INFLUENCE OF 30 YEARS OF ASSISTED REPRODUCTIVE TECHNOLOGIES ON HUMAN PROCREATION

AND FILIATION CHAINS

Sylvie EPELBOIN (France) Hpitaux Universitaires Paris Nord Val de Seine Among the major events of the medical history of the late Twentieth Century, following the contraceptive revolution of the 70s, which allowed control of fertility, ie the possibility for women and men to determine the timing of having a child, Assisted reproductive Technologies (ART) broke into the 80s and did not cease to grow since, giving infertile couples the opportunity to design and modify their reproductive future, saving women the pain of living without children, stigma, repudiation. The human desire to procreate,le dur dsir de durer, as said the poet Paul Eluard-, extend its existence, leaving a trace of ones time on earth, send a human experience, is old as the world. Profoundly selfish or altruistic desire, feeling or life plan, this concept is as difficult to define that sexuality and reproduction are representable. The reproductive medicine is an illustration of what Michel Foucault meant when he stated that the birth of the clinic was based on "where does it hurt?", and that the clinic art has become what do you want? ". If the act of giving birth is concrete, that to conceive is abstract, its medicalization renewing the fantasy world that surrounds instead of impoverishing it. A brief history of knowledge about human reproduction brings us to see that the birth of the individual is seen as a consequence of the unlikely meeting of two germs for a very short time. In the western world, it is from the sixth century BC. , and Hippocrates, that the generation of humans is related to the effect of seed, whose nature is discussed. During the Renaissance, anatomy of the genitalia is accurate, but their functioning remains a mystery. In the late seventeenth animalculists and ovists opposed, and the realization, in the eighteenth, of the first artificial insemination, was not enough to demonstrate the necessity of man and woman to conceive a child. The nineteenth is the time of the birth of the cell concept (1827), the role of sperm is rehabilitated, the cellular nature of the egg, embryo and sperm (1860) recognized. Then are known basics of embryology, theories on evolution, the observation in 1875 of a fertilized sea urchin egg, from which arises understanding of the conception in sexual beings. By 1880, chromosomes and cell nuclei appear fundamental in the process of reproduction, and Mendelian laws of heredity are known to the scientific world by 1900. The twentieth century is that of the development of knowledge of chromosomes, the discovery and synthesis of hormones, the understanding of the female cycle and her fertility, mechanisms of implementation, the development of hormone-profit contraception or inducing ovulation, infertility

surgery, in vitro fertilization (IVF). Various societies are developing models kinship where the genesis of the individual involves elements other than the encounter sexual fluids of both sexes. In "Metamorphosis of Kinship," Maurice Godelier describes several societies whose Baruya of New Guinea, where the father is considered as responsible for the conception, and the social father of the child. The woman Baruya is considered as a "receptacle" in a generated body, fed by the male sperm, but it is the Sun that animates the body of the child by giving him his breath making it human. Among the Trobriand Islanders of the Pacific, it is the mother who conceives - when this spirit - ancestral child enters his body to form the embryo of the future newborn. Father feeds this embryo of his sperm, it is considered only as the social father of this child. In the population Mossi of Burkina Faso, studied by D. Bonnet, there is a world "look back", which is both the one from where the children come and that toward which the ancestors return. Every woman has a capital of children in this world, which she invites to share the world of human persons, "the real world." In many societies, sexual relations are considered a necessary but not sufficient link to procreation ; in all cases, human intervention is not enough to make a baby. The fusion of gametes at the origin of a new life is neither a universal principle, nor common knowledge built long, where sex is seen as fertilizing. The development of medical imaging, the emergence of modern techniques of in vitro fertilization (IVF), helped popularize biological knowledge of the first stages of manufacturing of human beings. In 1978, Louise Brown, born by Caesarean section Wednesday, July 26 at the hospital in Oldham, on the outskirts of Manchester, was the only baby conceived by IVF among 122 million children born that year. Nowadays, children are 3.5 million estimated to be born from ART around the world. ART, according to the definition established in the first French law on bioethics, in July 1994 are practices for clinical and biological in vitro conception, the embryo transfer and artificial insemination, and any technique of equivalent effect to procreation beyond the natural process" The involvement of human societies in choosing what will be tomorrow's people is essential when these techniques, which were anecdotal 30 years ago, relate nowadays to 2-3% of births in countries that practice them. It should be therefore noticed that 99% of IVF babies are born in developed countries, as shown in 2010 world ART report. Various techniques, as the sperm sorting most likely to fertilize the egg, or the identification of a gene mutation in the cells of a three days embryo, open the possibility of offering answers to requests for child of men or women when natural procreation is impossible or dangerous. These techniques have generated considerable technological advances, but also ethical questions to which caregivers, philosophers, religious and political authorities have given different answers. Diversity intrastate regulation for access to ART is surprising, including or not homosexual couples, 3

