Maternidade Lésbica no Brasil: Uma revisão de teses e dissertações nas Ciências Sociais, Humanas e da Saúde / Lesbian Motherhood in Brazil: A review of theses and dissertations in the Humanities, Social and Health Sciences

O presente trabalho aborda a atenção dedicada à maternidade lésbica na produção acadêmica brasileira, tendo como unidade de análise as Teses e Dissertações em Psicologia, Ciências Sociais e áreas relacionadas à Saúde Coletiva do Brasil que apresentem tal temática como objeto de estudo. A escolha de trabalhar com teses e dissertações se deu a partir do entendimento de que tais estudos gozariam de certa representatividade e sensibilidade às tendências do campo abordado, dada à centralidade do âmbito acadêmico ­ particularmente da pós-graduação stricto sensu ­ na produção científica brasileira. O universo de análise deste trabalho de revisão conta com 25 pesquisas, entre dissertações e teses. Através deste material foi investigado o que tem sido observado, descrito, privilegiado e teorizado sobre maternidade lésbica, bem como os termos da discussão sobre configurações familiares e modelos de parentesco não hegemônicos, e as formas de conceber, gestar, parir e criar que comparecem nos estudos. Objetivou-se contribuir para a sistematização de um debate de ideias, destacando particularidades dos achados das pesquisas analisadas, relativas às dinâmicas sociais e de saúde e o estatuto da maternidade quando conjugadas com a sexualidade lésbica. Através da análise dos estudos foi possível encontrar os temas de maior ocorrência, que foram agrupados em dois eixos. O primeiro, apresentado no Capítulo 3, aborda as mudanças jurídicas e sociais nas concepções de família, parentalidade e laços de parentesco de casais LGBT, na busca por proteção legal. Emergem nesse capítulo os desafios para mulheres lésbicas que desejam ter filhas via adoção ou Reprodução Assistida (RA) e suas formas de conceber, gerar, parir e criar filhas. Abordam-se assuntos como: a organização familiar e cotidiana da criação de filhas, por parte de casais de mulheres, bem como as disputas políticas em torno do reconhecimento da maternidade compartilhada. O segundo eixo, apresentado no Capítulo 4, reuniu as discussões sobre a temática no campo da Saúde. Contemplaram-se as argumentações sobre: o preconceito e despreparo dos profissionais para atender este público; os Direitos Sexuais e Reprodutivos das mulheres lésbicas e bissexuais e sua (in) visibilidade no SUS; a utilização de Novas Tecnologias Reprodutivas (NTR) e seus desdobramentos; e as regulamentações do Conselho Federal de Medicina e o mercado da RA. A sistematização e consolidação dos argumentos e achados das pesquisas que compuseram esta revisão demonstra um processo de mudança social ilustrado por transformações das dinâmicas conjugais e familiares tanto no âmbito jurídico como no da vida cotidiana, com efeitos duradouros nas formas de conceber, gestar, parir e criar destas famílias

This dissertation addresses the attention given to lesbian motherhood in Brazilian academic research, using as unit of analysis the theses and dissertations in Psychology, Social Sciences and areas connected to Collective Health in Brazil which address this issue as their main subject. The choice of working with theses and dissertations was due to an understanding of their representativeness and sensitivity to the tendencies of said field, given the central role of academic institutions ­ graduate programs particularly ­ in Brazilian scientific production. The review covers 25 research projects, including dissertations and theses. In our examination of said works, we investigated what has been observed, written, privileged and theorized on lesbian motherhood, as well as the terms in which non hegemonic family and kinship models, ways of conceiving, gestating, giving birth and raising children found in these studies are discussed. The goal is to contribute to systematize a current debate, highlighting the singular characteristics found in the research analyzed, on the socio-cultural dynamics and health-related matters (including those related to health policy) affecting the statute of motherhood, when combined with lesbian sexuality. The analysis indicated a group of frequent themes, later assembled around two axes. The first one is found in Chapter 3, on legal and social changes in the conception of family, parenthood and kinship by LGBT couples in their search for legal protection. That chapter also highlights the challenges faced by lesbian women who want to adopt children, or who seek Assisted Reproduction (AR), by looking at the ways of conceiving, gestating, giving birth and raising those children. It addresses subjects such as family organization and the everyday life of female couples raising children, as well as the political disputes related to the recognition of shared motherhood. The second axis, found in Chapter 4, includes discussions on lesbian motherhood related to healthcare, and health policy. It considers arguments on: the incidence of prejudice and professionals' poor preparation and knowledge to attend to this group; the Sexual and Reproductive Rights of lesbian and bisexual women, and how the Brazil's public healthcare system fails to deal with them; their use of the New Reproductive Technologies (NRT) and its social unfolding; the regulation of NRT by Brazil's Federal Council of Medicine and the AR market. The systematization and consolidation of the arguments and findings of the research comprised in this review shows an ongoing process of social change illustrated by transformations in conjugal and family dynamics, both legal and in everyday life, with lasting effects on the ways lesbian families conceive, gestate, give birth and raise children

