Affordability and quality of cross-border reproductive care from the perspective of surrogacy mediating agencies in Spain / Asequibilidad y calidad de la atención reproductiva transfronteriza desde la perspectiva de las agencias mediadoras de gestación por sustitución en españa

RESUMEN La gestación por sustitución contribuye a la transformación de las concepciones sociales de la filiación y los cambios en las estrategias reproductivas de las familias. En la presente contribución se relaciona la teoría de la atención reproductiva transfronteriza con las teorías posmodernas de la vida familiar, con el propósito de explorar qué temáticas, elementos y contenidos utilizan las agencias intermediarias de gestación por sustitución que tienen por destinatarios a las madres y padres de intención españoles. Se utiliza la metodología cualitativa y la técnica de análisis de contenido temático tras el registro de la información online recogida de las agencias. Los resultados evidencian el papel de estas agencias mediadoras en los procesos de gestación por sustitución en España, además de generar conocimiento en el área de las nuevas formas familiares constituidas mediante técnicas de reproducción asistida.

ABSTRACT Substitution pregnancy contributes to the transformation of social conceptions of filiation and changes in the reproductive strategies of families. This contribution relates the theory of cross-border reproductive care with post-modern theories of family life in order to explore which themes, elements and contents are used by intermediary surrogate pregnancy agencies which target Spanish mothers and fathers. The qualitative methodology and the technique of thematic content analysis after registration of the online information collected from the agencies is used. The results show the role of these intermediary agencies in the process of gestation by substitution in Spain, as well as generating knowledge in the area of new family forms constituted by assisted reproduction techniques.

Expanded carrier screening for recessively inherited disorders: economic burden and factors in decision-making when one individual in a couple is identified as a carrier.

PURPOSE: When undergoing expanded carrier screening (ECS), couples are often screened sequentially to reduce need for a second individual's test. It is unknown how often partners of individuals found to be carriers complete the recommended testing with a sequential approach and what factors contribute to decision-making regarding partner testing. Additionally, the economic burden placed on individuals by ECS testing and its effect on partner testing has not been evaluated. METHODS: In part 1, all individuals at a university-affiliated reproductive endocrinology and infertility practice identified to be carriers of a recessively inherited mutation using the Counsyl/Foresight ECS were included. Conditions were categorized by severity according to a previously described classification system. In part 2, all individuals who underwent ECS with a single test provider between September 1, 2013 and February 1, 2020 were contacted via email to complete a confidential and anonymized online survey. RESULTS: In part 1, a total of 2061 patients were screened. 36.9% were carriers of one or more recessively inherited disorders. Twenty-seven percent of positively screened individuals did not have their partner screened. Carriers of a moderate condition had a trend towards a reduced odds for having their partner screened compared to a profound condition (OR 0.36, 95% CI 0.12-1.05, p = 0.06). Number of conditions was not predictive of subsequent partner screening (OR 0.95, 95% CI 0.72-1.25, p = 0.72). In part 2, the cost of ECS was not covered by insurance for 54.5% (103/189) and most paid over $300 out-of-pocket for testing (47.6%). The most common reason for not completing partner testing was that the results would not alter their course when seeking conception (33.3%). 73.5% of patients knew that the largest benefit of ECS comes from knowing a partner's results as well as their own. CONCLUSIONS: Not all carriers of recessively inherited disorders choose to undergo partner screening. Patients found to be carrier of more debilitating genetic disorders may be more likely to screen their reproductive partners. For many, ECS testing is not covered by insurance, and this test may impose a significant economic burden. For some patients, the results of ECS would not change what they would do when seeking conception. Providers should evaluate whether a patient's ECS result would change their treatment course prior to testing.

New York State Creates New Governance of Commercial Gestational Surrogacy.

United States law recognizes adult reproductive liberty and many states view surrogacy services through that lens. During the COVID-19 pandemic in March, 2020, New York State enacted the Child-Parent Surrogacy Act (CPSA) into law, after feminists and their allies had caused its defeat in 2019. Just before approval of the CPSA, a group of legislators introduced the Alternative Surrogacy Bill (ASB). This article is a case study that examines how the CPSA and not the ASB became law, examining surrogate rights, the best interests of the child, and the ethical issues related to adult donor-conceived and surrogacy born children's rights to information about their ancestry.

Infertility policy analysis: a comparative study of selected lower middle- middle- and high-income countries.

