Which types of conditions should be included in reproductive genetic carrier screening? Views of parents of children with a genetic condition.

Reproductive genetic carrier screening identifies couples with an increased chance of having children with autosomal and X-linked recessive conditions. Initially only offered for single conditions to people with a high priori risk, carrier screening is becoming increasingly offered to individuals/couples in the general population for a wider range of genetic conditions. Despite advances in genomic testing technology and greater availability of carrier screening panels, there is no consensus around which types of conditions to include in carrier screening panels. This study sought to identify which types of conditions parents of children with a genetic condition believe should be included in carrier screening. Participants (n = 150) were recruited through Royal Children's Hospital (RCH) Melbourne outpatient clinics, the Genetic Support Network of Victoria (GSNV) and a databank of children with hearing loss (VicCHILD). This study found that the majority of participants support offering carrier screening for: neuromuscular conditions (n = 128/134, 95.5%), early fatal neurodegenerative conditions (n = 130/141, 92.2%), chronic multi-system disorders (n = 124/135, 91.9%), conditions which cause intellectual disability (n = 128/139, 92.1%) and treatable metabolic conditions (n = 120/138, 87.0%). Views towards the inclusion of non-syndromic hearing loss (n = 88/135, 65.2%) and preventable adult-onset conditions (n = 75/135, 55.6%) were more mixed. Most participants indicated that they would use reproductive options to avoid having a child with the more clinically severe conditions, but most would not do so for clinically milder conditions. A recurring association was observed between participants' views towards carrier screening and their lived experience of having a child with a genetic condition.

Establishing a quality management system in a fertility center: experience with ISO 9001 / SISTEMA DE GESTÃO DE QUALIDADE NA CLÍNICA DE REPRODUÇÃO HUMANA: EXPERIÊNCIA COM A NORMA ISO 9001

In Fertility Centers, quality should be measured by how well the organization complies with pre-defined requirements, and by how quality policies are implemented and quality objectives achieved. Having a quality management system (QMS) is a mandatory requirement for IVF centers established in most countries with regulatory guidelines, including Brazil. Nevertheless, none of the regulatory directives specify what a QMS must have in detail or how it should be implemented and/or maintained. ISO 9001 is the most important and widespread international requirement for quality management. ISO 9001 standards are generic and applicable to all organizations in any economic sector, including IVF centers. In this review, we discuss how we implemented QMS according to ISO 9001 and what we achieved 5 years later. In brief, with ISO we defined our structure, policies, procedures, processes and resources needed to implement quality management. In addition, we determined the quality orientation of our center and the quality objectives and indicators used to guarantee that a high-quality service is provided. Once measuring progress became part of our daily routine, quantifying and evaluating the organization's success and how much improvement has been achieved was an inevitable result of our well-established QMS. Several lessons were learned throughout our quality journey, but foremost among them was the creation of an internal environment with unity of purpose and direction; this has in fact been the key to achieving the organization's goals.

Na clínica de reprodução humana, a qualidade deve ser medida pela maneira como a organização cumpre os requisitos pré-definidos, e pela forma como as políticas de qualidade são implementadas e os objetivos de qualidade alcançados. Ter um sistema de gestão da qualidade (SGQ) é um requisito obrigatório para centros de fertilização in vitro estabelecidos na maioria dos países com diretrizes regulatórias, incluindo o Brasil. No entanto, nenhuma das diretivas regulamentares especifica o que um SGQ deve ter em detalhe ou como ele deve ser implementado e/ou mantido. A norma ISO 9001 é a exigência internacional mais importante e adotada mundialmente para a gestão da qualidade. Os conceitos da norma ISO 9001 são genéricos e aplicáveis a todas as organizações em qualquer setor económico, incluindo as clínicas de fertilização in vitro (ou bancos de células e tecidos germinativos tipo 2, como denominados no Brasil pela Agência Nacional de Vigilância Sanitária). Neste artigo, discutimos como implementamos um SGQ de acordo com a norma ISO 9001 e o que conseguimos 5 anos mais tarde. Em suma, com a norma ISO definimos nossa estrutura, políticas, procedimentos, processos e recursos necessários para implementar a gestão da qualidade. Além disso, determinamos a orientação da qualidade do nosso centro além dos objetivos de qualidade e indicadores utilizados para garantir que um serviço de alta qualidade seja fornecido para nossos clientes. A partir do momento que a mensuração do progresso tornou-se parte da nossa rotina diária, quantificar e avaliar o sucesso da organização e os resultados atingidos passou a ser uma consequência inevitável de um SGQ bem estabelecido. Várias lições foram aprendidas ao longo de nossa jornada de qualidade, mas o mais importante foi a criação de um ambiente interno com unidade de propósito e direção, que se tornou peça chave para alcançar os objetivos da organização.