Men who seek infertility care may not represent the general U.S. population: data from the National Survey of Family Growth.

OBJECTIVE: To examine the National Survey of Family Growth to identify differences in the characteristics of men who did and did not seek infertility care to determine whether such men are representative of the U.S. population. METHODS: We analyzed the data from the 2002 (cycle 6) National Survey of Family Growth. In-home interviews were conducted from March 2002 to February 2003. A total of 4928 men were surveyed, with underrepresented groups sampled at greater rates to provide an adequate sample size for meaningful statistical analyses. The use of infertility services was queried by a single question: "Have you been to a doctor to talk about ways to help have a baby together?" The demographic and socioeconomic variables, including age, marital status, number of children, race, religion, income, education, and insurance status were analyzed for the 2161 men surveyed who were aged 30-45 years. We performed bivariate and multivariate logistic regression analyses to determine the predictors of infertility service use. RESULTS: Marital status and education level were strongly associated with infertility care seeking. In the adjusted analysis, married men were 9 times (odds ratio 9.3, 95% confidence interval 4.1-20.9) more likely to seek care than unmarried men, and men with a college degree and those with an advanced degree were 3 times (odds ratio 2.7, 95% confidence interval 1.4-5.0) and 5 times (odds ratio 4.7, 95% confidence interval 2.1-10.5) more likely to seek care, respectively. CONCLUSION: Men seeking infertility care in the United States tend to be married, older, and more educated than those not seeking care. Given these findings, some results of male infertility studies from cohorts of men from infertility referral centers might not apply to the U.S. population.

Incidence and costs of multifetal pregnancies in Andalusia (2000-2010).

In the past 50 years the incidence of multiple pregnancies has increased dramatically due almost exclusively to two factors: delayed childbearing and assisted reproductive techniques. In this paper we analyze the variations in the incidence of multiple gestations in Andalusia, one of the biggest administrative regions in Spain, over the last decade. Assisted reproduction techniques are very often evaluated only in terms of implantation and pregnancy rates per cycle, ignoring everything related to complications of multiple births, prematurity or economic overload. The rate of twins in Andalusia has increased from 10.9 per thousand in 2000 to 16.2 per thousand in 2009. The rate of triplet births has also increased in recent years. After a decline in 2003, motivated by promulgation of the first Human Assisted Reproduction Law, there was an increase after a second law came into effect in 2006. Health care spending attributable to the excess of multiple pregnancies reported in the decade 2000-2010 may have been much higher than € 25 million.

Predictors of pregnancy and discontinuation of infertility services among women who received medical help to become pregnant, National Survey of Family Growth, 2002.