BACKGROUND: Infertility has recently become a salient but neglected global issue. Policies to address the sexual and reproductive health and rights (SRHR) are vital, especially in lower middle and middle-income countries (LMICs). Hence, the aim of this study was to compare the national infertility policies in the selected countries (LMICs comparing with high-income) to determine gaps or to confirm desirable policies in the given health systems. METHODS: This study has executed a comparative policy analysis of infertility services using the universal health coverage framework (financial protection, population coverage, and service features) in three scopes (prevention, treatment, and supportive care). Seven countries that had infertility programs in their health sectors were selected. RESULTS: The results showed that financial protection was good in high and middle-income countries, but in a lower middle income, and in one high-income country was poor. The findings also showed that health systems in the same countries had no infertility services for men. Preventive and supportive care services were neglected in LMICs by governments. CONCLUSION: The findings indicate that income is not the only factor that fulfills universal health coverage for infertility care services. Perhaps to achieve equity in infertility care services, it should be seen as a universal human right to accomplish the right to have a child and to have a life with physical and mental health for all men and women.

Procreation machines: Ectogenesis as reproductive enhancement, proper medicine or a step towards posthumanism?

Full ectogenesis as the complete externalization of human reproduction by bypassing the bodily processes of gestation and childbirth can be considered the culmination of genetic and reproductive technologies. Despite its still being a hypothetical scenario, it has been discussed for decades as the ultimate means to liberate women from their reproductive tasks in society and hence finally end fundamental gender injustices generally. In the debate about the application of artificial wombs to achieve gender equality, one aspect is barely mentioned but is of crucial relevance from a medical-ethical perspective: whether and how could full ectogenesis be justified as a proper use of medicine? After characterizing the technology as a special form of human enhancement and as an extension of medical practice that goes beyond the traditional field of medicine, this paper critically assesses the theoretical possibilities of legitimizing this extension. We identify two ways of justification: either one argues that ectogenesis fulfils a proper goal of medicine (a justification we call pathologization), or one argues that the application of ectogenesis achieves a non-medical goal (which we call medicalization). Because it is important from a medical-ethical point of view to avoid an inappropriate instrumentalization or misuse of medicine and thus an undue medicalization of non-medical problems, a set of necessary conditions has to be met. It is doubtful whether full ectogenesis for non-medical purposes could fulfil these conditions. Rather, its comprehensive usage could be seen as a revolutionary modification of what it means to be human.

Gestation, equality and freedom: ectogenesis as a political perspective.

The benefits of full ectogenesis, that is, the gestation of human fetuses outside the maternal womb, for women ground many contemporary authors' arguments on the ethical desirability of this practice. In this paper, I present and assess two sets of arguments advanced in favour of ectogenesis: arguments stressing ectogenesis' equality-promoting potential and arguments stressing its freedom-promoting potential. I argue that although successfully grounding a positive case for ectogenesis, these arguments have limitations in terms of their reach and scope. Concerning their limited reach, I contend that ectogenesis will likely benefit a small subset of women and, arguably, not the group who most need to achieve equality and freedom. Concerning their limited scope, I contend that these defences do not pay sufficient attention to the context in which ectogenesis would be developed and that, as a result, they risk leaving the status quo unchanged. After providing examples of these limitations, I move to my proposal concerning the role of ectogenesis in promoting women's equality and freedom. This proposal builds on Silvia Federici's, Mariarosa Dalla Costa's and Selma James' readings of the international feminist campaign 'Wages for Housework'. It maintains that the political perspective and provocation that ectogenesis can advance should be considered and defended.

'We are not infertile': challenges and limitations faced by women in same-sex relationships when seeking conception services in São Paulo, Brazil.

The use of reproductive technologies has expanded beyond cases of infertility, and opportunities for individuals of different sexual orientations to use such technologies for conception have increased. The authors examined the challenges and limitations faced by women in same-sex relationships seeking conception services in São Paulo, Brazil. They interviewed 16 women in same-sex relationships who conceived children using reproductive technologies. Access to public health services for conception remains limited and exclusive to infertile heterosexual couples. Women in same-sex relationships are forced to select between costly medical treatments in the private sector, or self-insemination with sperm from a known donor. In this study, individuals reported that they experienced adverse effects of treatments; were treated with technologies for infertility when they were, in fact, fertile; and were exposed to unnecessary and invasive interventions. Growing political conservatism and the reduction of investment in public health services are factors that can directly affect sexual and reproductive health, including that of lesbians. Public policies that enable same-sex couples to conceive have yet to be developed in many countries, and a clearer articulation of the right to evidence-informed, rights-based care, consistent with national and international guidelines is a much-needed next step.