Filiación por técnicas de reproducción humana asistida, gestación por sustitución y consentimiento informado en Argentina. Aportes y cambios introducidos por el Código Civil y Comercial / Filiation by Human Assisted Reproduction Techniques, gestational surrogacy and informed consent in Argentina. Contributions and changes introduced by the Civil and Commercial Code

Este artículo busca describir los aportes del Código Civil y Comercial de Argentina en relación al consentimiento informado y la gestación por sustitución en el marco de la filiación (AU)

This article seeks to describe the contributions of the Civil and Commercial Code for Argentina, in relation to the informed consent and gestational surrogacy in the context of filiation (AU)

Situación actual de la técnica time lapse en el laboratorio / Current status of time-lapse systems in the laboratory

El uso de los sistemas time lapse está cada vez más extendido en los laboratorios, se ha demostrado su utilidad a la hora de seleccionar mejor los embriones en combinación con la morfología, que hasta hoy era el método utilizado para realizar esta selección. Aunque existen autores que no están muy de acuerdo con esta afirmación, hay una gran mayoría que coincide en que la monitorización continua de los embriones ofrece una información relevante a la hora de elegir los mejores embriones de un cultivo. Durante los últimos años han surgido estudios avalando el uso de esta técnica, así se ha descrito que se puede conseguir elevar las tasas de embarazo y apostar con más fuerza por la transferencia de embrión único. Todo lo descrito en la literatura habla de resultados con patrones de división y los distintos estudios que validan esos modelos, pero ninguno nombra en profundidad las especificaciones propias de cada sistema, por tanto, el objetivo de este estudio ha sido el intentar resaltar las diferencias existentes entre las plataformas que se pueden encontrar en el mercado e indicar el futuro de cada una de ellas

The use of time-lapse systems is increasingly widespread in laboratories, it has proved useful in the selection of the best embryos when combined with their morphology, the traditional method used until now. Although there are some authors that disagree with this statement, a large majority agrees that the continuous monitorization of the embryos offers relevant information at the time of choosing the best embryos within a culture. In recent years there have been studies that support the use of this technique, and have proven that higher pregnancy rates can be achieved with its use, placing more emphasis on single embryo transfer. Everything published in the literature describes the results of with division patterns and the various studies that validate those models, but none provide an in-depth description of their specifications, thus the aim of this study was to highlight the differences between each of the platforms found on the market and indicate the predicted future of each of them

La determinación de B-HCG el día 12 de la transferencia embrionaria como predictor del resultado gestacional en técnicas de Reproducción Asistida / B-HCG levels on day 12 after embryo transfer as a predictor of ongoing pregnancy in IVF cycles

OBJETIVOS: Encontrar un valor de β-HCG que prevea el resultado evolutivo de la gestación en una única determinación hormonal en nuestra población. Como objetivos secundarios nos planteamos valorar si ese valor tiene que ser ajustado en función del IMC y de la edad de la paciente. Ámbito: Pacientes sometidas a un ciclo FIV en nuestro centro Hospital Universitari de Girona Dr. Josep Trueta, entre julio de 2010 y diciembre de 2013. DISEÑO: Estudio retrospectivo descriptivo. MATERIAL Y MÉTODOS: Se incluyen 50 ciclos con β-HCG positiva a los 12 días de la transferencia embrionaria de un total de 139 pacientes sometidas a un ciclo FIV en nuestro centro entre julio de 2010 y diciembre de 2013. RESULTADOS: Las diferencias en el nivel de β-HCG el día 12 son estadísticamente significativas entre los diferentes grupos en función del resultado gestacional (p < 0.05). Si comparamos solamente las gestaciones viables con las gestaciones no viables las diferencias son todavía más significativas. Con una β-HCG media de 300,53 para las gestaciones viables y una B-HCG media de 88,66 para las no viables (p < 0,01). La curva ROC sugiere que un valor de β-HCG de 77 mUI/ml sería un buen nivel para prever una gestación viable, con una sensibilidad del 90,63% y una especificidad del 80%. No existen diferencias estadísticamente significativas del valor de β-HCG en función del IMC ni de la edad. CONCLUSIONES: Con un valor de β-HCG igual o superior a 77mUI/ml podemos orientar mejor a la paciente, y prever una gestación exitosa, ayudando a planificar el manejo médico así como disminuir la ansiedad materna. Este valor, además, y según nuestro estudio, no necesita ser ajustado por edad o IMC de la pacientes

