Assisted reproduction practice: religious perspectives

Navigating the gestational surrogacy seas: the legalities and complexities of gestational carrier services

This paper offers a comprehensive review of the gestational surrogacy process in the US, as well as internationally, focusing on the legal and ethical challenges that gestational carriers, intended parents, fertility providers, and OB/GYNs may face. The objective of this review article is to serve as an overview and provide information on legal, cultural, and ethical aspects of the decisions to pursue gestational surrogacy both for intended parents and gestational carriers in the US and globally. By understanding the surrogacy landscape and the obstacles, the surrogacy agencies and other involved parties can improve the surrogacy process to better serve all parties involved.

Klinefelter syndrome: etiology and clinical considerations in male infertility†

Klinefelter syndrome (KS) is the most prevalent chromosomal disorder occurring in males. It is defined by an additional X chromosome, 47,XXY, resulting from errors in chromosomal segregation during parental gametogenesis. A major phenotype is impaired reproductive function, in the form of low testosterone and infertility. This review comprehensively examines the genetic and physiological factors contributing to infertility in KS, in addition to emergent assisted reproductive technologies, and the unique ethical challenges KS patients face when seeking infertility treatment. The pathology underlying KS is increased susceptibility for meiotic errors during spermatogenesis, resulting in aneuploid or even polyploid gametes. Specific genetic elements potentiating this susceptibility include polymorphisms in checkpoint genes regulating chromosomal synapsis and segregation. Physiologically, the additional sex chromosome also alters testicular endocrinology and metabolism by dysregulating interstitial and Sertoli cell function, collectively impairing normal sperm development. Additionally, epigenetic modifications like aberrant DNA methylation are being increasingly implicated in these disruptions. We also discuss assisted reproductive approaches leveraged in infertility management for KS patients. Application of assisted reproductive approaches, along with deep comprehension of the meiotic and endocrine disturbances precipitated by supernumerary X chromosomes, shows promise in enabling biological parenthood for KS individuals. This will require continued multidisciplinary collaboration between experts with background of genetics, physiology, ethics, and clinical reproductive medicine.

"The biggest disappointment": women's expectations from sex are ignored, from the perspective of infertile women

OBJECTIVE

The aim of this study is to determine the attitudes, behaviours and experiences of infertile women towards sexuality.

METHODS

This study was carried out in the infertility outpatient clinic of a state hospital in Istanbul of Turkey. Fifteen infertile women who had been receiving primary infertility treatment for at least two years and were actively continuing infertility treatment were included in the study. Data were collected by means of an detailed information form and a semi-structured interview. Content analysis was applied to the data obtained from semi-structured interviews. Consistency percentage calculation was made between the codes and themes determined by 4 researchers who are experts in their fields.

RESULTS

Results based on the interviews with the participants, 2 main themes, 6 sub-themes and 27 codes related to sub-themes were determined as 'Factors Affecting Sexual Life' and 'Overview of Sexual Health and Sexuality'. 'Disappointment' was determined as the most commonly defined code in the determined main theme and sub-themes.

CONCLUSION

It was determined that the majority of infertile women base their sexual lives on reproductive functions, experience serious sexual health problems, feel worthless, and describe their sexual life as a great disappointment.

Exploring the experiences of English-speaking women who have moved to Israel and subsequently used Israeli fertility treatment services: A qualitative study

BACKGROUND

Israel's pronatalist cultures result in a social expectation to have children and drive Israel's fertility rate of 2.9. Israeli policy reflects this through funding unlimited fertility treatment up to two children. Societal pressure to have children exacerbates challenges of fertility treatment. Furthermore, the lack of financial burden creates a culture of perseverance following treatment failures. Whilst the experiences of Israeli women using fertility treatment have been studied, the experiences of women who migrated to Israel and were therefore raised in a different society have not. This study aimed to address this gap in knowledge.

METHODS

A qualitative study using semi-structured interviews to investigate the experiences of 13 English-speaking women who utilised Israeli state funded fertility treatment. Participants were located across Israel and were recruited using purposive sampling through social media. Data was analysed using framework analysis.

RESULTS

Despite not being aimed at specific ethnic or religious groups, all respondents were Jewish. Three themes were identified: 1. Systemic factors: The lack of financial burden was positive, however, participants struggled to navigate the bureaucratic healthcare system, especially when experiencing a language barrier. 2. Influence of others: Encountering a cold bedside manner alongside contending with the expectations of a pronatalist society was challenging. Participants utilised support from other migrants who appreciated the same culture shock. Understanding of healthcare professionals regarding shared religious values further improved treatment experiences. 3. Impact of journey: Participants often withdrew socially and the treatment process implicated upon their lives, jobs and relationships.

CONCLUSION

Navigating a bureaucratic system and pronatalist society are difficulties associated with fertility treatment in Israel. The lack of financial burden and an understanding of religious and cultural beliefs by healthcare providers improved treatment experience. Better provision of resources in English and further research into supporting women who are navigating Israel's pronatalist society is required.

Ethical Issues in Sperm, Egg and Embryo Donation: Islamic Shia Perspectives

Assisted Reproductive Technologies (ARTs) have been practiced in Islamic societies within married couples since their introduction. However, there are divergent views over the issue of third-party donation among Sunni and Shia scholars. This paper illustrates the different perspectives of Shia Muslims surrounding, sperm, egg, and embryo donation and ethical aspects thereof. The study reveals that there are different views regarding sperm, egg, and embryo donation among the Shia religious leaders around the world. Many Shia religious scholars, including the Iranian supreme religious leader Ali Hussein Khamenei allow sperm, egg, and embryo donation with certain conditions. However, the conditions stipulated by Shia religious scholars contradict the ethical and legal practices of sperm, egg, and embryo donation. Regarding sperm and egg donation, they declared that the donor child would inherit from a third-party donor and the commissioning parents would be adoptive parents. Thus, according to them, donor anonymity is impossible. Moreover, the Iranian act on embryo donation did not stipulate the right and responsibilities of the donor child and recipient couples and did not clarify the nature and number of embryos that can be donated and implanted. The paper argues that the lack of laws and guidelines on sperm, egg, and embryo donation raises many ethical problems. Based only on religious rulings, third-party donation has been practiced without foreseeing the well-being and safety of donor children, donors, and recipient couples.

