is what can we do second question is what should we do and the third question is how politic and moral implications relate to what we should do some things that we thought have been settled are actually being challenged by modern scientific advances he for example doing with one of the issues that will be discussed today which is who is the parent when multiple individuals are involved in a reproductive cycle the issue of surrogate motherhood have been relatively well settled among the most colorful authorities and that is based on the precept that the genetic material determines parentage so that a surrogate mother according to most authorities is a bystander in the birth process and the parents are actually those who contribute DNA however in September the first study its but won’t be no it noted that you can detect maternal DNA he will build the cord blood but it was assumed that that micro DNA had no effect on the fierce however in September the first study relatively well controlled study was published which showed that maternal DNA can not only affect what genes are expressed in the fetus but can it appears occasionally perhaps be incorporated into fetal DNA in microscopic quantities so the entire paradigm of who is the parent and surrogate motherhood in my view will be challenged if this preliminary data is supported by further scientific studies it’s an example of the interaction between reproductive advances a lava that takes place as scientific knowledge increases one of the basic principles are trying to apply halacha to modern technology such as this is that halacha has to have dare I say the word some degree of plasticity that is it has to be able to understand scientific advances to respond to

scientific advances and occasionally change thinking because of scientific advances one area where everyone has agreed but this can happen it should happen it has happened is the issue of early will preterm births in classical opera based on science that’s 2,000 years old when these principles were first developed a baby a fetus at seven months gestation eight months gestation and nine months gestation has different Halak status and as I said that original Halawa that a seven-month fetus is more likely to survive than eight month feeders which has very direct a lotta implications for what can do on Chavez intervene in a baby’s in fetuses survival or maybe survival battle otha has been rejected by all modern day health authorities it’s very clear that everyone agrees that regardless of the age at conception once the baby is born everything must be done to preserve life what’s fascinating is the helical constructs that have been used to try to justify that change and a change in nature or a combination of a change in nature and scientific vance’s has a result that it in changed the normative hahaha from a status several hundred years ago where a certain preterm infants would not receive maximal life-threatening thorough fee to the current high awful situation where every baby was born has the status of someone who will live and women whom halacha interventions require those are the kinds of issues which exist in reproductive medicine and the kinds of issues on mitochondrial transfer and other things that you’re going to hear about today from people who actually know what they’re talking about instead of cardiologists we try to think that into a penis so with that introduction turn it over to John lucky one of the co-directors of the conference to begin talking about what’s going to happen today John thank you very much I want to reiterate a welcome all of you come to slinger this is a very very exciting conference and the timing of this couldn’t be better because these new genetic technologies are reverberating into Reproductive Medicine in ways that we’ve never before imagined in 1918 84 was the first recorded our use of artificial insemination and human reproduction and it took almost a hundred years for this transformational technology to take the next step in Reproductive Medicine and that has to do with the birth of the first designer baby Lewis Brown using in vitro fertilization technology today we are engaged in what I call a third wave of revolutionary reproductive medicine that is by all these genetic discoveries we are now able to edit and modify the holy human grail that is our genetic code and we can do this very remarkable ways these discoveries have the potential to correct over 6,000 genetic mutations errors in our DNA including diseases that are responsible for tay-sachs cystic fibrosis deshays disease certain forms of early Alzheimer’s disease and of course some classes of counselors however we’re just beginning to understand how this research investigation should be applied to these diseases and what’s hovering over everybody’s mind are the ethical considerations of this just last week hundreds of scholars from all over the world gathered together in washington d.c DC to discuss all these issues on their a summit on gene editing and they issued words of caution that this these technologies should not be used to modify human embryos that are intended for the use in Reproductive Medicine listen to the words of the organizers it would be irresponsible to proceed with any clinical use of German editing unless and until one the relevant safety and efficiency issues have been resolved and to that there’s a broad social societal consensus about the appropriateness and the ethics of the proposed application let me apply