OBJECTIVE: To determine demographic characteristics associated with pregnancy and, separately, discontinuation of infertility services when unsuccessful at achieving pregnancy, among a national sample of women who received infertility services. DESIGN: Using a log-linear regression model, we examined associations with becoming pregnant among women who had received infertility services; and using a Cox proportional hazards model, we examined associations with earlier infertility service discontinuation. SETTING: 2002 National Survey of Family Growth, Cycle 6. PARTICIPANT(S): A total of 530 women aged 18-44 years in the 2002 National Survey of Family Growth who had received infertility services. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Relative risks for predictors of pregnancy after receiving infertility services; median time to discontinuation of infertility services; hazard ratios for predictors of earlier discontinuation of services. RESULT(S): Fifty-nine percent of respondents became pregnant while receiving infertility services, and 32% reported discontinuing infertility services before establishing a pregnancy. Women received infertility services for a median of 8 months; among those who discontinued services, more than half did so within 1 month. Among women who received infertility services, those who were white, nonsmokers, nulliparous, had insurance coverage, and received more than advice had a higher likelihood of pregnancy. Non-whites, parous women, and smokers discontinued infertility services earlier than others. CONCLUSION(S): Patients should be adequately counseled regarding modifiable behaviors and the range of services available before making decisions regarding their infertility.

Utilization of fertility-related services in the United States.

To describe trends in the types of fertility-related medical services that women and/or their partners have received while trying to become pregnant, the author analyzed data from women aged 20-44 years who participated in the 2002 National Survey of Family Growth. Advice (74%) and infertility testing (59%) were the most common types of fertility-related services received, and of those who received infertility testing, 66% responded that both partners were tested. Nearly half of the study population reported receiving drugs to improve ovulation.

Exploring the discourse between genetic counselors and Orthodox Jewish community members related to reproductive genetic technology.

OBJECTIVE: Genetic technology is complex, relatively new and involves sensitive issues pertaining to personhood and reproduction. While ethno cultural barriers to genetic care are well documented, little attention has been devoted to understanding religious beliefs pertaining to genetic services. This study evaluated the discourse between genetic counselors and Orthodox Jewish community members' perceptions of reproductive genetic technology. METHODS: A cross section of the Orthodox Jewish community was sampled through purposeful and snowball recruitment for in-depth interviews with key informants. RESULTS: Genetic counselors felt apprehensive about serving the Orthodox Jewish population and were unaware of social norms, religious and cultural practices unique to this population. Similarly, Orthodox Jewish consumers exhibited major misgivings about genetic testing. Importantly, stereotypic expectations by both counselors and consumers exacerbated existing communication difficulties. CONCLUSION: Cultural differences and poor communication between genetic counselors and Orthodox Jewish community members impeded the ability of the Orthodox Jewish community to utilize genetic services. PRACTICE IMPLICATIONS: This work illuminates complex issues pertaining to medical encounters between providers and patients with ideological, social and cultural differences. In particular, issues of access to care and transcultural competence in serving religious minority groups, such as Orthodox Jews are presented. On the whole, this group is largely unrecognized in the minority health literature in spite of barriers and challenges that they face. Findings of this study may have application to other cloistered and highly observant religious groups when dealing with reproductive technology and other populations with diverse values, beliefs and behaviors pertaining to reproductive health.

Changing their minds with time: a comparison of hypothetical and actual reproductive behaviors in parents of children with cystic fibrosis.

OBJECTIVE: Newborn screening for cystic fibrosis, with appropriate counseling, enables carrier parents to be informed early about future reproductive choices. Previous studies have assessed attitudes toward reproductive decisions in a hypothetical pregnancy or have measured reproductive behaviors. We aimed to measure parent attitudes to reproductive technologies and to compare prospectively these attitudes with later reproductive behaviors. METHODS: Parents of children who had cystic fibrosis and were aged 2 to 7 years were surveyed at baseline using a written questionnaire that explored attitudes to prenatal testing and termination of pregnancy in a hypothetical pregnancy. Parent knowledge and access to genetic counseling services also were assessed. Five years later, we compared attitudes with actual reproductive behaviors. RESULTS: Fifty-six mothers participated at baseline, and 43 were resurveyed 5 years later. Parent knowledge of cystic fibrosis and genetics was very good. A total of 93% had met a genetic counselor at the time of diagnosis, and more than half had on at least 1 subsequent occasion. At baseline, 82% reported that they would be likely to have prenatal diagnosis in a subsequent pregnancy, and 56% reported that they would be likely to terminate an affected pregnancy. Twenty-seven mothers since had been pregnant, with prenatal diagnosis used in 33 of the 55 pregnancies. In 67%, the hypothetically reported behavior regarding use of prenatal testing was the same as their actual behavior. Five of the 33 tested pregnancies were affected; all ended in termination. Reproductive choices in relationship to the number of children wanted, together with attitudes toward prenatal diagnosis and termination of pregnancy, were dynamic over time, with decisions having changed in both directions. CONCLUSIONS: This cohort of parents has actively used reproductive technologies since the birth of a child who has cystic fibrosis that was diagnosed by newborn screening. The dynamic aspect of reproductive choices highlights the importance of ongoing access to genetic counseling beyond the initial period of diagnosis and education, regardless of whether parents report that they expect to use reproductive technologies.