Optimizing female allocation to reproductive technologies considering merit, inbreeding and cost in nucleus breeding programmes with genomic selection.

Female reproductive technologies such as multiple ovulation and embryo transfer (MOET) and juvenile in vitro fertilization and embryo transfer (JIVET) have been shown to accelerate genetic gain by increasing selection intensity and decreasing generation interval. Genomic selection (GS) increases the accuracy of selection of young candidates which can further accelerate genetic gain. Optimal contribution selection (OCS) is an effective method of keeping the rate of inbreeding at a sustainable level while increasing genetic merit. OCS could also be used to selectively and optimally allocate reproductive technologies in mate selection while accounting for their cost. This study uses stochastic simulation to simulate breeding programmes that use a combination of artificial insemination (AI) or natural mating (N), MOET and JIVET with GS. OCS was used to restrict inbreeding to 1.0% increase per generation and also to optimize use of reproductive technologies, considering their effect on genetic gain as well as their cost. Two Australian sheep breeding objectives were used as an example to illustrate the methodology-a terminal sire breeding objective (A) and a dual-purpose self-replacing breeding objective (B). The objective function used for optimization considered genetic merit, constrained inbreeding and cost of technologies where costs were offset by a premium paid to the seedstock breeder investing in female reproductive technologies. The premium was based on the cumulative discounted expression of genetic merit in the progeny of a commercial tier in the breeding programme multiplied by the proportion of that benefit received by the breeder. With breeding objective B, the highest premium of 64% paid to the breeder resulted in the highest allocation of reproductive technologies (4%-10% for MOET and 19%-54% for JIVET) and hence the highest annual genetic gain. Conversely, breeding objective A, which had a lower dollar value of the breeding objective and a maximum of 5% mating types for JIVET and zero for MOET were optimal, even when highest premiums were paid. This study highlights that the level of investment in breeding technologies to accelerate genetic gain depends on the investment of genetic improvement returned to the breeder per index point gain achieved. It also demonstrates that breeding programmes can be optimized including allocation of reproductive technologies at the individual animal level. Accounting for revenue to the breeder and cost of the technologies can facilitate more practical decision support for beef and sheep breeders.

The assisted reproductive technology subsidy in Korea: criticism from a perspective of reproductive responsibility / El subsidio para la tecnología de reproducción asistida en Corea: crítica desde una perspectiva de responsabilidad reproductiva / A subvenção tecnológica de reprodução assistida na Coreia: uma crítica a partir de uma perspectiva de responsabilidade reprodutiva

The Korean government's new policy of subsidizing assisted reproductive technology (ART) fees to increase the birth rate reflects a lack of concern for future generations and their quality of life. It seems wrong to treat the future child as just a number that contributes to achieving the target birth rate, or as a mere means of solving a problem facing the current generation. However, when one tries to articulate the shortcomings of this new policy, one realizes that the ontological arguments surrounding this issue, namely the non-identity problem is complex. I propose the concept of reproductive responsibility as a response to the possible life. This concept presupposes a relationship between the reproductive agent and the possible new life. Since the concept draws the normative standard from that relationship, it resolves the non-identity problem and makes it possible to criticize the new policy of subsidizing ART.

La nueva política del gobierno de Corea de proporcionar subsidio para los costos de la tecnología de reproducción asistida (TRA), para incrementar el número de nacimientos, refleja falta de preocupación por las futuras generaciones y su calidad de vida. Parece equivocado tratar a un niño futuro como un número que contribuye a lograr la frecuencia de nacimientos objetivo, como un mero medio para resolver un problema que enfrenta la generación presente. Sin embargo, cuando uno trata de articular las deficiencias de esta nueva política, se da cuenta de que los argumentos ontológicos sobre el tema son complejos, principalmente el problema de falta de identidad. Propongo el concepto de "responsabilidad reproductiva" como respuesta a la posible vida. Este concepto presupone una relación entre el agente reproductivo y la posibilidad de nueva vida. Debido a que el concepto extrae su normatividad de esta relación, se resuelve el problema de falta de identidad y hace posible criticar la nueva política de proporcionar subsidio a TRA.