the famous principle of the rambam to decision Marcel vote see mama bunny the actions of our forefathers are served as signs for their future generations every scientist knows that the discov IVF in vitro fertilization were discovered today and presented today you’d have huge debates on the ethics and the safety of this technology the fact they’re 1978 dr. Edwards and steptoe presented the birth of a cute baby girl Time magazine establish proof of principle that demonstrated that this technology could generate healthy babies and as a result of this over 5 million babies have been born using IVF today’s conference will focus on two technologies in vitro fertilization and mitochondrial replacement therapy which is an example of genetic modifications many of you know about in vitro fertilization let me just highlight the potential of mitochondrial replacement therapy there are many women around the world the United States Great Britain who have mutations in their mitochondria they have errors and because of that they are effect with severe symptoms or mild symptoms but every one of their children they will have will have the same symptoms and disease and by using this mitochondria replacement therapy you will allow these women to have healthy babies so let me make a prediction that as soon as mitochondrial replacement therapy or any of these other genetic modifications intervened to actually create a healthy child that has a genetic mutation and it goes viral and Twitter and on Facebook millions of couples with threatening genetic diseases will overcome their by ethical fears and emotions and volunteer teams of utilized and to utilize these genetic technologies have healthy children this is the landscape today this is the lesson that we should learn from our history Marcel von similar body that if it works no matter how it’s done it’s going to be virally accepted and they’ll understand the side effects and they’ll either accept the side effects or they wrote how many of you would know if you have a purse if you knew that you had the genetics for early breast cancer or thoroughly alzheimers how many of you would take that chance pair that corrected with these technologies so today we’ve assembled legal medical and halak experts in the field of reproductive medicine to highlight the benefits the risks the ethical barriers of IVF and mitochondrial replacement therapy and they apply to the field of reproductive medicine you will hear from our experts that from a my ethical perspective Judaism has always recognized the sufferings of the infertile couple and has always taken a lead position to ensure appropriate halawet interventions we learn from Rahel our matriarch the seriousness of infertility as she declared to Yakov give me children otherwise I’m dead in addition we learn from repel the need to engage in potential therapy as she negotiated layer to take the dude I even so she would be we are privileged with us to have all these speakers dr. Susan labelled you learn more about the rabbi 3 flaw was a mascara and professor at lambda dr. egli who’s assistant professor from Columbia York stem cell foundation and of course rabbi dr. moshe toddler wonderfully post game is near Shiva at university and I’ll address the the halacha put the scientific parameters on these topics in the afternoon w panel discussion well you’ll have a chance to interact and we’ll be discussing the legal and ethical boundaries of these technologies now this conference and I’ll be brief year is being hosted by the new york medical college club University College of Physicians and Surgeons at the landing college for women there are so many people to thank in planning executed covers and they said I will be brief and recognize that my thanks are more profound than the words that I use first my poacher dr. IRA bed so the director of biomedical ethics and humanities programs at new york medical college he is work creatively and diligently to plan to actualize this conference credit of course has to go to dr. Ellen caters the present control college and the university system who is constantly expanding the academic

breadth of this amazing university as well as finding time to teach and to lecture to various students including those atlanta college for women we also acknowledge other keepers now at 12 where I Moshe Kripke the executive vice president dr. Mayer installed slightly the Dean of lcw and vice president for online learning guitar Oh Makka Fleischmann associate director graduated a graduate Jewish program in campus and touro college system Julia Rodriguez rent as his assistant director web communication the Office of Public Relation at new york medical college I now sameer no Nova who’s a lecture of computer science of course Wilmer oh and all the staff were responsible for the operations at college here we also want to thank Alex cook and Gary Medgar senior engineers at the Orthodox moon was the one of the sponsors for this program the other sponsors are listed in the program and you’re welcome to review them we thank them all and finally I’d like to thank my students basha bourbon hannah miller yeah Bree Mindy crushed velvet or dosti mile EV analysis Shimon blood from lcw Barnard and queen college of all helped to make this conference success now let me make the present to you dr. IRA bezo who will introduce dr thank you dr. Leakey before I mean how many people are as excited as I am to get this started already in