Perception of having children through surrogacy in individuals with MRKH in Vietnam: a qualitative study

Introduction

Mayer-Rokitansky-Küster-Hauser syndrome (MRKH) is rare condition that has a negative impact on quality of life because affected women lack a uterus and vagina, and are therefore unable to engage in sexual intercourse and experience natural pregnancy. This study evaluated perceptions of surrogacy in Vietnamese women with MRKH who have started families.

Method

Women with MRKH who had undergone successful vaginal reconstruction, were married, and had started families participated in a semi-structured, in-depth, one-on-one online video interview with an experienced female psychologist. Open-ended questions were used to encourage participants to express their perceptions of surrogacy; prominent themes were discussed, compared, and combined.

Results

Twenty women (mean age 31 years) agreed to participate. Key themes identified from interviews were the importance of having genetic offspring, consideration of surrogacy as a preferred solution to infertility, the barriers to surrogacy in Vietnam, lack of reproductive information and counselling, individuals concealing their health condition, the impact of religion on the possibility of surrogacy, the economic cost of surrogacy, and the difficulty in finding a surrogate under the restrictions imposed by Vietnamese law.

Discussion

Based on the perceptions of women from MRKH from Vietnam, there is an opportunity to improve how infertility is managed in these people, including information about surrogacy. These data show that individuals with MRKH should be provided with information about the possibility of surrogacy, encouraged to be open and seek support, and be managed by a multidisciplinary team that includes psychological support; the provision of economic support for fertility treatments in women with MRKH should also be considered.

Israeli students' perceptions regarding sperm donation: dilemmas reflections with dominant demographic effect

BACKGROUND

Sperm donation has undergone significant medical and social transformations in recent decades. This study aimed to explore Israeli students' perceptions towards sperm donation and investigate the potential influence of demographic characteristics on these perceptions.

DESIGN

The study encompassed 254 students from Tel-Aviv University, who completed an anonymous online survey in January-February 2021. This cross-sectional quantitative online survey, comprised 35 questions categorized into three sections: demographic data, assessment of prior knowledge, and perceptions of sperm donation (general perceptions related to both positive and negative stigmas associated with sperm donation, the roles and activities of sperm banks, and considerations surrounding identity disclosure versus the anonymity of sperm donors and their offspring).

RESULTS

Participants exhibited a relatively low level of prior knowledge (mean 31.2 ± 19 of 100). Scores for positive and negative stigmas ranged from 1.3 to 2.2. Notably, the statement "Donors' anonymity preservation is crucial to maintain sperm donation" received a mean of 3.7. Seeking for anonymous sperm donation identity both by recipients and offspring was ranked with low means (1.5 and 1.7, respectively). However, the pursuit of half-siblings by mothers or siblings themselves received higher ratings ranging from 2.7 to 3. Women's stigma ranking were notably lower, while men emphasized the importance of donor anonymity.

CONCLUSIONS

Sperm Banks hold a position of medical authority rather than being perceived as being commercial entity. The preservation of donor anonymity is widely accepted as a crucial element, prioritized over the requests for identity disclosure from recipients and offspring. Demographic parameters exhibit a strong and precise effects on participants' perceptions.

Attitudes of Different Religions Toward Surrogacy: Analysis of 11 Countries' Situation Using Machine Learning Approach and Artificial Neural Networks

Individuals may develop different attitudes on bioethics in general and reproductive ethics in particular, due to the effects of different sociocultural environments. Individuals' attitudes toward surrogacy are affected positively or negatively depending on religious and cultural environments. This study was conducted to determine and compare the attitudes of different religions toward surrogacy. This study is cross-sectional and collected from individuals living in Turkey, India, Iran, the Turkish Republic of Northern Cyprus, Madagascar, Nepal, Nigeria, Pakistan, Mexico, England, and Japan between May 2022 and December 2022. The study was conducted with individuals belonging to Islam, Christianity, Hinduism, Buddhism, and Atheism. The study was conducted with 1177 individuals from different religions who agreed to participate in the study by snowball sampling method. The introductory Information Form and "Attitude Questionnaire Toward Surrogacy" were used as data collection tools. R programming language 4.1.3 was used for regression analysis with machine learning approach and artificial neural networks, and SPSS-25 was used for other statistical analyses. There was a significant difference between the total mean score of the individuals' Attitudes toward Surrogacy Questionnaire and their religious beliefs (p < 0.05). When the results of the analysis of the regression model with the dummy variable, which was carried out with the aim of revealing the effects of religious belief on the attitude toward surrogacy, are examined, statistical estimates of the regression model show that the model is significant and usable F(4,1172) = 5.005, p = 0.001). It explains 1.7% of the total variance of the level of religious belief's attitude toward surrogacy. In the regression model, when the t-test results regarding the significance of the regression coefficient are examined, among the participants, it was determined that the mean score of those who believed in Islam (t =  - 3.827, p < 0.001) and those who believed in Christianity (t =  - 2.548, p < 0.001) was lower than the mean score of those who believed in Hinduism (Constant) (p < 0.05). Individuals' attitudes toward surrogacy differ according to their religion. The best performing algorithm for the prediction model was random forest (RF) regression. The contributions of the variables to the model were calculated with Shapley values (Shapley Additive Explanations (SHAP)). The SHAP values of the variables in the best performing model were examined to avoid bias in terms of comparison in the performance criterion. SHAP values (Shapley Additive Explanations) show the contribution or importance of each variable in the estimation of the model. It is determined that the most important variable that should be in the model to predict the Attitude Toward Surrogacy Survey variable is the Nationality variable. It is recommended that studies on attitudes toward surrogacy should be conducted by taking religious and cultural values into consideration.

