Uterus transplantation

27 08 2013

To the Editor:

We read with great interest the paper “Current status of uterus transplantation in primates and issues for clinical application” by Kisu et al. (1). In that paper, the authors address the present status of experimental and clinical uterus transplantation research and potential medical, social, and ethical issues related to it.

Uterine factor infertility (UFI), congenital or acquired, affects 3% to 5% of the general population (1, 2). At present, UFI patients have no option for having a genetically linked child other than with gestational surrogacy, which is illegal in many countries (1). Experimental studies carried out in the last decades have shown pregnancy and delivery in some allograft animal models (1). End to site anastomoses of two arteries and two veins in appropriate length and thickness to the recipients’ relevant external iliac vessels are defined as the best technique for vascular anastomoses based on experimental and clinical data (1-3). Warm ischemia time (WIT) both involves the ischemia during organ retrieval, from the time of cross clamping until cold perfusion is sustained, and the ischemia time starting with removal of the organ from ice until reperfusion (4) (35 minutes in our case). Cold ischemia time (CIT) starts when the organ is put in ice and cooled with a cold perfusion solution after organ procurement surgery, and ends after the tissue reaches physiological temperature during the transplantation procedure. Decreasing the length of CIT as well as WIT are important factors in improving graft survival in transplantation (4, 5). Read the rest of this entry »

Defining ART success

21 08 2013

To the Editor:

We are very pleased to note Dr. Meldrum’s “Conceptions” piece (1), following our recent report (2), reaffirming our main conclusion that the current IVF outcome reporting system requires a major overhaul. Dr. Meldrum, furthermore, emphasizes other points raised in our article, including the need for ART reports to incorporate maternal and perinatal outcomes rather than just pregnancy rates in defining assisted reproductive technology (ART) success, to better align reports with patient interests (3). We also agree with basing outcome reports on the total reproductive potential (TRP) of each initiated in vitro fertilization (IVF) cycle, which includes the initial fresh cycle plus subsequent frozen transfers, a process feasible from the current Society for Assisted Reproductive Technology (SART) database (4).

Dr. Meldrum’s main proposal of reporting outcome data on a per embryo transfer basis will, however, not solve the problem of outcome data manipulation in IVF, which our report brought into the open (2). In fact, reporting outcome data on a per embryo transfer basis may actually further exacerbate exclusion of poor prognosis patients who start cycles but, for various reasons (embryo banking with unsuccessful subsequent thaw, all embryos degenerate in extended day-5/6 culture, all embryos aneuploid after preimplantation genetic screening (PGS), etc.), never reach embryo transfer. Exactly these kinds of exclusions currently allow a small minority of reporting centers to disproportionately select out patients with low pregnancy potential and, thereby, to manipulate pregnancy rates in the centers’ favor (2). Read the rest of this entry »

Why should we discard all abandoned human embryos?

5 08 2013

To the Editor:

In the June 2013 issue of Fertility and Sterility, the Ethics Committee of the American Society for Reproductive Medicine published its latest opinion on the disposition of abandoned embryos (1), updated from 2004 (2). This is an important contribution to the literature on this timely issue, an issue that requires swift resolution.

At the conclusion of its 2013 article, the Committee writes:
“If a program reasonably determines…that embryos have been abandoned, the Ethics Committee concludes that the program may dispose of the embryos by removal from storage and thawing without transfer. In no case should embryos deemed abandoned be donated to other couples or be used in research” (emphasis added, 1849).

I agree with the Committee that clinics ought to be allowed to discard abandoned embryos. However, the Committee does not offer any argument to support their stronger claim that, if clinics are to do anything with abandoned embryos, they are morally permitted only to expressly discard them. (This lack of explicit argument is mirrored in their 2004 piece.) While we can reasonably expect that much discussion about this went on behind the scenes, presenting this position here—equipped with a normative prescription for clinicians about the disposition of abandoned embryos—without any explicit support, leaves the Committee’s position open to serious criticism. It is appropriate to ask the Committee for a statement of their reasons for making the strong conclusion that they do. Read the rest of this entry »