order to make sure that we have this first speaker come up as soon as possible I will get a brief introduction to shoes so you can be as aware as I am as how capable and how exciting this start to this wonderful database dr. Susan labelled graduated summa [ __ ] laude complete state university and harvard medical school she completed her residency training and obstetrics and gynecology and bring them in Women’s Hospital in Massachusetts General Hospital and a fellowship in Reproductive Endocrinology and infertility at Brigham and Women’s Hospital and Harvard Medical School she is board certified both in obstetrics and gynecology and reproductive endocrinology she also served on the faculty of Harvard Medical School she developed and directed the IVF program at Genesis fertility and reproductive medicine before leaving and founding metropolitan reproductive medicine dr Liddell is a member of the American Society for Reproductive Medicine the American College of Obstetricians and Gynecologists the Society for assisted reproductive technology and the American physicians fellowship she has privileges at Lenox Hill Hospital internationally renowned internationally known for our expertise dr. LaBelle has been the recipient of numerous awards for her excellent care and compassion she has lectured widely and has been interviewed many times on television and radio and now without further ado dr. LaBelle thank you for very kind introduction and I very much appreciate the opportunity to be here this morning so I’d like to start by giving a brief preview of in vitro fertilization and then some questions with regard to how aha and to ethics that are raised by the current technology which rabbi flam will address in the next lecture as mentioned the first in vitro baby was born in 1978 the the indications were blocked fallopian tubes the procedure was done using a natural ovulation cycle requiring surgical removal of the egg or what we call osit the success rate at that time was very low and in fact the joke was that more women got pregnant waiting to do IVF than actually doing IVF and there were a lot of concerns about the potential developmental risk of a baby born through in vitro fertilization today nearly 30 years 30 years later over 5 million children have been born from IVF worldwide over half a million IVF cycles are done annually worldwide the indications now include not only tubal occlusion but ovulatory disorders and Dimitri OSIS uterine factors sperm factors unexplained infertility and more and more for genetic disorders the cycles are done with medication and controlled ovarian hyperstimulation the eggs are extracted with ultrasound rather than surgery and overall the success rates are very good and we have a lot of data on the risks both to the mother and to the child now IVF is still based on the natural

conception cycle where for approximately two weeks the brain produces the hormone follicle stimulating hormone that enables an egg to mature another hormone is then released causing it’s causing the egg to be released from the ovary and picked up by the fallopian tube the sperm travels into the fallopian tube and in natural fertilization in vivo fertilization the egg and sperm meet in the tube where fertilization occurs and after two to three days the fertilized egg travels down into the uterus and after another few days implants in the uterus with in vitro fertilization conception occurs in the lab rather than in the fallopian tube in current technology in the menstrual cycle before the cycle in which IVF is performed the natural hormones are suppressed this can be done with either a generate a ganaste which is commonly referred to as lupron or with using oral contraceptive pills followed by using another medication gnrh antagonists as the egg matures after a woman gets her period she takes follicle stimulating hormone for approximately seven to twelve days to cause the egg to mature the medication dosage is titrated based on her response and this is measured by measuring estrogen levels and also the development of the follicles little cysts in which the egg develop on ultrasound when the eggs are mature based on the estrogen levels and on the follicles the ovulation is triggered the natural hormone is LH hormone but we commonly use HCG hormone to trigger ovulation ovulation will occur 36 hours after the hormone is given so we scheduled the egg retrieval 34 to 36 hours before the retrieval in other words we can time when we do the retrieval so we’re not doing it at two o’clock in the morning today most procedures are done in a small operating room located within an office which is adjacent to the laboratory intravenous sedation is used and the retrieval is done with an ultrasound and a needle rather than requiring surgery and on the picture this is a cross section of the uterus the fallopian tube and the ovary and a cross-section of the ovary with the stimulated follicles each one of these would contain an egg and the ultrasound probe is placed in the vagina with the needle attached that goes through the vaginal wall into the ovary and the follicular fluid is drained and then that’s given to the lab where they can identify the egg and this is how it looks on ultrasound and we pass the needle through and drain the fluid now on the same day that the egg is retrieved the sperm is produced in most cases this is done through masturbation it can also be done with sexual intercourse with a collection condom and in certain circumstances we use frozen sperm for example if a man has had cancer and froze firm prior to chemotherapy with various ejaculatory disorders or if there’s a blockage that precludes the sperm from coming out a needle can be put in to the to the vessels and the sperm aspirated prior to the day of IVF and in certain circumstances while no sperm is produced in the jacket there is sperm in the testicle and with the urologist biopsy the testicle sperm can be found that can be used in IVF now for the first number of years with IVF what was done and what still continues to be done in most cases is that the sperm is obtained it’s processed and placed in little oil droplets and an egg is placed in each droplet and allowed to fertilize naturally similar as to what occurs in