single women, as well as the donation of gametes or the treatment of embryos, whether to permit their preservation by freezing, research on them, which opens the debate on their status as human beings or becomings, allowing or not their gift to another infertile couple or their transfer into the uterus of a surrogate mother. All of these techniques help to create new structures of kinship and consequent changes in the traditional conception of the human lineage. The implications for public health of "epidemic" of multiple pregnancies - more than two million children born to date-, which take their full extent in the time of assisted reproduction, when considered in all ages and societies in ambivalence between fascination and repulsion, is a constant concern. The diversity of ethical positioning reflect societal positions resulting from the history of each population, more or less marked by the importance of religious authorities or a history of eugenics shamefully lived. Alternately witness and actor, the physician is consulted for advice on the appropriate medical response to human suffering of infertility, in an obligation of efficiency, suspected of abuses, watched by the media, placed by legislators in the delicate situation, for which he was never trained, as an intermediary between the political and the individual. The daily meeting and listening, for nearly thirty years, of infertile couples, collegial practice, are sources of clinical witness that integrates with broader bioethical reflection raised by the new techniques of human reproduction. Among fields of thought opened by reproductive medicine, we will favor the following: THE ETHICAL QUESTION OF THE INTERESTS OF THE CHILD IN BORDER INDICATIONS OF ART The ethical concerns in how to balance the demand of the couple and interest of the future child, takes place in various situations, as the access to parenthood for men and women with reduced life expectancy, when improvement in the prognosis of diseases have naturally sparked the desire to conceive in young adults who suffer from it. We will develop, from the example of cystic fibrosis (CF) clinical ethics approach that guides decisions based on the criteria of autonomy, competence, justice and beneficence / nonmaleficence. Cystic fibrosis (CF) is an inherited autosomal recessive disorder, CF population is 0.7/10 000 evaluated in the 27 European countries, ie 5 000 to 6 000 patients in France. This genetic disease leads mainly to repeated respiratory infections, declining lung function, malabsorbtion, under-nutrition, diabetes mellitus. The impact on fertility is permanent sterility in men by azoospermia, and relative infertility in some women. Indications and management of ART in infertile CF women or men are debated according to the improvements in the prognosis of this disease in few past decades. Life expectancy, which did not 4

exceed 5 years in 1965, twenty in eighties, is currently exceeding 38 years. The proportion of adults has reached 50%. Therefore, both the desire to have children and the number of pregnancies have been on the rise. In CF women, these pregnancies have long been considered at high risk. Encouragingly yet unexpectedly the median survival of CF women who had a pregnancy has been recently shown as exceeding that seen in other patients never pregnant. Current data indicate that ART is a valuable option for CF women who are infertile, which does not increase mortality or morbidity for either mother or infant, and offers the prospect of positively impacting on their quality of life when the desire to conceive becomes fulfilled. Ethical concerns are to consider the welfare of the child who will be born to a family stung by the crippling disease of the parent bearing the prospect of needing an organ transplant and whose life expectancy is nevertheless reduced. The ART procedures involve physicians in an acting role in the genesis of pregnancy, as translators of social current thought, which is a fundamental difference with the usual medical practice based on reactivity to a set situation. Therapeutic advances generate the desire for a normal life, including access to parenting. These projects are not without a feeling of revenge on the disease, and often worn by the family environment. They are limits considering the Convention on the Rights of the Child: "right to be raised by his parents until his majority". This case is exemplary of other requests for couples with severe or disabling physical condition, mental disease, or situation of social precariousness, where the future of the child raises questions. There is no consensus among professionals on risk situations, but a variety of implicit attitudes to prevent the risk assessment according to the values and experiences of each, which incorporate a sense of "responsibility" towards the child. The medical aim is to refrain both from lax decisions or discrimination as a form of eugenics. Considerations are also to protect themselves from the stigma associated with a refusal, signing an abuse of medical power, or an acceptance contrary to the interests of the child, opposed by pediatricians, and a subsequent claim prejudice of conception by the child himself. Societal issues are formulated as: are we not in a compassionate approach that would fall under unreasonable obstinacy? How far to take risks for physical or psychological child in consideration of emotional suffering of his parents? What assessments do we have? Which can decide the quality of life of a person not yet conceived? Cystic fibrosis is an example of the evolution of the indications of ART and ethical questioning in relation to therapeutic advances made in other fields of medicine. Access to ART is as part of the evolution of the disease, a factor of insertion into a normal life. Optimistic results, however, must be confirmed by the long-term monitoring of sick parent and child. Moreover, current thinking is extended by the assessment of situations estimated at high risk as the demand for children of women lung-transplanted. Risks to mother and child are high, the existing assessment is limited but 5