A nova política de governo coreano de subsidiar a tecnologia de reprodução assistida (ART) para aumentar a taxa de natalidade reflete uma falta de preocupação com a geração futura e sua qualidade de vida. Parece errado tratar a futura criança como apenas um número que contribui para atingir a meta de taxa de natalidade, ou como um mero meio de resolver um problema que enfrentam a atual geração. No entanto, quando tenta-se articular as deficiências desta nova política, percebe-se que os argumentos ontológicos em torno desta questão, ou seja o problema da não-identidade é complexo. Eu proponho o conceito de responsabilidade reprodutiva como uma resposta para a vida possível. Este conceito pressupõe uma relação entre o agente reprodutivo e a possível nova vida. Uma vez que o conceito desenha um padrão normativo desta relação, ele resolve o problema da não-identidade e torna possível criticar a nova política de subsidiar ART.

Ácido fólico 400mcg em associação a vitamina E 10mg para prevenção de distúrbios do tubo neural relacionados à deficiência de ácido fólico em mulheres que estejam em idade fértil / Folic acid 400mcg in combination with vitamin E 10mg for prevention of neural tube disorders related to folic acid deficiency in women who are of childbearing age

CONTEXTO: Os defeitos do tubo neural são defeitos congênitos severos do sistema nervoso central que se originam durante a embriogênese, entre o 18º e 28º dias após a fertilização. Referem-se à fusão incompleta ou fechamento defeituoso da região mediana dorsal do embrião e podem ser divididos em cranianos e espinhais. Os mais comuns são anencefalia, as encefaloceles e a espinha bífida. As características clínicas associadas a essas deformidades variam bastante, principalmente com relação à severidade. Lesões abertas que afetam o cérebro (anencefalia, craniorraquisquise) são invariavelmente letais antes, no momento ou pouco tempo após o nascimento. As encefaloceles também podem ser letais a depender da extensão do dano cerebral relacionado à protrusão (herniação). Casos de espinha bífida aberta são compatíveis com a sobrevivência após o nascimento, entretanto o comprometimento neurológico resultante do local afetado pode traduzir-se em perda sensorial, incapacidade de andar e incontinência. O tratamento principal para as encefaloceles e para a espinha bífida é o cirúrgico, quando possível. No Brasil a prevalência de todos os defeitos do tubo neural no período de 2005 a 2007 foi de 24,3 por 10.000 nascimentos. Uma importante intervenção médica é a prevenção de defeitos do tubo neural por meio da suplementação periconcepcional com ácido fólico. O Ministério da Saúde por meio do Programa Nacional de Suplementação de Ferro (PNSF) e da Política Nacional de Alimentação e Nutrição (PNAN) (Portaria nº 1.977, de 12 de setembro de 2014) recomenda em Manual de Condutas Gerais do Programa Nacional de Suplementação de Ferro que a suplementação com ácido fólico deve ser iniciada pelo menos 30 dias antes da data em que se planeja engravidar para a prevenção da ocorrência de defeitos do tubo neural e deve ser mantida durante toda a gestação para a prevenção da anemia. TECNOLOGIA: Ácido fólico 400 mcg em associação a acetato de dextroalfatocoferol (vitamina E) 10 mg. PERGUNTA: O DTN-Fol® é uma opção eficaz, segura e econômica para a prevenção de defeitos do tubo neural (DTN) associados à deficiência de ácido fólico em mulheres que estejam em idade fértil ou que desejam engravidar em comparação com as opções disponibilizada pelo Sistema Único de Saúde? EVIDÊNCIAS CIENTÍFICAS: Atualmente não há estudos nos quais se comparem de forma direta os efeitos da suplementação periconcepcional com ácido fólico isoladamente com os da suplementação com ácido fólico em associação com vitamina E na prevenção de defeitos do tubo neural ou em outros importantes desfechos relacionados à gestação e maternidade. Em revisão sistemática de estudos controlados e randomizados de boa qualidade apontou-se efeito benéfico da utilização preconcepcional de ácido fólico na prevenção de defeitos do tubo neural independentemente da associação desse composto a outras vitaminas e sais minerais. Após a publicação dos estudos controlados randomizados nos quais se demonstra efeito protetor da suplementação com ácido fólico, foram conduzidos vários estudos observacionais e de