the fallopian tube but what was noticed early on as the indications for IVF were expanded from not just blocked tubes but for the many circumstances where there’s a decrease in the sperm parameters that in ten percent of the time even when you placed thousands of sperm right next to the egg no fertilization would occur and so a technique was developed intracytoplasmic sperm injection which we refer to as XE in which a single sperm head is placed inside the egg and this is conventional IVF with the little droplets and an egg in each droplet and this is it see where the egg is held and the sperm had directly injected into the egg now this is what an egg looks like on the day that it’s obtained on day one we can see two pronuclei and that confirms that there’s fertilization even when we do it see where we actually put a sperm inside the egg which you could think of as fertilization but with IVF we refer to fertilization when the nuclei joined and not all eggs will fertilize and while at some level this is frustrating we feel most of the time this is because there’s either an abnormality in the egg or the sperm and it’s Nature’s Way of precluding the development of an abnormal embryo and this was a major concern in the early days of IVF that you know how would the scientists know which is a normal agar which is a normal sperm but fortunately the checks and balances that nature’s has remain intact even with IVF intervention and what we observe in the laboratory is fertilization on day 1 by day to the egg should have undergone one or two divisions and we have 22 24 cells in the embryo on day 3 with a normally developing embryo we have six to eight cells on day four there’s a rapid increase in division to what we call a morir law which looks like a bunch of grapes and by day five and a six the embryo differentiates into a blastocyst now the number of embryos to transfer is predicated on enough on several factors one is maternal age that pregnancy rate decreases with maternal age and to also with regard to paternal age another important factor is the quality of the embryos that the scientists look at the embryos and grade them based on factors such as the evenness of the cells the contact amongst the cells whether there’s fragmentation on the earlier stages and with blasts assests on other developmental factors and there’s a rough correlation between the quality how an embryo looks and whether or not it will implant it also depends on the number of prior IVF cycles we’re going to put back fewer sike fewer embryos and someone trying for the first time rather than someone trying for the fourth time and it’s also the risk of multiple gestation in someone with underlying medical problems such as obesity or increased blood pressure or an abnormality of the uterus we’re going to be much more concerned about multiples whereas if someone’s been trying for a few years they most of the time would really want to have twins although we still have concerns because there are increased risks and in recent years there’s been a lot of push to decrease the risk for triplets and quadruplets which we’ve been successful with and with the embryo transfer is in some ways more important but less involved than the retrieval no anesthesia is required and we take a little catheter and with the embryos loaded inside and pass it through the vagina through the cervix to approximately a centimeter from the top of the uterus and inject the embryos sometimes it goes easily

other times it can be rather tricky to pass the catheter through we also do this with ultrasound guidance the early emphasis was on improving embryo quality and improving pregnancy rates as procedures develop both technically and with the the various fluids that are used in the laboratory for embryo development we aimed more and more extra embryos and up until fairly recently we could freeze the embryos but oftentimes the embryos wouldn’t survive freezing and the pregnancy rate was generally about half of that for frozen embryos than for fresh embryos but with advances in freezing technology we currently can freeze embryos so that most embryos survived freezing and currently the pregnancy rate with frozen embryos is approximately the same as fresh embryos and so this has opened up a lot of opportunities it also decreases the pressure for the number of embryos to put back because we can put back one embryo and freeze the rest and if someone doesn’t get pregnant we still can be fairly confident that we’ll have good embryos for them on another cycle pregnancy test is done 14 days after retrieval now even with putting back a very good looking embryo not all embryos will implant sometimes this can be a technical issue