unfavorable ... as for cystic fibrosis 15 years ago. The ethical issue is also that of the life debt, transplants are scarce resources, but reservations are opposed to the autonomy of patients involved and informed. Ultimately, the evolution of medicine generates requests shortly before deemed "non-standard" of pregnancies that disturb the common sense of medical responsibility and are consistent with the evolution of ethical thought. The medical terms are relatively clear, the techniques are not a specific problem. The predominance of ethical principles (autonomy, justice, beneficence / nonmaleficence) is shaped specifically on the balance of attention at the request of the couple or projections on the child's life ... knowledge somewhat supported INS AND OUTS OF EMBRYO FREEZING The freezing of gametes and embryos, both allows pregnancies in lifetime previously unthinkable, and arises ethically controversial questions about delayed embryo transfers, even postmortem if died father. In 1984, Zoe, born in Melbourne, was the first child born in Australia and the world of a frozen embryo at 8-cell stage, the transfer of three embryos transferred immediately first unsuccessful. In 1987, a British gave birth to a girl after frozen embryo transfer, 18 months after the birth of her older sister conceived the same day , The First French cryo birth occurred in 1986. The shelf life, the legal status of the embryo, were discussed only a posteriori, as the technical success were going very quickly, resulting in ethical and legal imbroglios. The most famous, in the first times, was that of embryos Rios, from South American billionaires parents in care for IVF in Melbourne in 1981, both died in a plane crash on their way to Australia (for embryo transfer) in April 1983. Michael, son of first marriage of Mr. Rios, took a lawyer to protect his legacy against his potential siblings. How to decide the future of frozen embryos, conceived with a sperm of donor? Dozens of U.S. couples were candidates for uterine transfer of these embryos potentially billionaires! Nowadays, the number of children born through frozen/thawed embryo transfer (FET) is steadily rising (nearly 100000 a year), as well as questions about their neonatal health and development. Benefits of cryopreservation are no more to be demonstrated, because of increasing in the cumulative pregnancy rate, of the comfort of treatment without hyper stimulation and oocyte retrieval and cost effectiveness Looking back, emerging questions are about particular representations of pregnancies and births of the specific freezing event, as family impact of twining by simultaneous conception and delayed birth 6

(if two births from the same attempt). Psychological data are now related, when conflicts in the sibling, as well as questions of the ex-cryo child about the reason for choosing one or the other on the day of the first transfer. Some countries, like France, have framed very narrowly the time of embryo cryo preservation and their use at the end of parental finalized project. The couples, consulted annually for five years on their project for their spare embryos, can request a transfer (in case of failure of the transfer "fresh", or after childbirth) stopping the conservation, consent to donation for research or embryo donation. At the same time, the maximum duration of storage of embryos was ten years in Finland, Israel, Spain, Taiwan, five years in Britain, Switzerland and Argentina, only one year in Austria, Switzerland and Denmark. In Ireland, Austria, Norway and Israel, the embryos not "used" by the couple could not be given, or to another, or for research. Under French law, the embryo is not a "simple" element of the human body, but a "potential person", what distinguishes the law in his gift of gamete donation. In the first bioethics law in1994, the embryos could be kept five years, and stopping the conservation could not be considered, but exceptional. Yet every day in laboratories, multiple embryos judged by embryologists unable to evolve properly are "thrown". This possibility could not be applied to frozen embryos, because of favorable estimated prognosis, as if the freezing step- human interventionsanctified them by giving them an extra spark of humanity. Procedures for embryo donation have a court order and therefore are processes close to those of adoption. Nevertheless, embryo donation is considered as ART with donors regarding the anonymity and free. Various questions considering this in utero adoption remain nowadays. For parents who have done this gift, will there be a detrimental impact on their future life (sorry, not to take an additional pregnancy), or transforming their family and social representation? (generous gift or guilt of abandonment?). For recipients or foster parents who obtained a birth after a long medical history, will they be brought to see their child as having a share of foreign to them, what interference in the acquisition of their parenting? How the children from embryo donation will they find their place into the chain of generations, born from a double project, those of the donors and the recipients? How will the society integrate these families of new composition? The answers to all these questions, are conditioned by secrecy, or the revelation of fashion conception, both to the child and his family group and relational, and in the first family, where IVF children will have to be informed of the existence of brother or sister born of another mother, they will never know. 7