[Trends in perinatal health in metropolitan France between 1995 and 2003: results from the National Perinatal Surveys]. / La santé périnatale en France métropolitaine de 1995 à 2003. Résultats des enquêtes nationales périnatales.

OBJECTIVE: To study trends in the main indicators of health, medical practice and risk factors in France. Population and method. A sample of all births during one week was set up in 1995 (N=13,318), 1998 (N=13,718) et 2003 (N=14,737). We compared data from these three years. RESULTS: Between 1995 and 2003, there was an increase in maternal age, a development of some characteristics of care (HIV screening procedure, maternal serum screening of Down syndrome, in utero transfers) and an increase in the proportion of caesarean sections, epidurals and spinal anesthesia. The proportion of livebirths before 37 weeks of gestation and the proportion of newborns under 2,500 g slightly increased but the differences were mainly between 1995 et 1998. In 2003, obstetrician gynecologists were the main care providers during pregnancy. However 24.3% of women had their first visit with a general practitioner. For the following visits, 15.4% of women had seen a GP at least once and 26.9% had seen a midwife in maternity unit at least once. CONCLUSION: Because of the trends in obstetrical practice and organisation of services, routine national perinatal surveys are useful to show major changes and yield quick answers to specific questions.

Prioritising for fertility treatments--the effect of excluding women with a high body mass index.

The effect of clinical priority access criteria for access to infertility treatment was examined for women outside the body mass index (BMI) range of 18-32 kg/m2. Treatments and outcomes were analysed from 1280 cases referred from 1998 to May 2005. Sixteen percent of women had a BMI of >32 kg/m2. Overall, 38% of these women had a birth from conceiving a treatment-related pregnancy or spontaneous pregnancy, compared with 52% of women with BMI < 32 kg/m2. Weight loss allowed women in the BMI group >32<35 kg/m2 to access treatment, but women in higher BMI groups were less successful.

Fertility following spinal cord injury: a systematic review.

STUDY DESIGN: Systematic review. OBJECTIVES: To review systematically fertility of persons with spinal cord injuries (SCI) and their partners. METHODS: Reports from six databases (1966-2003), selected annual proceedings (1997-2002) and manufacturer's information were screened against eligibility criteria. Searches covered female obstetrical issues, and the efficacy of vibration and electroejaculation for males, as well as advanced fertility (AF) treatments for partners of SCI males. Data were pooled from case-series reports on SCI males' ejaculation, and pregnancies and live births for partners of SCI males. RESULTS: In all, 2,127 unique reports were evaluated, of which 66 reports were included. No studies investigated fertility in SCI females. Ejaculation interventions in the last decade resulted in response rates of 95% (95% confidence intervals (CI) 91%, 99%), with 100% response rate reported in several recent publications. A total of 13 studies (1993-2001) yielded pregnancy rates of 51% (95% CI 42%, 60%) in partners of SCI males. Of these, 11 studies (1993-2003) yielded live birth rates of 41% (95% CI 33%, 49%). CONCLUSIONS: Fertility of SCI males is extensively studied. Semen for fertility purposes can generally be obtained using vibration and electroejaculation. AF techniques are increasing pregnancy rates. Research is needed to improve sperm quality. Freezing of sperm is unlikely to significantly improve fertility rates. Fertility of SCI females is addressed only in case reports and opinion articles. The opinion that female fertility is unaffected by SCI should be further investigated using appropriate research methodology.

Weaknesses in reports of "fertility" for horses and other species.