Perspectives surrounding fertility preservation and posthumous reproduction for adolescent and young adults with terminal cancer: Survey of allied health professionals

BACKGROUND

While all reproductive-aged individuals with cancer should be offered fertility preservation (FP) counseling, there is little guidance over offers to adolescent and young adults (AYA) with terminal diagnoses, especially when considering posthumous assisted reproduction (PAR). The Enriching Communication skills for Health professionals in Oncofertility (ECHO/ENRICH) trains Allied Health Professionals (AHPs) to improve communication with AYAs with cancer. Little is known about AHPs' role in assisting in FP and PAR decisions.

METHODS

This is a cross-sectional survey of ECHO/ENRICH trainees' attitudes and experience with FP and PAR in AYA with terminal cancer.

RESULTS

The response rate was 61% (365/601). While 69% felt comfortable discussing FP with terminal AYA after ECHO/ENRICH training, 85% desired further education. The majority (88%) agreed FP should be an option for AYA with cancer, though some agreed offering FP provided false hope (16%) or was a waste of resources (7%). Most shared that avoidance of FP discussions was common practice, especially in the medically fragile, late-stage disease, or among minors. Many attributed lack of conversations to oncology team goals. Only 9% had prior experience with PAR. Many were conflicted about how PAR reproductive material should be gifted and who should be permitted to use PAR. Several raised moral concerns for PAR, or discomfort advising family. Many voiced desire for additional PAR-specific education.

CONCLUSION

ECHO/ENRICH trainees had varied levels of exposure to FP in terminal AYA and limited experiences with PAR. Many expressed uncertainties with PAR, which may be alleviated with further training and transparent institutional policies.

Assisted Reproductive Technologies: Comparing Abrahamic Monotheistic Religions

The impact of culture and religion on sexual and reproductive health and behavior has been a developing area of study in contemporary time. Therefore, it is crucial for people using reproductive procedures to understand the religious and theological perspectives on issues relating to reproductive health. This paper compares different perspectives of three Abrahamic faiths, i.e., Judaism, Christianity, and Islam on ARTs. Procreation, family formation, and childbirth within the context of marriage have all been advocated by these three major religions of the world. Judaism permits the use of all assisted reproductive technologies when the oocyte and sperm come from the husband and wife, respectively. The different denominations of Christianity have diverse views on reproductive practices. Although the Vatican does not approve of assisted reproduction, Protestant, Anglican, and other religious groups are free to use it. ARTs are acceptable in Sunni Islam, although they can only be carried out if the couples are married. Shia Islam, however, permits third-party donations to married couples under specific restrictions. This comparison reveals that while the three major world religions utilize assisted reproduction in distinct ways, there are also many comparable aspects of each religion.

Exploration of decision-making regarding the transfer of mosaic embryos following preimplantation genetic testing: a qualitative study

STUDY QUESTION

What are patients’ reasoning and decisional needs in relation to the transfer of mosaic embryos following preimplantation genetic testing (PGT)?

SUMMARY ANSWER

This study identified four themes, which were patients’ reasoning behind decision-making, their decisional needs, the influence of the mosaic embryos on the decision-making and the role of health professionals.

WHAT IS KNOWN ALREADY

To date, no study has investigated the reasoning of patients behind their decision-making and the influence of mosaic embryos.

STUDY DESIGN, SIZE, DURATION

This is a cross-sectional study using a qualitative approach. Twenty participants were interviewed, and recruitment was ceased when no new information was identified in the data analysis. It ensured a sufficient sample size for a qualitative study.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were females with mosaic embryos. Semi-structured in-depth interviews were conducted via telephone.

MAIN RESULTS AND THE ROLE OF CHANCE

Four themes were identified: reasoning behind decision-making, decisional needs, influence of mosaic embryos on decision-making and the role of health professionals. Potential risks of transferring mosaic embryos and prioritization of euploid embryos were the main reasons for not transferring mosaic embryos. A lack of alternatives, perceived benefits and risk tolerance were main reasons for transferring mosaic embryos. Patients reported that information on mosaic embryos, amniocentesis and termination was important to support their decision-making. Unmet needs relating to healthcare services and social support were reported. In addition, having mosaic embryos affected the patients’ emotional and behavioural responses, discussions about prenatal testing, attitudes to termination and further IVF cycles and attitudes towards PGT. Health professionals were found to influence the patients’ decision-making.

LIMITATIONS, REASONS FOR CAUTION

Participants were recruited through one clinic, which may limit the transferability of results. Also, patients’ experiences in relation to financial aspects of PGT may not be relevant to other jurisdictions due to different healthcare policies.

WIDER IMPLICATIONS OF THE FINDINGS

The results may inform how clinicians provide healthcare services based on factors influencing patients’ decision-making. Health professionals should be aware of the influence their attitudes can have on patients’ decision-making and should present information accordingly. Also, providing all relevant information may help to facilitate informed decision-making. Provision of psychological support from professionals and support groups is also critical during the process of testing and transfer. Patients have educational needs regarding mosaic embryos, and educational resources including decision aids in plain language are needed.

STUDY FUNDING/COMPETING INTEREST(S)

B.M. was funded through a Senior Research Fellowship Level B (ID 1078523) from the National Health and Medical Research Council of Australia. L.C. was supported by a University International Postgraduate Award under the Australian Government Research Training Program (RTP) scholarship. No other funding was received for this study. The authors report no competing interests.

TRIAL REGISTRATION NUMBER

N/A.