but most of the time we feel it’s because it’s not a healthy embryo and so while it’s frustrating it’s a natural block of nature and in the big picture it’s a good thing naturally thirty-three percent of all conceptions and did miscarriage and again most is it’s time this occurs because nature’s preventing an abnormal embryo from developing further and in a classic study that was published in the New England Journal about 20 years ago was found that thirty three percent of all natural conceptions and in miscarriage but twenty-five percent of recognized pregnancies in other words women not uncommon Lee will conceive but the pregnancy just lasts a short time and they won’t even realize that they’re pregnant the risk of miscarriage increases with age and so while the overall rate is twenty-five percent of recognized pregnancy in general the miscarriage rate is around fifteen percent for women in their early 20s versus fifty percent for women at age 40 initially is mentioned there was a lot of concerned about what ivf babies would look at now that we have looked like now that we have five million of them we can be reassured that for the most part ivf babies are like all other babies there are difficulties in doing Studies on ivf babies because the studies are confounded by why the couple is doing ivf if you have a couple where the husband has a very very low sperm count it’s more likely that there’s some genetic factor in the sperm that can be passed along to the child but for the most part when this is taken into consideration overall it’s felt that there is a very small increased risk of birth defects in children from ivf but this is far outweighed by the benefit of having these children that the exit procedure has a very small increase in two disorders called imprinting disorders but again overall the chances are very very small with ivf there because generally we put back more than one embryo there is an increased risk of multiple gestation with going to blastocysts where the embryos develop further that we are now putting back fewer embryos and there’s a been a concerted effort to put back fewer embryos again because we have them develop more so we can be more selective and also with having a better freezing option so as we’re as fifteen years ago

having triplets from ivf was fairly common nowadays it’s fairly uncommon studies have shown again it’s their confounding factors by the underlying fertility problem that there probably are some increased risks with pregnancy with IVF but again most pregnancies and well now IVF has been a tremendous boon and tremendous help for many couples having difficulty conceiving but more recently we’re doing IVF more and more for couples that have a genetic disease or have the potential to pass a genetic disease on to their children and this is a very exciting development in our field and one that we hope will progress further and this was made possible by the remarkable remarkable developments in molecular biology and it’s now the point where couples can be tested with the blood test to see if they’re a carrier for genetic disease and we can take a few cells from the embryo and by ups in the embryo and determine if the embryo is a carrier for the disease or affected by the disease the biopsy is usually done on day three or day five or six of development and more and more we’re doing this on day five or six at the blastocyst stage because the embryo is more developed there’s more unanimity amongst the cells and it’s also felt it’s probably less harmful to the embryo by up seeing at this stage so the embryos are formed their biopsy the embryos are frozen and then the removed cells are tested to see if the disease is present or carrier for the disease and we also test the embryo for normal chromosome content because it wouldn’t make sense that if we found an embryo is doesn’t have taste Sachs disease but it has an extra chromosome 8 then when we would put it back either it wouldn’t implant or the woman would miscarry so we want to put back in embryo that both is not affected by the disease but has a normal chromosome content and so after the embryos are tested the woman comes back and on a thaw embryo cycle we thaw out an healthy embryo and transfer it back yielding a good pregnancy rate now while the technique was developed for testing for specific genetic diseases we can ask what we call pre-implantation genetic diagnosis we can also do preimplantation pre-implantation genetic screening where there’s no disease present but we can test the embryos for chromosomal content again the procedure is the same that the embryos are biopsied the normal cells the cells are removed and the normal embryos are identified and then just transferring back those with normal chromosomes now this is something that is a field of an area of a lot of debate in our field right now because most abnormal embryos will not implant or if they implant they’ll miss Kari fairly early on by op Singh the embryos freezing the embryos transferring them back adds thousands of dollars to the cost of the procedure and in many circumstances it’s not necessary if you have a young patient and you put back a single embryo most likely it’s going to have normal chromosomal content or if it doesn’t and then you transfer back a second embryo on a thaw cycle it’s still going to cost you less than going through biopsy the embryo and testing it on the other hand if you have a 40 year old patient who’s had several miscarriages this can be very helpful in increasing the chance of conceiving and decreasing the chance of miscarriage but it’s also important to note that even though an embryo may have chromosomal content normal chromosomal content it can still miss Carrie and can still develop other abnormalities now that’s an overview of where IVF stands right now because IVF is a