GAMETE DONATION AND PRESERVATION OF FERTILITY The reshaping of traditional families by birth of children from donated gametes or embryos raises the question of the dissociation between genetic, uterine, and social motherhood, Different countries have or not regulations or laws, relevant to social choices. Egg Donation is banned in some countries and regulations differ in countries where it is allowed. It is monetized in some countries like the United States. The donation is allowed in postmenopausal women in some places and forbidden elsewhere Thus, the French system provides egalitarian access to infertility treatments and well distributed over the territory. The founding principles guarantee to the whole of the population quality, safety, free and equal access to care. It allows professionals to implement techniques for the purpose of better outcome in terms of risk / benefit ratio. Reimbursement of 4 attempts resulting in an embryo transfer, and the authorization (and results) of embryo freezing, allowed the development of single embryo transfer (SET) in the most optimistic case, or, in the other, limiting the number of embryos transferred to two in most cases. This transfer strategy has limited multiple pregnancies and their consequences on maternal and fetal health, dominated by premature births and their consequences in terms of individual and public health, when financial argument prevails in some countries to "return" of expensive treatments for couples with a higher risk taking. This fair is facing nonetheless defined access conditions, such as the concept of a couple "of childbearing age," which opposes the principle of "the child at all costs" and autonomy of choice for couples. Reimbursement of IVF in France ends at 43rd birthday, since we consider that ovarian failure in fourties will not lead to success-through natural or IVF conceptions. This also applies to oocyte donation. However, the evolution of morals suggests that a happy motherhood may occur beyond this age, and obstetric complications related to age really happen that beyond 45 years, which could admit to favorably consider the breach of natural fertility. This limit is 50 years in Spain. Moreover, the principle of free limits the number of voluntary donors. This allows the development of "procreative tourism", where "cross-border 'practices take an even greater importance than the offers are multiplying more or less transparent disseminated through modern means of communication. On-demand services are growing, as payment for human body parts, whose practice is theoretically banned in Europe (Oviedo Convention on Human Rights and Biomedicine). The notion of "childbearing age" is much less clear in men, given the opportunity to conceive naturally in old age. The absence of limitations related to the dangers of pregnancy at an advanced age, and relationship management in ART and age is less dependent on medical choices that societal choices. The fertility preservation has long been possible in men, a self-preservation is proposed before any 8

treatment which could cause lasting damage sperm quality, including cancer treatments. Stored sperm can then be used on demand, when the condition is stabilized or cure obtained. Sperm banks in France, however, set a maximum age (60 to 65) for the subsequent use of sperm. This is the source of debate, supporters of the absence of limits arguing that it is not logical that ART generates superior moral requirements than situations of natural conception. Preservation of female fertility is current latest, because until recently time, preservation technique of oocytes was not feasible. Oocyte vitrification, or rapid freezing, now opens opportunities wherever it is allowed. The difference with men is of course the time of pregnancy, and pathologies known to late pregnancy. Everyone agrees on the medical indications (as preservation before cancer treatment, for use when healing), but it is the extension of the indications which is under debate. Everyone has in mind the dramatic consequences for the mother and the child of some pregnancies after oocyte donation in excess of 50 years, that were exploited by the media. The oocyte auto-conservation called "for convenience" in women who know that after 35 years of ovarian reserve is diminishing and that have not fully realized their professional lives, or simply have not found the desired partner and future father, generate contradictory positions. The argument of freedom available to women, on equal terms with men, of childbearing when they want, is opposed to those of an age limit for life bearing, the medical reason, and the interest of child to avoid generational confusion. Among other emerging issues in the development of gamete preservation, dominate those of the future of gametes not used, of determining who is responsible, including to stop conservation and when, and thus the definition of their property. An ethical strong argument is the preference for the conservation of gametes to limit the number of stored embryos. Indeed, it is the fate of frozen embryos, overall parental project, which frightens the perspective of abuses, arising from their primary purpose of these potential human lives. Considering human being and becoming, the most debated technique is certainly surrogacy. Surrogacy is the implantation in the uterus of a woman, of an embryo resulting from in vitro fertilization of an egg of a woman deprived of uterus by sperm from her husband. The "surrogate mother" bears and gives birth to the child born of this conception on behalf of those "intending" parents. The elements of the controversy are multiple, medical, psychological, ethical and legal, religious, philosophical. They question the definition of the human lineage, the danger of exploitation of women's bodies, the physical and psychological risks they face, the interest of the child "at any cost" and the family group concerned, as well as mercantile risks of abuse and economic issues of cross-border procedures. There is a wide disparity among states as to the authorization of surrogacy, with or without a legal framework, or prohibition of this practice. It is strictly prohibited in France, Germany, Italy, Spain and Switzerland. It is authorized, in Britain, Spain, Greece, Belgium and the Netherlands, Belarus, 9