casocontrole, nos quais, em sua maioria, obtém-se resultados que corroboram os estudos clínicos, observando-se o efeito protetor do ácido fólico tanto proveniente de programas de fortificação alimentar quanto da suplementação direta. Em revisão sistemática de boa qualidade metodológica não se identificou efeito benéfico da suplementação periconcepcional com vitamina E em importantes desfechos relacionados à gestação, à maternidade e à saúde do feto. Em função da comprovação do efeito protetor do ácido fólico grande quantidade de países, por meio de seus órgãos sanitários, recomendam a suplementação periconcepcional com esse composto. Em nenhum país recomenda-se a suplementação com vitamina E de forma específica. AVALIAÇÃO ECONÔMICA: A análise de custo-minimização apresentada pelo demandante não foi considerada adequada para o contexto apresentado porque, de acordo com as evidências avaliadas nesse parecer, não se deve considerar as tecnologias em análises intercambiáveis, não se justificando uma suplementação em nível populacional com vitamina E. Outra questão diz respeito ao preço do ácido fólico isolado utilizado, o preço fábrica da tabela CMED, que é mais alto que o valor praticado de fato no SUS, quando se avaliam registros de compras recentes. O que se observa na prática é que a tecnologia em análise é mais cara que o ácido fólico isolado, não se justificando uma análise de custo-minimização. AVALIAÇÃO DE IMPACTO ORÇAMENTÁRIO: Uma possível incorporação da associação entre ácido fólico e vitamina E causaria um aumento de gasto incremental de R$ 6.928.122,00 no primeiro ano e um gasto acumulado incremental nos três anos de R$ 68.254.800,30. RECOMENDAÇÃO INICIAL DA CONITEC: A recomendação inicial da Comissão Nacional de Incorporação de Tecnologias no SUS, na 66ª reunião ordinária no dia 10 de maio de 2018, foi por unanimidade não incorporar a associação entre ácido fólico (400 mcg) e vitamina E (10 mg) (DTN-FOL®), entendendo que apesar de ser forte a recomendação da utilização adequada de ácido fólico periconcepcional para a prevenção de defeitos do tubo neural, não há evidências sobre o efeito da utilização periconcepcional da associação entre ácido fólico e vitamina E ou de vitamina E isolada em desfechos relacionados a defeitos do tubo neural. Além disso, uma possível incorporação da referida associação estaria relacionada a um aumento de gastos para o SUS. CONSULTA PÚBLICA: A consulta pública nº 29/2018, publicada no diário oficial da união de 25/05/2018, foi realizada entre os dias 26/05/2018 e 14/06/2018. Foram recebidas 82 contribuições, sendo 9 pelo formulário para contribuições técnico-científicas e 73 pelo formulário para contribuições sobre experiência ou opinião de pacientes, familiares, amigos ou cuidadores de pacientes, profissionais de saúde ou pessoas interessadas no tema. Após apreciação das contribuições encaminhadas pela consulta pública, o plenário da CONITEC entendeu que não houve nem um fato novo e suficiente para alterar a conduta atual do Ministério da Saúde que é a da utilização de ácido fólico na concentração de 400 mcg no período periconcepcional para prevenção de defeitos do tubo neural, não entendendo que a associação obrigatória com vitamina E, apesar de segura, traria algum benefício adicional. Dessa forma, mantém a recomendação inicial desfavorável à incorporação da associação fixa entre ácido fólico e vitamina E. Reforça-se que o medicamento DTN-FOL® é eficaz e seguro, entretanto de composição muito específica, com apenas um produtor nacional em contexto de utilização do ácido fólico em escala nacional para prevenção de defeitos do tubo neural, como política pública em saúde. RECOMENDAÇÃO FINAL DA CONITEC: Os membros da CONITEC presentes na 69ª reunião ordinária, no dia 01 de agosto de 2018, deliberaram, por unanimidade, por recomendar a não incorporação ao SUS da associação entre ácido fólico (400 mcg) e acetato de dextroalfatocoferol (vitamina E) 10 mg para prevenção de defeitos do tubo neural relacionados à deficiência de ácido fólico em mulheres em idade fértil. Foi assinado o Registro de Deliberação nº 359/2018. Decisão: Não incorporar o ácido fólico 400 mcg + acetato de dextroalfatocoferol 10 mg para prevenção de distúrbios do tubo neural relacionados a deficiência de ácido fólico, para mulheres em idade fértil no âmbito do Sistema Único de Saúde ­ SUS

