Prevalence, pathophysiology, endocrinology, diagnostics, therapeutic options

Prevalence, pathophysiology, endocrinology, diagnostics, therapeutic options

This chapter considers the legacy of the 1984 Warnock Report, and its continued impact on the regulation of assisted conception, embryo research and surrogacy in the UK. On the one hand, it is extraordinary that a regulatory system grounded in recommendations made only six years after the birth of the first ‘test tube baby’ has stood the test of time so well. The HFEA regulatory model – in which an ‘arm’s-length body’ issues licences, backed up by criminal sanctions, and in which primary legislation is supplemented by regularly updated codes of practice – has proved remarkably resilient, and has since been used to regulate other areas of medical practice. On the other hand, there may be disadvantages in trying to regulate a twenty-first-century industry using tools that were designed for a very different age. The chapter looks at two developments that the Warnock Report did not anticipate and hence did not make provision for in its recommendations: the emergence of a lucrative market in fertility services; and the increasing acceptance that fertility treatment should be available to would-be parents who do not conform with the ‘two-parent family, with both father and mother’ model.

There is no doubt that intracytoplasmic sperm injection (ICSI) has been a major breakthrough in treating male infertility, accounting for 70–80% of all the cycles performed worldwide. Surprisingly, there were very few animal studies conducted before the first babies were born, in part because of technical challenges that were experienced in most animal systems. Technological advancements were required to develop appropriate animal models for assessing the safety of ICSI. These studies identified many cytoskeletal changes that occurred in the oocyte cytoplasm after ICSI versus natural conception or even IVF, raising concerns about the long-term health of ICSI offspring. This chapter summarizes the animal models that have contributed to our understanding of the cellular and molecular aspects of ICSI, as well as providing models to investigate both the developmental origins of adult disease and transgenerational implications as they relate to ICSI.

Medical Ethics is increasingly recognised to be central to Good Medical Practice and the field of reproductive medicine presents some of the most challenging and complex issues of any branch of medecine. Scientific progress in ART has advanced so rapidly that Ethicists struggle to keep pace, but fertility clinicians can help to bridge the gap between clinical care and the sometimes ‘sci-fi’ world of the embryology laboratory. They can help patients benefit from developments that offer would-be parents the chance of a family without the risk of genetic disease and thereby advance one of humanity’s major goals. Society too is entitled to be engaged in the debate: the transition in just 42 years from in vitro fertilisation being a way of by-passing blocked Fallopian tubes to egg donation, egg freezing, womb transplantation, posthumous reproduction and CRISPR gene editing has raised issues that legislators struggle to explain and some faith groups strive to contain. As clinicians, we are confronted with the patient in the consulting room whom we long to help. We face a difficult balancing act between what is technically feasible, what is practically possible and what is ethically acceptable given resource and other restraints.This chapter is intended to help fertility clinicians achieve that balance.