OBJECTIVES: The aim of our study is to find a value of β-HCG to predict the outcome of pregnancies in a single hormone determination in our population. As secondary objectives, we will assess whether this value has to be adjusted for BMI and age of the patient. SETTING: Patients subjected to an IVF cycle at our center Hospital Universitari de Girona Dr. Josep Trueta, between July 2010 and December 2013. DESIGN: Retrospective and descriptive study. MATERIAL AND METHODS: A total of 50 cycles with a positive β-HCG the day 12 after the embryo tranfer were analyzed with respect to pregnancy outcome from a total of 139 patients subjected to an IVF cycle at our center between July 2010 and December 2013. RESULTS: The differences in the level of β-HCG at day 12 are statistically significant between different groups based on gestational outcome (p < 0,05). Comparing only viable pregnancies with nonviable pregnancies the differences are even more significant. With a β-HCG 300,53 average for viable pregnancies and average β-HCG for nonviable 88,66 (p < 0,01). The ROC curve suggests that a value of β-HCG 77 mIU / ml would be a good level to predict a viable pregnancy with a sensitivity of 90.63 % and a specificity of 80 %. There are not statistically significant differences in the value of β-HCG in terms of BMI or age. CONCLUSIONS: With a value of β-HCG of 77mUI/ml or more, we can better guide the patient and provide for a successful pregnancy, helping to plan medical management and reduce maternal anxiety. This value, in addition and according to our study, does not need to be adjusted for age or BMI of the patient

Taming Our Brave New World.

Advances in reproductive technology have already revolutionized our culture in various ways, and future potential developments, particularly in genetics, promise more of the same. The practice of surrogacy threatens to upend the way we understand the family. Germline engineering of human embryos could, among other things, lead to the treatment of genetic diseases hitherto incurable; but the widespread use of such engineering could have broader ramifications for our culture, for better and for worse. Parents may eventually be able to select for desirable traits in their offspring, whether by genetic modification at conception or by choosing to implant one of several genetically profiled embryos. Authors in this issue of The Journal of Medicine and Philosophy address some of the ethical implications of these technological and cultural changes.

La percepción del hombre cuando acude a un centro de reproducción asistida / Male perception of assisted reproduction treatments

Objetivo: El objetivo de este trabajo es describir la percepción de varones infértiles que se someten a tratamientos de reproducción asistida (RA). Se recogió información acerca de su experiencia antes y después del tratamiento, pruebas realizadas, atención médica recibida, etc. Material y métodos: Se trata de un estudio prospectivo, observacional y descriptivo, donde se entrevistaron un total de 46 hombres de los muchos que acudieron a la I Feria de Reproducción Asistida, celebrada en Valencia. Todos los individuos completaron un cuestionario con un total de 33 preguntas relacionadas con su experiencia personal durante el tratamiento realizado. Resultados: Durante la anamnesis, el 22% de los hombres manifiestan que no se les interrogó, y el 52% de que fue breve. No se realizó una exploración genital al 67% de los casos. Hasta el 55% de los pacientes declaran que han sido poco o nada informados acerca de la causa de su esterilidad. En la mitad de los casos con un tratamiento previo, no se explican las posibles razones del resultado fallido. Conclusiones: Aunque el número de casos es limitado, las conclusiones son claras acerca de la poca participación de andrólogos/urólogos en los centros de reproducción asistida. Se percibe una falta de información general tanto en la fase diagnóstica como durante el tratamiento. Es imprescindible mejorar esta situación, ampliando este tipo de estudios y adecuándolos como herramientas rutinarias para conocer el grado de calidad asistencial de nuestros pacientes (AU)