Homoparentalidade feminina: nuances da assistência à saúde durante concepção, gravidez, parto e pós-parto / Female homoparentality health care during conception, pregnancy, childbirth and postpartum

Com a possibilidade de acesso a tecnologias reprodutivas cresce o número de mulheres em relação homoafetiva que engravidam e buscam o sistema de saúde. Estudos mostram que a qualidade do atendimento pode ser afetada por questionamentos inadequados, homofobia e comunicação heteronormativa. O objetivo deste trabalho é compreender a percepção de mulheres em relação homoafetiva sobre a assistência à saúde recebida durante concepção, gravidez, parto e pós-parto em serviços públicos e privados na região metropolitana de São Paulo. Neste estudo qualitativo foram entrevistadas de forma individual 19 mulheres que tiveram filhos biológicos durante uma relação homoafetiva, totalizando a história de dez casais. Os resultados apontam que o acesso aos serviços públicos de concepção permanece exclusivo aos casais inférteis heterossexuais. Os casais homoafetivos precisam escolher entre tratamentos médicos caros e invasivos no sistema privado ou uso de inseminação caseira com esperma de doador conhecido, técnica não regulamentada no Brasil e que pode acarretar problemas legais futuros caso o doador decida requerer direitos de paternidade. Mais do que apenas eventos biológicos, a concepção, gestação, o parto e a amamentação possuem dimensões sociais e relacionais importantes de vínculo da parceira que não gesta com o bebê, e também com a companheira que está grávida. No entanto, a reprodução ainda requer a legitimação e o reconhecimento das especificidades de casais homoafetivos por diversos atores envolvidos nesse processo, entre eles os profissionais da saúde. Após a gravidez, a maioria das participantes foi atendida no sistema suplementar de saúde e, apesar da avaliação positiva em geral, foram relatadas situações de desconforto com a postura dos profissionais em diversos momentos, incluindo suposição de heterossexualidade; formulários e orientações voltadas para pai/mãe, questionamento da legitimidade do casal e algumas situações de discriminação e privação de direitos. Os avanços e limites do reconhecimento desse momento para ambas as mulheres, com ênfase na inclusão da parceira que não está biologicamente grávida, foram aspectos destacados pelas participantes deste estudo como determinantes na qualidade dessa experiência de parentalidade. Mesmo com a conquista de direitos legais, como a aprovação do casamento entre pessoas do mesmo sexo, entre outras, muitas instituições e profissionais de saúde continuam despreparados para oferecer assistência adequada para casais homoafetivos. Diferentes intervenções podem melhorar a qualidade dos cuidados prestados aos casais homossexuais, incluindo a implementação de leis e políticas públicas; mudanças estruturais dentro do sistema de saúde; e melhor treinamento para profissionais de saúde. A reivindicação é por uma mudança cultural que exige a participação ativa dos profissionais de saúde, gestores e responsáveis por sua formação

With improved access to reproductive technologies, more women in same-sex relationships are choosing to plan pregnancies and are accessing the health system for care during conception, pregnancy, delivery and postpartum. Studies show the affect that homophobia, heteronormative communication, and inappropriate questioning by healthcare practitioners can have on the quality of care that is given. The objective of this study is to understand the perceptions of women in a same-sex relationship on the quality of healthcare received throughout conception, pregnancy, delivery and postpartum while using public and private health services in the metropolitan region of São Paulo. In this qualitative study, 19 women who had biological children while in a same-sex relationship were interviewed, amounting to the shared histories and experiences of ten couples. Access to conception services provided by the public health system in Brazil remains exclusive to infertile heterosexual couples, leaving many homosexual women to choose between two primary options. They can purchase costly medical treatments and services from the private health system or they can perform self-insemination using donated sperm. The latter technique is not regulated in Brazil and could expose women to potential legal problems associated with the possible decision of sperm donors to pursue paternity rights. More than just its biological impact, conception, gestation, childbirth, and breastfeeding have important social and relational effects on attachment for both the partner who is carrying the pregnancy as well as for the partner who is not pregnant with the baby. The legitimation and recognition of the specificities of samesex couples is required by several actors involved in this process, chief among them being health professionals. After pregnancy, the majority of the participants were attended to in the public health system. Despite predominantly positive evaluations overall, participants also reported some discomforting situations involving the behavior of health professionals including assumptions of heterosexuality; forms and orientations addressing parents as only father / mother, doubts or questions cast on the legitimacy of the couples\' relationships, and a few instances of discrimination and violated rights. Participants of this study highlighted how the acknowledgement of this moment for both women, with particular emphasis on the inclusion of the partner who is not biologically pregnant, is a large determinant of their perceptions on the quality of that parenting experience. Even with the advancement of legal rights such as the federal approval of same-sex marriage, among other civil rights achievements, many institutions and health professionals remain unprepared to provide adequate assistance and care that addresses the specific needs of homosexual couples. Different types of interventions can improve the quality of care provided to homosexual couples, include incorporating changes in laws/policies; structural changes within the health system; and better training for health workers. The aim is for a cultural change that requires the active participation of health professionals, managers, and those responsible for their training