Apparent fertility of a male or group of females is considered frequently by veterinarians or animal scientists. Unfortunately, concepts of experimental design and statistics impacting validity and interpretation of values for average pregnancy rate frequently are ignored. The magnitude of this problem was documented by examination of published papers; 51 of 67 (76%) were considered flawed for one or more reasons. The discussion considers why: (a) conclusions from most published fertility studies reporting no significant difference due to treatment(s) are suspect, because too few males and/or females were used; (b) the experimental unit in an IVF study should be a droplet of co-incubating gametes rather than an ovum; (c) apparent fertility of a male is profoundly influenced by the range in actual fertility of the females with which he was mated, and thus might shift over a two- to three-fold range; and (d) scientists should refrain from conduct of studies destined to be inconclusive, and should be candid in reporting each fertility trial. It was emphasized that no fertility data were better than an imprecise average value for a given male or a conclusion based on an inadequate research study or incomplete report of what was done.

[Prognosis of the reproduction health care in the Czech Republic until 2010: II. Planned parenthood]. / Prognóza péce o reprodukcní zdraví v CR do roku 2010: II. plánované rodiovství.

OBJECTIVE: To prepare a prognosis of development of contraception, artificial termination of pregnancy and asisted reproductive technologies until 2010, based on the trend in their indicators in the previous years. DESIGN: A retrospective epidemiological study to be used as a basis for the prognosis SETTING: Mother and Child Care Institute, Prague - Podolí METHODS: For outlining the probable trend in the use of various types of contraceptives (IUD) as well as for artificial termination of pregnancy, evaluated according to their internationally recognised indicators, the extrapolation of the trends in these criteria prevalent in the period 1995-2002 was used. RESULTS: The prognosis of increase in the number of female users of hormonal contraception at the expense of IUD as well as the decrease in the number of women solving their problem with unwanted pregnancy by artificial termination of pregnancy (ATP), based on the said extrapolation of their indicators with a prospect until 2010, is probably overly optimistic. Due to probable changes in the political, social and economic circumstances as well as in the women's attitudes, it is expected that this trend will slow down. This is why it is expected that the number of female users of hormonal contraception will increase merely to 500 and that the women using IUD will decrease to 50 per 1,000 fertile women. Also, as concerns the number of ATPs, it is expected that it will decrease merely just below 10 for every 1,000 fertile women and to 20 for every 100 births. Even if the trends of all these indicators slow down, it can be expected that they will reach the average levels reported in the countries of Western Europe. As for the trend in asisted reproductive technologies (ART), whose share in the total number of births will rise, the main emphasis will be put on consistent nationwide registration, amendments to legislation and research mainly in the area of psycho-neurological development of these children, as recommended by the WHO. CONCLUSION: The expected rate of growth of the number of female users of effective contraception and the expected rate of decline of the number of ATPs, corresponding to the trend of the recent years, will probably decrease by 2010 but the average levels reported by the countries of Western Europe will still be reached. According to the recommendation of the WHO, the trend in some forms of ART will require research in the field of psycho-neurological development of the children from these pregnancies until they reach adulthood as well as some amendments to legislation.

[Evaluation of success in assisted reproduction]. / Hodnocení úspesnosti v asistované reprodukci.

OBJECTIVE: Summarize different ways of assisted reproduction performance evaluation. DESIGN: Review. SETTING: Centre for Assisted Reproduction, Department of Gynaecology and Obstetrics, 1st Faculty of Medicine, Charles University, Prague. METHODS: In databases of assisted reproduction centres, in national and international registers we evaluate data concerning in vitro fertilisation and related methods. Target of this evaluation is, first of all, to increase efficiency. RESULTS: Outputs of all the registers inform about absolute numbers of cycles, deliveries, born babies and about relative parameters (implantation rate, pregnancy rate), describing the efficiency of the treatment. CONCLUSION: The output evaluation must consider the influence of the age of female, number of transferred embryos and other factors.

Assisted reproductive technology in Europe, 1998. Results generated from European registers by ESHRE. European Society of Human Reproduction and Embryology.