process that occurs over two weeks and involves a woman’s menstrual cycle there are certain issues that develop with regard to Jewish ritual and when I came to New York I looked at these issues and set up our program to try to get around as many issues as possible and my former mentor from Harvard dr. Selwyn osco it’s dubbed it kosher IVF so I will leave it to Rabbi flam to go over the hollow ha and how significant the various issues are but our approach was just to avoid them as much as possible so first issue what was with regard to mikva that as I mentioned that the woman takes eggs just takes medication to stimulate the development of the eggs and generally this shortens the first part of the cycle from the traditional 14 days to less than that and so potentially that could be an issue with mikvah where so there’s the issue of doing the retrieval before the mikvah but more importantly if a couple is producing the sperm sample through intercourse it’s obviously going to be a problem if if the retrieval falls before mikvah now this is something that can be easily gotten around with the use of the medication lupron that I mentioned earlier that the woman starts the medication about a week before she gets her period this stops the brain from producing hormones to stimulate the ovary so she’s in kind of a limbo face and theoretically she could stay stay on the Lupron for weeks before starting ivf we don’t leave her on lupron for weeks but whereas generally people start stimulating the ovaries at around day three of the menstrual cycle we just wait a few days more to start the stimulation and this will ensure that the retrieval falls after mikvah another issue is with Shabbat and holidays so with regard to holidays we just don’t cycle if the retrieval could possibly fall near a holiday and also the monitoring and with regard to Shabbat since that’s every week that’s a little bit more complicated to avoid but again using the medication lupron that we found that if we start the stimulation on Friday or Saturday given that the stimulation is almost always at least seven days that will ensure that the retrieval Falls after Shabbat with regard to monitoring on Shabbat that to follow the development of the eggs we usually can monitor the patient about every other day sometimes we’re required to monitor two days in a row but generally when you over the results from one day you can pretty much predict what’s going to happen over the next two days so in our Jewish patients we monitor on Friday and Sunday and that usually will avoid Shabbat rarely if someone’s having a very aggressive response it will be important to monitor them on Shabbat and what we do is instead of having them come into our office practicing in New York many people live close to a commercial lab so they can walk to a quest or labcorp or if that’s not available the organization a time has an arrangement with the gentleman will come to a woman’s home and draw her blood and bring it into the lab but again fortunately most of the time we can avoid that with regard to the embryo transfer whereas the retrieval can only be done on one day when the eggs are ready if you have a good embryo it doesn’t matter if you put it back on day two day three or day five the longer the embryos are developed in the lab the mall the more fall off there is in the development leading the embryos that are more likely to implant and nowadays we mostly put back embryos on day five but if day five is Shabbat we can put the embryos back on day three or if there are only a few embryos and we were going to put them back on d3 and

day three issue by we can put them back on day two and having done this many times we haven’t found any compromise in our pregnancy rates now in the laboratory that that we have various eggs and sperm and that every reputable lab has a lot of precautions so that the eggs and sperm aren’t mixed up because you know if we took someone’s kidney and put it in the wrong patient the body would reject the kidney but with embryos if we were to put there isn’t the same rejection process so if we were to put back the wrong embryo the body would accept it and this creates the obvious problem not being the person’s own genetics but also legally if you give birth to an embryo if you give birth to a baby it’s your baby and so all programs have very strict rules and the few times where there have been cases of mix-up if you look back it’s almost always because someone or I shouldn’t say almost I said every case that I’m aware of it’s because someone in the lab broke the rules but because of that that some authorities feel that you should have hash kaha where a train supervisor will be there in the lab and observe the eggs and sperm at all times and once the eggs and sperm are combined and put in the incubator we have a separate incubator that sealed by the mosh [ __ ] and the eggs and sperm are only taken out under the vision of the mosh [ __ ] so that there’s a witness that can attest to the fact that the proper eggs and sperm were used okay so now I’d like to raise a few ethical issues for the rabbit to address with