The Special Features of Prenatal and Preimplantation Genetic Counseling in Arab Countries

Genetic counseling services have only recently been introduced in most Arab countries, and their utilization is increasing. Prenatal genetic counseling is essential, particularly in the Arab context, which is characterized by high rates of consanguinity. Nevertheless, little is known about the decisions faced by parents and the factors underlying the complex decision making that must occur when accessing these services in Arab countries. Herein, we performed a narrative review to discuss the reported experiences of parents accessing genetic counseling in the prenatal setting in the 22 Arab countries. We also highlight the different types of decisions encountered and the factors influencing them. We report that: (i) utilization of genetic counseling services varies across different Arab countries; (ii) many factors affect decision making and service utilization, especially religion; and (iii) parents are faced with an array of decisions in the prenatal setting, partly driven by increased utilization of prenatal diagnosis and preimplantation genetic testing in some countries. Our work is the first to highlight the different factors and decisions influencing genetic counseling in Arab countries. Understanding these factors is essential for improving genetic counseling services in the region and helping counselors facilitate informed decision making.

The impact of religion and culture on medically assisted reproduction in the Middle East and Europe

Infertility is a medico-socio-cultural problem associated with gender-based suffering. Infertility treatment, including assisted reproductive technology (ART), is a human right. Culture and religion were among the stumbling blocks to early acceptance of ART, particularly in the Middle East and to a lesser extent in Europe. This was mostly due to the different cultural and religious perspectives on the moral status of the embryo in the two regions and the concerns about what could be done with human embryos in the laboratory. There is an increased demand for ART in both the Middle East and Europe, although the reasons for this increased demand are not always the same. Although Europe leads the world in ART, there is an unmet need for ART in many countries in the Middle East. Where ART is not supported by governments or insurance companies, a large percentage of couples paying for ART themselves will stop before they succeed in having a baby. There are similarities and differences in ART practices in the two regions. If a healthcare provider has a conscientious objection to a certain ART modality, he/she is ethically obliged to refer the patient to where they could have it done, provided it is legal.

Factors Associated With University Students' Attitude Toward Euthanasia

Although euthanasia has been practiced for thousands of years, a wide controversy still exists around it. This study aimed to assess the attitude of university students toward euthanasia and its associated factors. The study included an online self-administered survey. Survey questions consisted of demographic information, psychological condition, and attitude toward euthanasia. A total of 1,188 students participated in the study. Approximately only one-third of the respondents (34.1%) viewed euthanasia as a moral practice, and just one-quarter (25.3%) supported legalizing it. The main reason for not supporting euthanasia was religious considerations (72.2%), followed by moral considerations (46.5%). Factors that predicted a positive attitude toward euthanasia (p < .05) included undefined religion, being male, feeling lonely, or having suicidal thoughts. Conclusively, the negative attitude toward euthanasia is primarily driven by religious beliefs. Furthermore, gender and psychological status play critical roles in students' attitudes toward euthanasia.

The Principle of "Damage Exclusion" as a Benchmark in Catholic Discussions of Homologous Artificial Insemination

The Catholic perspective rejects assisted human reproduction techniques, but the morality of artificial insemination (AI) is open for discussion. This article aims to analyze the morality of AI from a new angle, namely whether these interventions exclude all possibility of damaging the human embryo and the offspring's health. The scientific evidence about the children's health who are born through AI allows us to affirm that the procedures do not comply with the principle of damage exclusion: AI does not exclude all possibility of damaging the embryo and impacting the health and exposure to disease of the offspring born through these techniques.

Thoughts on the ethics of gestational surrogacy: perspectives from religions, Western liberalism, and comparisons with adoption

BACKGROUND

In gestational surrogacy, a woman incubates an embryo to which she is not genetically related. Genetic distance from both her and the commissioning parents is increased further when donor gametes are employed. Ethical implications vary depending on the extent to which the parents and surrogates share genetic material with the produced child.

PURPOSE

This paper seeks to address two primary questions: What do selected ethical frameworks tell us of (1) the relationship between genetic motherhood, gestational motherhood, social motherhood, and marital fidelity? And (2) the effects of gestational surrogacy and gamete donation on our understanding of lineage and heritability?

METHODS

Current literature and thought on these questions were considered through the classical ethics lenses of religion, the adoption standard, and Western liberalism.

RESULTS

A genetic link between the parents and the child serves to simplify the adoption process (if one is required) and supports a family's desire to resemble as much as possible a traditional biological family, thus providing a minimum set of challenges to religious or conservative hesitations.

CONCLUSION

Inasmuch as gestational surrogacy, with or without donor gametes, is tolerated in a variety of ethical contexts; the basis of its acceptance may be the Western liberal celebration of contractual agreement.

Protestant Christian attitudes to ART

STUDY QUESTION

How do Christian religious beliefs affect attitudes to ART?

SUMMARY ANSWER

Attitudes to ART depend on the religiosity of the respondent, and although the majority of those that had successfully used ART were positive or moderately positive in their views, the acceptability of procedures fell when damage to the marriage relationship or the embryo was a potential outcome.

WHAT IS KNOWN ALREADY

Religion can impact views on ART. Sanctity of marriage and sanctity of the embryo are major concerns for some Christians, but details are unclear.

METHODS

A cross-sectional online survey was used to collect data from 1587 participants over a 3-month period in 2013, of which 1334 were of the Christian faith and included in this study. Descriptive statistics were reported for individual ARTs, and a general score of all ART approval was calculated. A multivariable linear and logistic regression was conducted on general approval for ART to identify predictors of ART approval.

MAIN RESULTS AND THE ROLE OF CHANCE

Indicators of religiosity (religious meeting attendance and Bible reading frequency) showed that this was a highly religious sample. We found that in this cohort of English-speaking, well-educated, practising and mainly Protestant Christians 164 (12.3%) of those had personal experience of ART. Most participants that had successfully used ART were positive or moderately positive in their views. Throughout the cohort, procedures were less acceptable if there was a perception that the marriage relationship or the life of the embryo was threatened: including donated gametes (28.7-29.1% approval), surrogacy (22.7-33.1% approval), and PGD (1.0-23.8% approval). A multivariable analysis of the ART approval score found that it was higher among those with Protestant compared with Catholic/Orthodox faith (P < 0.001; mean score difference, 5.06; 95% CI 4.36-5.81) and those who believe life begins after fertilisation (P < 0.001; mean score difference, 4.86; 95% CI 4.14-5.57). Approval was also higher, but to a lesser extent, in women than men (P = 0.008; mean score difference, 0.73; 95% CI 0.18-1.28), and those with lower religiosity (P < 0.001). The area raising most indecision for this cohort was disposal of excess embryos.