Objective: The aim of this paper is to describe the perceptions of infertile men who undergo assisted reproduction treatments. Information about their experience (before and after the treatment), diagnostic tests and medical care were collected. Material and methods: A prospective, observational and descriptive study with a total of 46 men who visited the I Assisted Reproduction Fair held in Valencia was carried out. All subjects completed a questionnaire with a total of 33 questions related to their personal experience during the treatment performed. Results: In the anamnesis phase, men reported they had not been questioned adequately in 22% of cases, and questioned briefly in 52% of cases. A genital exploration was performed in 33% of cases. Clinical information received about the cause of infertility was poor or non-existent in 55% of cases. In previously treated patients, up to 50% of cases were not informed of potential causes of failures. Conclusions: Although the number of cases is limited, the findings are clear about the low participation of andrologists/urologists in assisted reproduction centers. A general lack of information on both the diagnostic phase and during treatment is perceived. It is essential to improve this situation, to extend these studies and adapt them as a routine to determine the care quality of our patients (AU)

Semen parameters and their influence on pregnancy after assisted reproduction: Report of the Hospital Centre of Porto / Parámetros seminales y su influencia en las técnicas de reproducción asistida: experiencia del Centro Hospitalario de Porto

Introduction: Several studies analyzed the possible relationships between semen parameters and assisted reproductive technologies (ART) treatments. However, none could establish a threshold to guide in the decision of which treatment technique will be better facing spermiogram values. Objectives: A database with spermiogram and clinical parameters was built in order to search for relevant interactions between semen parameters and different ART treatment techniques. Materials and methods: A general statistical analysis evaluated semen parameters, followed by correlations to study their influence on the pregnancy rate for each type of treatment technique. Results: A predominance of teratozoospermia and asthenozoospermia was observed, with strong positive correlations between age and total motility, as well as obvious correlations between concentration and motility. Of the studied population, 41.8% went for ART consultations and presented a mean time of infertility of 2.9 years, a mean male age of 33.4 years and a mean female age of 31.9 years. Of these, 17.1% achieved a spontaneous pregnancy. Of the treatment cycles, 13.1% were by intra-uterine insemination (10.2% of clinical pregnancy rate, CP, with six newborn, NB), 24.9% by in vitro-fertilization (21.7 CP, 18 NB) and 44.9% by intracytoplasmic sperm injection (25.3% CP, 40 NB). From the analysis between semen parameters and the pregnancy rates, per type of ART technique, a significant positive correlation between techniques was found, revealing thresholds associated with the probability of a successful clinical pregnancy. Conclusions: The present results suggest that spermiogram reference limits can be developed for each treatment technique that are associated with a higher probability of achieving a clinical pregnancy (AU)

Introducción: Varios estudios han examinado las posibles relaciones entre los parámetros seminales y los resultados derivados de los tratamientos de infertilidad. Sin embargo, no hemos logrado establecer umbrales que puedan guiar a la hora de la decisión de que técnica de reproducción asistida (ART) se debe elegir. Objetivos: Se construyó una base de datos con los parámetros seminales y los resultados clínicos de los tratamientos de infertilidad para que se puedan investigar las interacciones relevantes entre ellos. Materiales y métodos: Después de un análisis estadístico general de los parámetros seminales, se realizó un estudio de correlación entre aquellos y las tasas de embarazo por la técnica de tratamiento. Resultados: Hubo un predominio de teratospermia y astenozoospermia, con fuertes correlaciones entre la edad y la motilidad total, así como correlaciones evidentes entre la concentración y la motilidad. En la población de estudio, el 41,8% ha visitado las consultas de infertilidad, presentando un tiempo medio de 2,9 años de infertilidad, y una edad media de 33,4 (hombres) y 31,9 (mujeres) años. De éstas, el 17,1% logró un embarazo espontáneo. De los tratamientos de ART realizados, 13,1% se debieron a la inseminación intrauterina (tasa de embarazo clínico del 10,2%, GC, con 6 recién nacidos, RN), el 24,9% en la fertilización in vitro (21.7 GC, RN 18) y 44,9% por microinyección intracitoplasmática de espermatozoides (25,3% GC, RN 40). Del análisis entre los parámetros seminales y las tasas de embarazo, para cada tipo de técnica de tratamiento, se observó una correlación significativa entre las técnicas, revelando los umbrales asociados a la probabilidad de lograr con éxito un embarazo clínico. Conclusiones: Los datos sugieren que pueden ser creados los umbrales de referencia de los parámetros seminales para cada técnica de tratamiento, los cuales están más fuertemente asociados con la capacidad de lograr con éxito un embarazo clínico (AU)