Optimization of the sperm:oocyte ratio and sperm economy in the artificial reproduction of Rhamdia quelen using fructose as a sperm motility modulator.

This research was conducted to evaluate the effects of fructose as a modulator of sperm motility and its effects on the reduction in number of sperm cells in IVF using cryopreserved Rhamdia quelen semen. Sperm activation occurred in solutions containing fructose (0.0, 0.9, 1.8, 2.7, 3.6 and 4.5%). The sperm motility rate, velocity and duration of sperm motility were assessed by polynomial regression analysis and grouped by the principal component analysis (PCA). Then, the oocytes were mixed with semen at proportions of 1×10(4), 3×10(4), 5×10(4), 7×10(4) and 9×10(4) for the sperm:oocyte ratio and fertilization was induced by the activation of gametes with the fructose-containing solutions. The fertilization, hatching and larval normality rate were evaluated by response surface protocol and were further grouped by PCA. All sperm variables were affected by the activating solutions, and the most desirable theoretical results for the rate of sperm motility were obtained when using a solution containing 2.85% fructose. In the IVF and incubation assays, there was an interactive effect between the motile sperm:oocyte ratio and the fructose concentration on the rates of oocyte fertilization, hatching and on the clustered index for reproductive success. The results suggest the possibility of reducing the sperm cells on IVF by 17.77% when using a solution containing 2.28% fructose. In conclusion, the use of solutions containing fructose at concentrations that maximize sperm movement allow the reduction of the motile sperm:oocyte ratio, thus promoting sperm metabolic efficiencies and contributing to the feasibility of using cryopreserved semen at a large-scale in IVF.

Controversies in faith and health care.

Differences in religious faith-based viewpoints (controversies) on the sanctity of human life, acceptable behaviour, health-care technologies and health-care services contribute to the widespread variations in health care worldwide. Faith-linked controversies include family planning, child protection (especially child marriage, female genital mutilation, and immunisation), stigma and harm reduction, violence against women, sexual and reproductive health and HIV, gender, end-of-life issues, and faith activities including prayer. Buddhism, Christianity, Hinduism, Islam, Judaism, and traditional beliefs have similarities and differences in their viewpoints. Improved understanding by health-care providers of the heterogeneity of viewpoints, both within and between faiths, and their effect on health care is important for clinical medicine, public-health programmes, and health-care policy. Increased appreciation in faith leaders of the effect of their teachings on health care is also crucial. This Series paper outlines some faith-related controversies, describes how they influence health-care provision and uptake, and identifies opportunities for research and increased interaction between faith leaders and health-care providers to improve health care.

Estudo comparativo das regulamentações de reprodução assistida e das leis de abortamento de Brasil, Alemanha, Colômbia e França / Comparative study of regulations of assisted reproduction and abortion laws between Brazil, Germany, Colombia and France

OBJETIVO: Descrever as regulamentacões de Reprodução Humana Assistida (RHA) e as leis de abortamento do Brasil, Alemanha, Colômbia e Franc¸a. MÉTODO: Foi feito estudo qualitativo transversal das regulamentações referentes à reproducão humana assistida e ao abortamento no Brasil, na Colômbia, Alemanha e Franca entre agosto de 2014 e março de 2015. RESULTADOS: Para a RHA o Brasil tem a resolucão do Conselho Federal de Medicina 2.013/2013, a Colômbia o decreto 1.546/1998 para a doacão de gametas, a Alemanha e Franc¸a leis específicas. Em relacão à lei do abortamento, os quatro países têm leis específicas. CONCLUSÃO: Considerando todas as regulamentacões de RHA e leis de abortamento, verificamos que os países encontram-se em situacões distintas em relacão à RHA e que todos têm leis específicas para o abortamento.