European results of assisted reproductive techniques from treatments initiated during 1998 are presented in this second ESHRE report. Data was collected from 18 European countries usually from pre-existing national registers. A total of 521 clinics from these 18 countries reported 232 443 cycles: IVF 103 919 intracytoplasmic sperm injection (ICSI) 89 192 unclassified fertilization method 667 frozen embryo replacement (FER) 34 03 oocyte donations (OD) 4629. In nine countries where all clinics reported to the register a total of 128 801 cycles were performed in a population of 165 million corresponding to 781 cycles per million inhabitants 3.2 cycles per 1000 women aged 15-49 years. After IVF ICSI the distribution of transfer of 1, 2, 3 > or =4 embryos was 11.5, 37.2, 42.0 and 9.4% respectively. Huge differences existed between countries. For IVF the clinical pregnancy rate per aspiration per transfer was 23.2% 27.0% respectively. For ICSI the corresponding rates were 24.8% 26.8%. The distribution of singleton, twin, triplet, quadruplet deliveries for IVF and ICSI combined was 73.7, 23.9, 2.3 and 0.1%. This gives a total multiple delivery rate of 26.3%. The range of triplet deliveries after IVF and ICSI differed from 0.2-5.3% between countries. Compared with 1997, the number of reported cycles has increased by 14% and the number of reporting clinics by 8%. The clinical pregnancy rate per transfer increased from 26.1 to 27.0% after IVF and from 26.4 to 26.8% after ICSI. Multiple deliveries after IVF and ICSI decreased from 29.6 to 26.3%.

Frequency of a monochorionic pair in multiple gestations: relationship to mode of conception.

OBJECTIVE: To determine whether the mode of conception affects the frequency of monochorionicity in multiple gestations. METHODS: Our study population consisted of all women with multiple gestations who had a first-trimester sonogram at our institution between May 1998 and April 2000. The frequency of monochorionicity in pregnancies conceived naturally was compared with the frequency in pregnancies achieved via any form of assisted reproductive technology and among the different types of assisted reproductive technology. RESULTS: Our study consisted of 464 multiple gestations comprising 332 twin, 113 triplet, 16 quadruplet, and 3 quintuplet pregnancies. The higher the fetal number, the more likely the pregnancy resulted from assisted reproductive technology (72.6% of twins, 84.1% of triplets, 92.8% of quadruplets, and 100% of quintuplets; P < .05, Fisher exact test). Monochorionic pairs were found more commonly in naturally conceived pregnancies than in those resulting from assisted reproductive technology (28.2% versus 5.4%; P < .000001, chi2 test). The frequency of monochorionic pairs after in vitro fertilization with blastocyst transfer on day 5 (10.5%) was double the frequency from in vitro fertilization with cleavage stage transfer on day 3 (4.9%), but the difference was not statistically significant (P = .24, Fisher exact test). CONCLUSIONS: Monochorionic pairs are relatively common in naturally conceived twins and in higher-order multiple gestations with more than 3 fetuses arising from assisted reproductive technology, but they are uncommon in twins and triplets arising from assisted reproductive technology There is a trend toward a higher frequency of monochorionic pairs after day 5 blastocyst transfer than day 3 transfer, but a larger study population is needed to confirm this finding.

Reproduction in the Noughties: will the scientists have all the fun?

The past 20-30 years have seen major advances in our understanding of human reproduction and in our ability to manipulate it, as well as major social changes in human reproductive and sexual attitudes. Many of these advances and changes developed out of the first successful in vitro fertilisation (IVF) of the human oocyte. It is also the case that 30 years ago few foresaw what was to come, and many were at best doubtful and often were very critical of the scientific work which led to human IVF and to many of the subsequent developments. This lack of foresight provides us with a lesson about the dangers that we face in looking forward and attempting to predict the future. This review will try to convey, not comprehensively but through examples, the flavour of current activities in Assisted Reproduction clinics and research laboratories around the world and what is being talked about for the future in respect of emergent patient demands and anticipated clinical needs. This clinically driven approach will form the basis for consideration of some underlying scientific aspects of reproductive research, some of the ethicolegal issues that may arise, and the implications of this anticipated future for our current approaches to medical education. The future will be considered not simply in terms of the New Reproduction itself but also in its interaction with the opportunities and challenges presented by the New Genetics. It is perhaps in the interaction between these two fields of endeavour that some of the most difficult challenges ahead lie.