Moldova, Russia, Ukraine, Israel and India. In United States and Canada, the laws vary from state to state. The arguments in favor of the legalization of surrogacy take into account primarily the desire of child of couples where the woman has no uterus, overshadowing, and the interests of the child, and that of the "surrogate mother". However, the process involves all these protagonists and their relatives. The suffering of couples, when the woman's uterus is absent or unable to develop a pregnancy, is indisputable. The good intentions of those couples towards the desired child are undeniable. Nevertheless, the acceptance in principle of surrogacy opens the debate on certain indications commonly treated as aberrations, psychological (desire for children hampered by the fear of suffering the vagaries of pregnancy) or societal (elder women, desire of parenthood for single men, or couples gay men). Associations suggest that the uterine, but not ovarian mother, could live pregnancy detached from the prospect of a child. However, no one can assume that carrying a child genetically of other generate a surrender easier after pregnancy. Is the genealogy of a child based on its conception, or biological and / or social birth? The argument of the preponderance of gestational link on the genetic link is evoked for decades in consultations with couples whose infertility involves the use of donor gametes to strengthen their proposals in anticipation of a future relationship unequivocally. As we already saw it, the embryo donation is based, unlike surrogacy, on a recovery time of uterine pregnancy of a child conceived from the gametes of others, what motivates couples in that it represents an essential alternative to adoption. Arguments based on optimization of structuring the relationship during pregnancy cannot easily be reversed to the needs of another cause. The psychosocial concerns are based on evidence that pregnancy is not only an individual event, but involves the family, nuclear and extended, and society. How, for the surrogate mother, deal with issues of pregnancy outcome without children, the gaze and questions of her relatives, imagine a future where the memory of the surroundings will never do it to ignore this time life? What can be the experience of her children, husband? How could we anticipate the perturbation for an older child to see her pregnant mother giving her baby, even with explanations? At what price and for what benefit could a child share the generosity of his mother? What feeling in a future pregnancy for herself for a next child? On the medical front, however, pregnancy, although often smooth, is still an event that can kill or disable. Every pregnancy is at risk. Miscarriage, ectopic pregnancy , are sources of pain and bleeding risks or secondary infertility. Taking risks of deleterious effects of pregnancy cannot be considered in the same way as part of a proposed child within a couple, or a surrogacy without the benefit of motherhood. From this contrast emerges the moral objection to what is described as the instrumentalization of the body, even a dehumanizing, since all the affects need to be suppressed "in 10

the bud". What about the interests of the child without unreasonable projections? The mother-child relationship that is established during pregnancy, considered by many psychologists is no longer denied by anyone. Whatever one thinks of that link, it is nevertheless difficult to imagine that we can, even before embryonic conception, program to break it. Time of pregnancy is that of hormonal, nutritional exchanges, maintained by the perception of movements of the child in utero, ultrasound imaging. Project the shelving of the emotional aspects of these moments of pregnancy seems hardly conceivable without consequence, for the mother or the child. There are also situations where it is difficult to anticipate the future of the child, in case of abnormal development, malformation, or premature birth with risk of residual disability. The emotional investment or disinvestment cannot, in any event, be insured under a contract. Finally, the remuneration for the business side of the disposal of the womans body and a life time, gives the child a commodity status, which is not morally defensible. Motherhood is a lifetime event too intimate and too important link in the family to think of any transaction on behalf of the issue of the biological child. It does not seem acceptable to consider replacing the suffering of a woman by the endangerment of another. CONCLUSION Life configurations have been revolutionized in recent decades by the emergence of technologies that disrupted the fate that was the sterility of men and women for centuries. These beneficial effects, accessible to a minority, however, have opened a vast field of questions which we have here given some modest insights. Technical progress is permanent, the prospects for preservation of human fertility also offer changes in organizational life time. Children born from reproductive techniques are the result of lifestyle choices. Trivializing these techniques leave however, so exhilarating, a great deal of mystery at birth, provided we keep a commitment to reflection on the limits not to exceed REFERENCES 1. 2. 3. BONNET Doris., la procration, la femme et le gnie (les Mossi de Haute Volta) , Canto-Sperber M., Frydman R. (2009), Naissance et libert. La procration. Quelles DELAISI DE PARCEVAL G., la gestation pour autrui, un bricolage des

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