OBJECTIVE: This study aims to describe the regulations of Assisted Human Reproduction (AHR) and the abortion laws of Brazil, Germany, Colombia and France. METHOD: A cross-sectional qualitative study of regulations relating to assisted human reproduction and abortion in Brazil, Colombia, Germany and France between august 2014 and March 2015. RESULTS: For the AHR Brazil has the resolution of the Federal Council of Medicine 2013/2013, Colombia has the 1546/1998 decree for the donation of gametes, Germany and France have specific laws. Regarding the abortion law, the four countries have specific laws. CONCLUSION: Considering all the regulations of AHR and abortion laws, we found that these countries are in different situations regarding the AHR and that they all have specific laws for abortion.

Direito ao conhecimento da origem biológica na reprodução humana assistida: reflexões bioéticas e jurídicas / Right to knowledge of biological origin in human assisted reproduction: bioethical and legal reflections

Este artigo discute o direito ao conhecimento da origem biológica da pessoa gerada por técnica de reprodução humana assistida, apresentando argumentos e problemas envolvidos nesse complexo processo que inclui diferentes interesses. Nesse sentido, foi desenvolvido um estudo hipotético-dedutivo, com base referencial teórica sustentada na bioética e no direito, na medida em que esses dois campos se interseccionavam quanto à natureza da matéria. O estudo avança, ainda, abordando os riscos decorrentes dos avanços tecnológicos e das expectativas dos sujeitos envolvidos, inclusive a vulnerabilidade, o consentimento para doação de gametas e o anonimato dos doadores. Discute, também, os conceitos de "identidade genética" e direito ao conhecimento da "origem biológica", traçando analogia com a legislação brasileira relativa à adoção. Por fim, trata do chamado "pertencimento do segredo", refletindo sobre os argumentos encontrados na literatura afim, inclusive o contexto de "desbiologização" atualmente defendido pelos tribunais superiores...

Este artículo aborda el derecho al conocimiento del origen biológico de la persona generada por técnica de reproducción humana asistida, presentando los argumentos y problemas implicados en este complejo proceso que involucra diferentes intereses. En este sentido, se ha desarrollado un estudio hipotético-deductivo, con sustento teórico en bioética y derecho, y la intersección de estos dos campos respecto a la naturaleza del tema. El estudio avanza, haciendo relación a los riesgos de los avances tecnológicos y las expectativas de los participantes, la vulnerabilidad, el consentimiento para la donación de gametos y el anonimato de los donantes. Son analizados también los conceptos de "identidad genética" y el derecho a conocer el "origen biológico", haciendo una analogía con la legislación brasileña relativa a la adopción. Por último, se aborda la llamada "pertenencia del secreto ", al reflexionar sobre los argumentos de la literatura al respecto, incluyendo el contexto de " desbiologización " actualmente defendida por los tribunales superiores...

What is the harm in harmful conception? On threshold harms in non-identity cases.

Has the time come to put to bed the concept of a harm threshold when discussing the ethics of reproductive decision making and the legal limits that should be placed upon it? In this commentary, we defend the claim that there exist good moral reasons, despite the conclusions of the non-identity problem, based on the interests of those we might create, to refrain from bringing to birth individuals whose lives are often described in the philosophical literature as 'less than worth living'.

How useful is the concept of the 'harm threshold' in reproductive ethics and law?

In his book Reasons and Persons, Derek Parfit suggests that people are not harmed by being conceived with a disease or disability if they could not have existed without suffering that particular condition. He nevertheless contends that entities can be harmed if the suffering they experience is sufficiently severe. By implication, there is a threshold which divides harmful from non-harmful conceptions. The assumption that such a threshold exists has come to play a part in UK policy making. I argue that Parfit's distinction between harmful and non-harmful conceptions is untenable. Drawing on Kant's refutation of the ontological argument for God's existence, I suggest that the act of creation cannot be identical with the act of harming-nor indeed of benefiting-however great the offspring's suffering may be. I suggest that Parfit is right that bringing children into existence does not usually harm them, but I argue that this must be applied to all conceptions, since Parfit cannot show how the harm threshold can be operationalised. If we think certain conceptions are unethical or should be illegal, this must be on other grounds than that the child is harmed by them. I show that a Millian approach in this context fails to exemplify the empirical and epistemological advantages which are commonly associated with it, and that harm-based legislation would need to be based on broader harm considerations than those relating to the child who is conceived.