the screening of the embryos were able to identify the sex of the embryo and so couples will come to us sometimes and say well we’d like to have a firstborn boy we don’t have any fertility issues but we want to have a boy can we do IVF another situation is where a couple is doing IVF 44 tility or genetic reasons and because we’re going to screen the chromosomes we’re going to find out which embryo is male in which embryo is female so in that situation is the couple able to request a particular sex it’s very common now that through draw reassuring certain couples are screened before before getting married but that doesn’t scream for all genetic diseases and before we do IVF that we screen couples for over 100 genetic diseases and the issue arises if if a couple is a carrier for disease are they obligated to do IVF and to prevent their child from having the disease or for being a carrier for the disease and genetic diseases are generally generally fall into two categories those that are autosomal dominant where someone will have a good gene and a badging but the bad gene is active an example of this is Huntington’s Korea so that this is a disease that that occurs later in life so someone’s father may unfortunately develop Huntington’s Korea they find out that they’re a carrier um and so each of their children will have a fifty percent chance of inheriting the disease so is it okay for them to say ok we’ll we’ll go with the fifty-fifty odds or are they required to do IVF to prevent passing on this deadly disease to their children most diseases are recessive an example of this is k sex where as long as

someone has one good gene the disease won’t be manifest in them but if someone’s who’s a carrier marries another carrier then their child has a twenty-five percent chance of having the disease and again with IVF we can lower the chance to virtually zero so do they take the odds that most likely child won’t have it or do they do IVF another factor that arises is that now that we have IVF which has such good success rate how quickly should a couple go to IVF that more than half the time when a couple has difficulty conceiving it’s due to an element of sperm factor and now that we have XE on ivf has a very very high success rate in couples with a sperm factor the natural conception rate is twenty percent per month in other words if you have a couple that has normal fertility and they have intercourse at the right time of the month the chances of conceiving or twenty percent so if a couple has a fertility factor that’s going to lower their chances somewhat so there are situations where a couple may feel well we don’t want to try for six months let’s just go to IVF where we’ll have over a fifty percent chance per month of conceiving on the opposite and their situations where a couple has a low chance of conceiving but either for their reasons or for the rabbi’s reasons they delay doing IVF and under goat costs and anxiety when they could conceive much more quickly so where is the proper line as I mentioned earlier that a third of all conceptions and in miscarriage and particularly for a couple who’s had difficulty conceiving a miscarriage is a very sad event sometimes there are underlying factors that we can treat but most of the time it’s a chromosomal factor and so that most miscarriages while difficult are due to factors preventing an abnormal child if we do IVF with screening the embryos because we’re only putting back nor embryos with normal chromosomes we can decrease the chances of miscarriage it won’t totally prevent miscarriage but there’s a significant cost it can be if someone doesn’t have any coverage when you include the cost of IVF the cost of the medications the cost of freezing the embryos testing the embryos thaw in the embryos it’s around twenty thousand dollars per cycle also if you do I BF it and create a lot of extra embryos and a couple gets pregnant and has a healthy child they now have these extra embryos so what are they to do next time can they try on their own or they obligated to use the frozen embryos and there are situations where if you have I recently had a patient who was 25 who had conceived easily and unfortunately had two miscarriages both of which were chromosomally abnormal now statistically in a 25 year old the chances of miscarriage or around fifteen percent and studies have shown that someone in her situation has over seventy percent chance of conceiving a good pregnancy she went to so I told her and it’s unfortunate but you can be reassured that most likely next time you’ll can see the healthy pregnancy she went to a different doctor who said well you can do IVF and I would recommend that you do IVF with screening of the embryos and this way we can put back in embryo that’s chromosomally normal and this will decrease your chance of miscarriage which was correct but it was also at a cost of twenty thousand dollars in creating the extra embryos and if you’re starting with about a fifteen percent chance of miscarriage you’re really not lowering the chance all that much um you know versus if you have a 40 year old woman who’s had three miscarriages she is a much higher chance of miscarriage so by doing the screening you’re really going to lower her chance of miscarriage so I hope I’ve given you an overview of where we stand with standard technology and the questions that have arisen and I leave it to Rabbi

flam to address the halacha can ethical issues do we have time for questions