LIMITATIONS REASONS FOR CAUTION

This sample includes an uneven geographical spread of respondents and restriction to English-speaking participants. Different views may be expressed by a different religious cohort. Use of an online survey platform means that a bias towards those with computers (consistent with education levels of this cohort) could exist. Use of this platform also makes it impossible to know the response rate, and the veracity of responses cannot be verified. However, despite these limitations we believe this survey gives us insight into the reservations held among a certain population of Christians regarding the use of reproductive technology.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings highlight the need for ART clinicians to consider the influence of patient spiritual beliefs on therapeutic options and provide detailed information that will allow them to be accommodated. Practices such as widening the options for collecting semen and limiting the number of embryos created through IVF so as to reduce or eliminate excess embryos may be helpful for these patients.

STUDY FUNDING/COMPETING INTERESTS

This study was supported by a grant from The Center for Bioethics & Human Dignity in Deerfield, Illinois, USA. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

A case of Mayer-Rokitansky-Küster-Hauser syndrome in a low-resource tertiary hospital in Douala, Cameroon

The Mayer-Rokitansky-Küster-Hauser syndrome is the congenital absence or underdevelopment of the uterus and vagina even though the external genitalia, ovaries and ovarian function are normal. This condition is uncommon in Cameroon. A 23-year-old woman of the Fulbé tribe, a predominantly Islamic tribe of the northern part of Cameroon, complained of the absence of menstruation after age of puberty and lower abdominal pain occurring almost at the same period every month. She has been married polygamously for 10 years and has been having normal, satisfactory sexual intercourse. The sonographic and laparoscopic findings of this patient were consistent with Mayer-Rokitansky-Küster-Hauser syndrome. The patient was counseled for in vitro fertilization and surrogacy. Patients with Mayer-Rokitansky-Küster-Hauser syndrome typically present with primary amenorrhea during adolescence. With the existing medical technology in Cameroon, this condition is easily accessible in tertiary healthcare facilities. Patients with Mayer-Rokitansky-Küster-Hauser syndrome could become mothers through in vitro fertilization and surrogacy, but the cost is prohibitive in Cameroon.

Racial and Ethnic Differences in the Utilization of Prayer and Clergy Counseling by Infertile US Women Desiring Pregnancy

Religion can have a significant influence on the experience of infertility. However, it is unclear how many US women turn to religion when facing infertility. Here, we examine the utilization of prayer and clergy counsel among a nationally representative sample of 1062 infertile US women. Prayer was used by 74.8% of the participants, and clergy counsel was the most common formal support system utilized. Both prayer and clergy counsel were significantly more common among black and Hispanic women. Healthcare providers should acknowledge the spiritual needs of their infertile patients and ally with clergy when possible to provide maximally effective care.

Perspectives and attitudes of Jordanian medical and paramedical students toward surrogate pregnancy

PURPOSE

This study aims at investigating the perspectives of Jordanian medical and paramedical students on surrogate pregnancy.

METHODS

A questionnaire-based cross-sectional study design was used. The sample consisted of n=328 students of both genders. The questionnaire responses were numerically coded and analyzed across gender and the level of education.

RESULTS

Approximately, 18% of the students reported good awareness about the ethical dilemmas of surrogacy. The results showed a general reluctance to accept surrogate pregnancy as the majority (80.5% of male students and 97.6% of female students) had a negative attitude toward surrogacy. In addition, undergraduate students were less supportive to surrogate pregnancy than graduate students. Religious considerations were the main reason (accounts for about 70%) for driving negative attitude toward surrogacy.

CONCLUSION

The findings of the study indicate a general reluctance toward accepting the concept of surrogate pregnancy, which is mainly due to religious reasons.

High and growing disapproval of sex-selection technology in Australia

BACKGROUND

In Australia, the National Health and Medical Research Council has banned the use of assisted reproductive technology for social sex selection, but notes "there is limited research into the question of whether Australians support the use of sex selection for non-medical purposes". This paper investigates Australian attitudes to sex-selection technology by different means (IVF, abortion, and a hypothetical pill), for different reasons (medical, family balancing, any reason), and by differing respondent characteristics (age, sex, education and religiosity).

METHODS

In 2007 and 2016, the Australian Survey of Social Attitudes (AuSSA) collected data on the attitudes of Australian adults to sex selection through IVF, abortion, and a hypothetical pill. We calculate population-weighted distributions and 95% confidence intervals of responses, and carry out logistic regressions to investigate the demographic characteristics of Australians who strongly disapprove of IVF or abortion for sex selection.

RESULTS

In 2016, around three-quarters of AuSSA respondents were opposed to legalising sex selection through IVF for any reason, or for family balancing for a second or third child. Thirty-seven per cent were opposed to IVF for medical sex selection. Two-thirds of respondents in both 2007 and 2016 disapproved or strongly disapproved of IVF for sex selection, while the proportion who strongly disapproved increased from 31 to 40%. Disapproval/strong disapproval of abortion for sex selection increased from 74 to 81% from 2007 to 2016, while strong disapproval alone rose from 44 to 55%. More than 70% of respondents in both 2007 and 2016 stated that a hypothetical pill for sex selection should not be legal. Our analysis finds that female, young, more-educated, and more religious respondents are more likely to strongly disapprove of sex selection via IVF or abortion, and that the increase in those who strongly disapprove from 2007 to 2016 is statistically significant.

CONCLUSIONS

Australians generally disapprove of the use of sex-selection technology. If legislation is to be guided by community attitudes, then the prohibition against sex selection for non-medical purposes through assisted reproductive technology should be maintained.