[Activities and responsibilities of workers in embryologic and andrologic laboratories in assisted reproduction centers]. / Cinnosti a odpovednosti pracovníku embryologické a andrologické laboratore v centrech asistované reprodukce.

This paper presents the current status and rules for the laboratory staff activities and their competences in the centers of assisted reproduction. The rules were processed by the members of the Association of Reproductive Embryology (ARE) committee under the current legislation. Committee members of the Czech Sterility and Assisted Reproduction Society and Czech Gynecology and Obstetric Society approved these rules as obligatory for assisted reproduction centres in Czech Republic.

Niveles de PAPP-A y fßhCG en gestantes gemelares bicoriónicas concebidas por técnicas de reproducción asistida (FIV-IAH) y sus implicaciones en el cálculo del riesgo del cribado prenatal del primer trimestre / PAPP-A and fBhCG levels in dichorionic twin pregnancies conceveid by assisted reproductive technologies (IVF-AIH) and their implications to calculate the prenatal risk on first trimestry

Objetivo: Evaluar los niveles de proteína plasmática placentaria (PAPP-A) y fracción libre de la βhCG (fßhCG) en gestaciones gemelares bicoriónicas concebidas mediante técnicas de reproducción asistida tipo fertilización in vitro (FIV) o inseminación artificial (IA) en nuestra población. Posterior cálculo de los factores de corrección necesarios a aplicar para el screening de primer trimestre en gestantes gemelares concebidas mediante FIV. Población en estudio: Se han estudiado 171 gestantes gemelares. Un grupo compuesto por 71 gestaciones bicoriónicas concebidas mediante FIV, con una edad media de 36,3 años; un grupo control de 76 gestaciones bicoriónicas concebidas por gestación espontánea, con una edad media de 31,8 años; y un último grupo de 24 gestaciones bicoriónicas concebidas por IA, con una edad media de 32,9 años. Resultados: Las gestantes gemelares bicoriónicas concebidas mediante FIV respecto el grupo control, concebidas espontáneamente, presentan unos niveles estadísticamente inferiores de PAPP-A (2,17 MoM versus 2,41 MoM, p<0,008) y valores superiores no significativos de fßhCG (2,33 MoM versus 2,05 MoM, p=0,144). Las medias de la translucencia nucal (Tn) entre ambos grupos tampoco muestran diferencias significativas (p=0,178). Esta misma tendencia se observa en los valores de PAPPA y fßhCG para las gestaciones concebidas mediante IA, pero con un número menor de gestantes no significativo. Conclusiones: Las mujeres con gestaciones gemelares concebidas por técnicas de reproducción asistida han sido sometidas a tratamientos para la estimulación de la ovulación. Este hecho se ha postulado como una de las causas que podrían explicar la presencia de valores de PAPP-A significativamente inferiores y de fßhCG superiores, aunque no significativos, a las gestantes gemelares espontáneas. Por ello se aconseja la elaboración de curvas propias con gestantes gemelares FIV, o en su defecto, el empleo de factores de corrección para disminuir este efecto. Se comprueba que con la aplicación de estos factores de corrección la tasa de falsos positivos de los gemelares bicoriónicos concebidos por FIV baja de 4,22% a 1,41% en nuestra población, con la consecuente disminución de biopsias de corion que son especialmente complejas en gestaciones gemelares (AU)