Views of parents of children with sickle cell disease on pre-implantation genetic diagnosis

Pre-implantation genetic diagnosis (PGD) is an option for parents who have a child with sickle cell disease (SCD) to have another child without SCD. We conducted a survey of 19 parents with at least one child with SCD to investigate views on PGD. Before education, 44% of parents were aware of PGD. All parents rated PGD education as important. All parents considering another child also reported interest in using PGD if insurance covered its costs. Parents who have a child with SCD appear to be interested in PGD and educational tools informing this group about PGD should be developed.

Cross border reproductive care (CBRC): a growing global phenomenon with multidimensional implications (a systematic and critical review)

PURPOSE

Many people travel abroad to access fertility treatments. This growing phenomenon is known as cross border reproductive care (CBRC) or fertility tourism. Due to its complex nature and implications worldwide, CBRC has become an emerging dilemma deserving more attention on the global healthcare agenda.

METHODS

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review of the literature was performed for all relevant full-text articles published in PubMed in English during the past 18 years to explore CBRC phenomenon in the new millennium.

RESULTS

Little is known about the accurate magnitude and scope of CBRC around the globe. In this systematic and critical review, we identify three major dimensions of CBRC: legal, economic, and ethical. We analyze each of these dimensions from clinical and practical perspectives.

CONCLUSION

CBRC is a growing reality worldwide with potential benefits and risks. Therefore, it is very crucial to regulate the global market of CBRC on legal, economic, and ethical bases in order to increase harmonization and reduce any forms of exploitation. Establishment of accurate international statistics and a global registry will help diminish the current information gap surrounding the CBRC phenomenon.

How Infertility Patients and Providers View and Confront Religious and Spiritual Issues

Questions arise concerning whether and how religion affects infertility treatment decisions. Thirty-seven infertility providers and patients were interviewed. Patients confront religious, spiritual, and metaphysical issues coping with treatment failures and religious opposition from clergy and others. Religion can provide meaning and support, but poses questions and objections that patients may try to avoid or negotiate-e.g., concealing treatment or changing clergy. Differences exist within and between religions. Whether and how much providers discuss these issues with patients varies. These data, the first to examine several key aspects of how infertility providers and patients confront religious/spiritual issues, have important implications for practice, research, guidelines, and education.

A COMPARATIVE ANALYSIS OF BIOETHICAL ISSUES FROM VIEW POINTS OF RELIGIOUS AFFAIRS ADMINISTRATION IN TURKEY, ROMAN CATHOLICISM AND ORTHODOX JUDAISM

The arguments set forth by religious authority are important since they play a crucial role in shaping the social values of the public and influence the decision of individuals in practice pertaining to bioethical issues. The Religious Affairs Administration (RAA) was established at the inception of the Republic of Turkey in 1924 to guide religious considerations moving out of the Ottoman caliphate to a secular bioethical framework. In this article, the bioethical views of the RAA under Islamic tradition is examined and contrasted with those influenced by the Roman Catholic and Orthodox Judaic traditions. On bioethical deliberations related to the beginning and end-of-life, all three religious traditions justify sacredness of life and that of God's will in its preservation it. Assisted reproduction techniques between spouses is considered to be appropriate, although third party involvement is explicitly forbidden. Organ transplantation is approved by all three religious traditions, except uterine transplantation. Contraceptive practices are approved under certain conditions - views differ most on approaches to contraception and the appropriateness of methods. The RAA judgement on cloning is to prohibit it, like Roman Catholicism and Orthodox Judaism. In other topics, cosmetic surgery and gender determination are approved only for treatment.

First successful trial of preimplantation genetic diagnosis for pantothenate kinase-associated neurodegeneration

PURPOSE

We aim to present a case of a healthy infant born after intracytoplasmic sperm injection-in vitro fertilization (ICSI-IVF) with a preimplantation genetic diagnosis (PGD) for pantothenate kinase-associated neurodegeneration (PKAN) due to PANK2 mutation.

METHODS

ICSI-IVF was performed on a Thai couple, 34-year-old female and 33-year-old male, with a family history of PKAN in their first child. Following fertilization, each of the embryos were biopsied in the cleavage stage and subsequently processed for whole-genome amplification. Genetic status of the embryos was diagnosed by linkage analysis and direct mutation testing using primer extension-based mini-sequencing. Comprehensive chromosomal aneuploidy screening was performed using a next-generation sequencing-based strategy.

RESULTS

Only a single cycle of ICSI-IVF was processed. There were seven embryos from this couple-two were likely affected, three were likely carriers, one was likely unaffected, and one failed in target genome amplification. Aneuploidy screening was performed before making a decision on embryo transfer, and only one unaffected embryo passed the screening. That embryo was transferred in a frozen thawed cycle, and the pregnancy was successful. The diagnosis was confirmed by amniocentesis, which presented with a result consistent with PGD. At 38 weeks of gestational age, a healthy male baby was born. Postnatal genetic confirmation was also consistent with PGD and the prenatal results. At the age of 24 months, the baby presented with normal growth and development lacking any neurological symptoms.

CONCLUSIONS

We report the first successful trial of PGD for PKAN in a developing country using linkage analysis and mini-sequencing in cleavage stage embryos.

An Ethical Analysis of Assisted Reproduction Providers' Websites in Pakistan

Assisted reproductive technologies (ARTs) and reproductive genetic technologies (RGTs) are intertwined and coevolving. These technologies are increasingly used to fulfill socially and culturally framed requests, for example, "family balancing," or to enable postmenopausal women or homosexual couples to have genetically linked children. The areas of ART and RGT are replete with ethical issues, because different social practices and legal regulations, as well as economic inequalities within and among countries, create vulnerable groups and, therefore, the potential for exploitation. This article provides an overview of the ART and RGT landscape in Pakistan and analyzes the available online content addressing Pakistani citizens and international clients. We explored the topic in view of socioeconomic challenges in Pakistan, particularly deeply rooted poverty, lack of education, gender discrimination, and absence of regulation. As online information given by ART and RGT providers is readily available and could easily raise false hopes, make use of discriminatory statements with regard to women, and promote gender selection to meet sociocultural expectations, it should be subjected to quality control.