Objective: Evaluation of levels of PAPP-A and fßhCG in dichorionic twin pregnancies conceived by Assisted Reproductive Technology, i.e. In Vitro Fertilization (IVF) and Artificicial Insemination (AI) in our population. Calculate the necessary correction factors for first trimester screening in pregnancies conceived by IVF. Study population: One hundred seventyone twin pregnancies were considered within this study. One group was composed by 71 dichorionic twin pregnancies conceived by IVF with an average maternal age of 36.6 years. The control group was composed by 76 dichorionic twin pregnancies conceived spontaneously with an average maternal age of 31.8. A third group was composed by 24 dichorionic twin pregnancies conceived by AI with an average maternal age of 32.9 years. Results: Dichorionic twin pregnancies conceived by IVF present statistically significant lower values for PAPP-A than the control group (2.17 MoM versus 2.41 MoM, p<0.008) and higher values of fßhCG though this difference is not significant (2.33 MoM versus 2.05 MoM, p=0.144). In the other hand, average nuchal translucency (NT) does not show statistical differences between these two groups (p=0.178). Twin pregnancies conceived by AI present these same results tendencies for PAPP-A, fßhCG, and NT, with a lower number of patients not significant. Conclusions: Women with twin pregnancies conceived by Assisted Reproductive Technology (ART) have undergone treatments to induce ovulation. These treatments are proposed as one of the causes that may justify lower PAPP-A values and higher (though not significant) fßhCG values, when twin pregnancies conceived by ART are compared to spontaneously conceived twin pregnancies. Construction of normality curves for twin pregnancies conceived by IVF or calculation of correction factors is advised, in order to decrease this effect in the studied biochemical parameters. Applying these correction factors to our population data, the rate of false positives in first trimester screenings in dichorionic twin pregnancies conceived by IVF is decreased from a 4.22% to a 1.41%; this consequently implies a reduction of chorion biopsies, which are specially complicated in twin pregnancies (AU)

Ventajas e inconvenientes de la transferencia embrionaria en +3 y en blastocisto / Advantages and disadvantages of embryo transfer in day 3 and blastocyst stage

Objetivo: Entre los diversos factores con influencia en las tasas de implantación y gestación evolutiva, la calidad del embrión es uno de los factores pronósticos más importantes. Sin embargo, la elección del embrión con el mayor potencial de implantación para transferir sigue siendo uno de los puntos críticos dentro del laboratorio de fecundación in vitro (FIV). Hoy en día, a pesar de la existencia de múltiples sistemas de selección no invasivos, los parámetros morfológicos siguen siendo uno de los criterios más utilizados por los embriólogos. Los avances en los medios de cultivo embrionario han permitido a los laboratorios de FIV el cultivo óptimo de embriones hasta el estadio de blastocisto. La razón principal para realizar una transferencia en esta etapa es mejorar la sincronía entre ambiente uterino y desarrollo embrionario y la selección de los embriones más viables. El objetivo de este estudio es realizar una revisión bibliográfica con el fin de poder determinar en que situaciones la transferencia de blastocistos (día 5 y 6) mejora las tasas de implantación comparado con los embriones tempranos (día 2 y 3), y evaluar las posibles ventajas e inconvenientes en cada caso. Material y métodos: Se han analizado 10 estudios randomizados que comparan la efectividad de la transferencia de blastocistos y embriones en estadios más precoces. Conclusión: Existe una pequeña diferencia en la tasa de recién nacido vivo (RNV) y de implantación a favor del cultivo a blastocisto. Se ha observado que la transferencia en estadio de blastocisto podría incrementar las tasas de implantación en pacientes jóvenes con un mínimo de embriones de buena calidad en día 3, dando lugar a una mayor sincronía con el ambiente endometrial y coincidiendo con un menor grado de contracciones uterinas en el día de la transferencia. Este estadio permite hacer una selección embrionaria más precisa, ya que la activación del genoma embrionario se produce cuando los embriones están a 8 células aproximadamente. También se observa un menor número de embriones aneuploides, ya que la prolongación del cultivo permite incrementar la selección del embrión más viable. Es necesario establecer cuidadosamente aquellos grupos de pacientes a los que la transferencia en blastocisto representaría una mejora en los resultados del ciclo, reduciendo al máximo las posibilidades de cancelación de ciclo y favoreciendo la transferencia electiva de un único embrión (SET: single embryo transfer), el único método realmente efectivo para evitar las gestaciones múltiples, una de las complicaciones más importantes de los tratamientos de FIV (AU)

Among several factors that influence implantation rate and pregnancy outcome, embryo quality is one of the most important. However, the election of the embryo with the highest implantation potential is still a matter of debate at the vitro fertilization laboratory (IVF). Nowadays, despite the existence of multiple noninvasive selection systems, morphological parameters remain one of the main criteria used by embryologists. Advances in embryo culture media have allowed IVF laboratories to successfully grow embryos to the blastocyst stage. The main reason to perform the embryo transfer at this stage is to improve the synchrony between the uterine environment and embryonic development and the selection of the most viable embryo. The aim of this study was to review the literature in order to determine in which transfer at blastocyst stage (day 5 and 6) improves implantation rates compared to transfer at earlier stages (day 2 and 3), and to evaluate the potential advantages and disadvantages in each case. Methods:We analyzed 10 randomized trials comparing the effectiveness of early cleavage versus blastocyst stage transfers. Conclusion: There is a small difference in live birth rate (LBR) and implantation in favour of transfer at blastocyst stage. It has been observed that this could increase implantation rates in young patients with a minimal of three top quality embryos on day 3, resulting in greater synchrony with the endometrial environment and coinciding with a lower degree of uterine contractions on the day of transfer. Blastocyst stage allows more accurate embryo selection, because the activation of the embryonic genome occurs approximately at 8 cells stage. Moreover, due to the culture extension, fewer aneuploidembryos are observed. It is necessary to establish carefully those groups of patients who will benefit from a blastocyst transfer, minimizing the chance of cycle cancellation and favouring elective transfer of a single embryo (SET: single embryo transfer), which is the most effective method to avoid multiple pregnancies (AU)

Recommendations for gamete and embryo donation: a committee opinion.

This document provides the latest recommendations for evaluation of potential sperm, oocyte, and embryo donors, incorporating recent information about optimal screening and testing for sexually transmitted infections, genetic diseases, and psychological assessments. This revised document incorporates recent information from the U.S. Centers for Disease Control and Prevention, the US Food and Drug Administration, and the American Association of Tissue Banks, with which all programs offering gamete and embryo donation services must be thoroughly familiar, and replaces the document titled, "2008 Guidelines for Gamete and Embryo Donation: A Practice Committee Report," last published in Fertil Steril 2008;90:S30-44.

On the cutting edge: ethical responsiveness to cesarean rates.

Cesarean delivery rates have been steadily increasing worldwide. In response, many countries have introduced target goals to reduce rates. But a focus on target goals fails to address practices embedded in standards of care that encourage, rather than discourage, cesarean sections. Obstetrical standards of care normalize use of technology, creating an imperative to use technology during labor and birth. A technological imperative is implicated in rising cesarean rates if physicians or patients fear refusing use of technology. Reproductive autonomy is at stake since a technological imperative undermines patients' ability to choose cesareans or refuse use of technology increasing the likelihood of cesareans. To address practices driven by a technological imperative I outline three physician obligations that are attached to respecting patient autonomy. These moral obligations show that a focus on respect for autonomy may prove not only an ideal ethical response but also an achievable practical response to lowering cesarean rates.

Biotechnology regulation: is policy transfer an appropriate answer?

En el campo de la regulación de la biotecnología, la recomendación de consultar la legislación de otros países se presenta con bastante frecuencia. Conocida como en materia de análisis de políticas públicas, el propósito de tal recomendación es que quienes deban formular una política puedan hacer uso de la experiencia de otros Estados como base para desarrollar los marcos reglamentarios más apropiados en el momento oportuno. Este artículo analiza si la transferencia política es relevante como instrumento para la regulación de la biotecnología y, si lo es, en qué medida. Nuestro análisis toma como ejemplo las Técnicas de Reproducción Humana Asistida (TRHA) y se desarrolla de acuerdo a los siguientes pasos argumentativos. Comenzaremos con la discusión sobre la transferencia política como característica reconocida de la elaboración de políticas en la literatura relativa al análisis de políticas públicas. Posteriormente, introduciremos una distinción entre la dimensión técnica de la elaboración de políticas públicas y su componente político. Demostraremos que, en el caso de las políticas públicas de moralidad, los Estados se han alejado del enfoque de la transferencia política. Finalmente, estableceremos que las TRHA calificadas como política pública de moralidad, sugieren que la transferencia política probablemente no es el instrumento más apropiado de la elaboración de políticas públicas en lo que respecta a la regulación de la biotecnología. Sin duda, yendo más allá de la cuestión de las TRHA con el fin de ampliar nuestro razonamiento a la regulación de la biotecnología, concluiremos que, si bien la experiencia de otros Estados puede ser útil, la transferencia política no es suficiente para informar en la elaboración de las políticas públicas en el caso de los avances biotecnológicos (AU)