Limitations and barriers in access to care for male factor infertility

The primary challenge to identifying and addressing barriers in access to care for male factor infertility is accurate measurement of the prevalence of male infertility. Current estimates are based on couples pursuing assisted reproduction, and likely underestimate the problem. These estimates also fail to account for the number of patients facing infertility due to cancer or cancer treatment. Lack of health insurance coverage for the diagnosis and treatment of infertility presents a major barrier for couples struggling with infertility. However, it is not the only barrier. Education level, household income, cultural norms, religious beliefs, geographic location, and the availability of specialty-trained reproductive urologists are all important factors in determining the ease with which patients access and obtain infertility care. Addressing each of these obstacles directly is imperative to improving reproductive care and outcomes for infertile couples in the United States.

Culture and religious beliefs in relation to reproductive health

An increasing number of contemporary research publications acknowledge the influence of religion and culture on sexual and reproductive behavior and health-care utilization. It is currently hypothesized that religious influences can partly explain disparities in sexual and reproductive health outcomes. In this paper, we will pay particular attention to Muslims in sexual and reproductive health care. This review reveals that knowledge about devout Muslims' own experience of sexual and reproductive health-care matters is limited, thus providing weak evidence for modeling of efficient practical guidelines for sexual and reproductive health care directed at Muslim patients. Successful outcomes in sexual and reproductive health of Muslims require both researchers and practitioners to acknowledge religious heterogeneity and variability, and individuals' possibilities to negotiate Islamic edicts. Failure to do so could lead to inadequate health-care provision and, in the worst case, to suboptimal encounters between migrants with Muslim background and the health-care providers in the receiving country.

The Social Consequences of Infertility among Iranian Women: A Qualitative Study

BACKGROUND

Infertility may prevent couples to achieve the desired social roles and lead to some social and psychological problems. This study aimed to explain the social consequences of infertility in Iranian women seeking treatment.

MATERIALS AND METHODS

A qualitative content analysis was conducted based on 32 semi-structured interviews with 25 women affected by primary and secondary infertility with no surviving children. The participants were purposefully selected with maximum variability from a fertility health research center in Tehran, Iran, from January to October 2012. Data were collected using semi-structured interviews and analyzed using the conventional content analysis method.

RESULTS

Our findings indicate that the consequences of infertility are divided into five main categories: 1. violence including psychological violence and domestic physical violence, 2. marital instability or uncertainty, 3. social isolation including avoiding certain people or certain social events and self-imposed isolation from family and friends, 4. social exclusion and partial deprivation including being disregarded by family members and relatives and reducing social interactions with the infertile woman and 5. social alienation.

CONCLUSION

This study reveals that Iranian women with fertility issues seeking treatment face several social problems that could have devastating effects on the quality of their lives. It is, therefore, recommended that, in Iran, infertility is only considered as a biomedical issue of a couple and pay further attention to its sociocultural dimensions and consequences.

First childbirth and motherhood at post natural fertile age: a persistent and intergenerational experience of personal and social anomaly?

This study was aimed at understanding long-term psychosocial implications of first childbirth at post natural fertile age following assisted reproductive treatment. Twenty women, whose average age at childbirth was 45, participated. Findings show that the sense of anomaly experienced prior to pregnancy and childbirth related to infertility and advanced age continued during treatment, pregnancy, and motherhood. Participants associated their advanced age as cause for what they perceived as a similar sense of anomaly experienced by their children. The issue of a continuing and intergenerational sense of anomaly should be addressed when counseling women considering fertility treatment at advanced age.

Assisted conception and South Asian communities in the UK: public perceptions of the use of donor gametes in infertility treatment

This paper explores 'public' attitudes to the use of donated gametes in infertility treatment amongst members of British South Asian communities in the UK. The study included 14 single-sex focus groups with a total of 100 participants of Indian, Pakistani and Bangladeshi origins in three English cities and 20 individual semi-structured interviews with key informants. It explores five themes from the data: childlessness and stigma; using sperm and using eggs; cultural connections; choosing gametes; religion and the use of donated gametes; and disclosure and the management of information. The paper demonstrates that the socio-cultural context of fertility treatment is highly relevant and those delivering services and those consulting the public need to be aware of cultural and gender differences. Third party assisted conception represents a challenge to received ideas of identity and has implications for social reproduction and kinship which go well beyond immediate conjugal relationships.

Australian perspectives on surrogacy: the influence of cognitions, psychological and demographic characteristics

BACKGROUND

The aim of the present study was to explore current Australian support levels for surrogacy treatments and also whether this support differed between traditional surrogacy and gestational surrogacy. The focus was also on understanding the underlying influences on surrogacy attitudes. It was hypothesized that cognitions, psychological and demographic characteristics would all predict attitudes to surrogacy and that cognitive concerns about surrogacy would be the strongest predictor.

METHODS

Participants (N = 195: 79 male, 116 female; age range 18-76 years) were first-year psychology undergraduates (47%) and friends and associates of the authors (53%). They completed a survey pack which assessed attitudes and knowledge about surrogacy, as well as empathy and other personality characteristics.

RESULTS

The results indicated that there has been a marked increase in support for surrogacy treatment in recent years, with nearly 80% of participants supporting surrogacy, and that support for gestational surrogacy was greater than that for traditional surrogacy (P< 0.001). As anticipated, cognitive concerns about surrogacy were the strongest predictors of surrogacy attitudes (R(2)= 0.393).

CONCLUSIONS

A limitation of the present study was the use of a non-representative, self-selected sample that tended to be well educated and perhaps liberal minded. Despite this, given the high levels of support, it could be concluded that the recent, more permissive legislative changes, which were finalized in 2010, are reflective of the values of Australian society.