In the world of biotechnology regulation, one often encounters the suggestion that the legislation of other countries should be consulted. Known as "policy transfer" in the field of public policy analysis, the purpose of such a recommendation is for policymakers to use the experiences of other states as a basis for developing appropriate regulatory frame works in a timely manner. This paper examines whether policy transfer is relevant as an instrument for biotechnology regulation, and if it is, to what extent. Our analysis uses the example of Assisted Reproductive Technologies (ART), and unfolds accordant to the following argumentative steps. We will begin literature pertaining to public policy analysis. We will then introduce a distinction between the technical dimension of policymaking and its political component. We will refer to "morality policy" as an illustration of policymaking directed toward its political component. We will show that, in the case of morality policy. States have moved away from a policy transfer approach. We will then establish that ART qualifies as morality policy, suggesting that policy transfer is most likely not the optimal policymaking tool for dealing with biotechnology regulation. Moving beyond the issue of ART in order to expand our reasoning to biotechnology regulation as a whole, we will conclude that, although the experiences of other States may be useful, policy transfer does not suffice in terms of informing policymaking in the case of biotechnology advances (AU)

[Assisted procreation technology and people with HIV]. / Aide médicale à la procréation chez les personnes infectées par le VIH.

In France, a ministerial decree dated 10 May 2001 authorizes the use of assisted reproduction technologies (ART) for people infected with the human immunodeficiency virus (HIV), either to reduce the risk of transmission between partners or to treat the couple's infertility. The HIV patient must have a CD4 T lymphocyte count>200/mm(3) and a stable viral load (no increase exceeding 0.5 log(10) copies/mm(3)) between 2 samples during the 6 months preceding ART. Co-infections with hepatitis B or C must be assessed by a specialist. When the man is infected, only ART allows conception while simultaneously ensuring safe sexual relations between the couple. ART is performed with prepared spermatozoa, validated negative for HIV RNA. The particular ART method depends on the results of the couple's fertility assessment and the quantity of virus in the seminal fluid. Antiretroviral treatment is not required for ART but may be necessary if the seminal viral load is elevated. When the woman is infected, the couple must be informed about the risks of HIV transmission to the child and of toxicity to mother and fetus from the antiretroviral treatments. These risks must guide optimization of the antiretroviral treatment, which is not routine during ART but is systematic during the last trimester. Management of pregnancy planning should propose artificial insemination and rapid recourse to ART because ovarian function appears to deteriorate quickly in women with HIV. Several thousand couples in Europe have used ART without any cases of contamination reported so far. Approximately half of these couples can hope to have a child, but approximately one third decide against ART after consultation.

[Fertility treatments: possibilities for fewer multiple births and lower costs--the 'Umbrella' study]. / Vruchtbaarheidsbehandelingen: mogelijkheden voor minder meerlingen en lagere kosten--de 'Paraplustudie'.

Since the 1980s, increasingly more fertility treatments have been performed in the Netherlands. The use of ovarian hyperstimulation during in vitro fertilisation (IVF) and intrauterine insemination (IUI) has contributed to an explosive increase in the number of multiple births. To control the costs of treatment and outcomes, the Minister of Health, Welfare and Sport commissioned research on possible improvements in the performance of fertility treatments in 1999. The results of this research ('Umbrella study'), reported in 2005, suggested that costs and the incidence of multiple births could be reduced if (a) IUI is only performed if the chance of spontaneous pregnancy is less than 30%; (b) the guideline 'Intrauterine insemination' is followed more closely regarding hormonal stimulation; (c) stimulation is used less frequently during IVF; and (d) no more than 1 embryo is placed in the uterus at a time. To achieve these results, all parties involved must revise their policies. In particular, current reimbursement regulations inhibit the implementation of the research results in practice.