Physicians' undecided attitudes toward posthumous reproduction: fertility preservation in cancer patients with a poor prognosis

BACKGROUND

The American Society for Clinical Oncology (ASCO) established guidelines for fertility preservation for cancer patients. In a national study of US oncologists, we examined attitudes toward the use of fertility preservation among patients with a poor prognosis, focusing on attitudes toward posthumous reproduction.

METHOD

A cross-sectional survey was administered via mail and Internet to a stratified random sample of US oncologists. The survey measured demographics, knowledge, attitude, and practice behaviors regarding posthumous reproduction and fertility preservation with cancer patients of childbearing age.

RESULTS

Only 16.2% supported posthumous parenting, whereas the majority (51.5%) did not have an opinion. Analysis of variance indicated that attitudes toward posthumous reproduction were significantly related to physician practice behaviors and were dependent on oncologists' knowledge of ASCO guidelines.

CONCLUSIONS

Physician attitudes may conflict with the recommended guidelines and may reduce the likelihood that some patients will receive information about fertility preservation. Further education may raise physicians' awareness of poor-prognostic patients' interest in pursuing this technology.

Tackling burden in ART: an integrated approach for medical staff

Discontinuation is a problem in fertility clinics. Many couples discontinue assisted reproductive technologies (ART) without achieving a live birth for reasons other than poor prognosis or the cost of treatment. Discontinuation has been attributed to the burden of treatment. The causes of burden can be broadly classified according to whether they originate in the patient, clinic or treatment. Interventions to alleviate these burdens include provision of comprehensive educational material, screening to identify highly distressed patients, provision of tailored coping tools and improvements in the clinic environment and medical interventions. Practical interventions to reduce the different causes of burden in ART exist, but further development and evaluation of the efficacy of these interventions requires more precise definition of terms and theory. In this paper, we propose a general integrated approach to cover different perspectives in dealing with burden in ART clinics. We firstly describe the integrated approach and present common sources of burden. We then describe interventions that could help reduce the burden in ART. Our paper is aimed at fertility clinic staff because of their day-to-day involvement with patients. However, this discussion should also be relevant to companies that develop treatments and to psychosocial experts. Reducing the burden of treatment should lead to improved outcomes, namely better quality of life during treatment and lower discontinuation rates.

Ovum donation: examining the new Israeli law

Ovum donation affords countless couples that under natural circumstances would not be able to produce offspring the ability to carry out natural pregnancies. With advancements in biotechnology including egg collection and in vitro fertilization (IVF), physicians can now successfully implant fertilized embryos. Due to Israel's tremendous involvement in IVF for its own citizens, the national laws that govern egg donation are of great importance. On September 5th 2010, the Israeli Parliament (Knesset) passed a law that allows young women between the ages of 21 and 35 to donate their eggs for paid financial compensation. The new law allows infertile women between the ages of 18 and 54 to request egg donation and IVF, which will partially be covered under state insurance plans. This article provides a description of the new Israeli law regulating ovum donation and the practical, moral and ethical debate surrounding the new system.

Specifying the effects of religion on medical helpseeking: the case of infertility

Several recent studies have examined the connection between religion and medical service utilization. This relationship is complicated because religiosity may be associated with beliefs that either promote or hinder medical helpseeking. The current study uses structural equation modeling to examine the relationship between religion and fertility-related helpseeking using a probability sample of 2183 infertile women in the United States. We found that, although religiosity is not directly associated with helpseeking for infertility, it is indirectly associated through mediating variables that operate in opposing directions. More specifically, religiosity is associated with greater belief in the importance of motherhood, which in turn is associated with increased likelihood of helpseeking. Religiosity is also associated with greater ethical concerns about infertility treatment, which are associated with decreased likelihood of helpseeking. Additionally, the relationships are not linear throughout the helpseeking process. Thus, the influence of religiosity on infertility helpseeking is indirect and complex. These findings support the growing consensus that religiously-based behaviours and beliefs are associated with levels of health service utilization.

Sex and reproduction: an evolving relationship

BACKGROUND

Although sexual activity has, until very recently, been essential to reproduction, this did not preclude the non-reproductive importance of sexual relationships and non-conceptive copulations. Technological advances, however, now allow for both sex without reproduction and reproduction without sex. This review summarizes social and ethical commentaries on the new relationship between sex and reproduction.

METHODS

For each main area discussed, a systematic search was made using (depending on the subject) PubMed, Medline, ScienceDirect, classic books, Google and/or religious websites. The search focused on publications between 1975 and 2009, although some materials from the first part of the 20th century were also utilized.

RESULTS

The classic picture of sex for reproduction and bonding between mating partners is increasingly being replaced by reproduction separate from sexual activity. Although not every advance in assisted reproduction produced, per se, a further separation from sexual intercourse, these two fundamental human activities are today increasingly carried out independently, as reproduction is possible, not only without sex, but even through the intervention of more than two partners. The possibility of reproduction with only one or even no gametes, although highly controversial and not yet feasible, is nonetheless being investigated.

CONCLUSIONS

Technological advances in the field of reproductive biology have enabled couples considered infertile to conceive and have healthy babies, causing a revolution in culture and customs. Today the independence of sex and reproduction is established and in the future human reproduction may move even further away from the sexual act, an option definitely unacceptable to some ethicists.

Looking at infertility through the lens of religion and spirituality: a review of the literature

In spite of the growing body of literature that has focused on medical, psychological, social, and cultural consequences of infertility, issues such as religious and spiritual dimensions of infertility have received little attention. Considering that infertility is a multifaceted problem and results in multiple losses, we argue that health professionals need to consider all aspects of holistic care when caring for women with fertility problems. Holistic care considers not only the psychological, social and cultural needs of individuals, but also their religious and spiritual needs. Women may use their religious/spiritual beliefs to cope with crisis, and to find meaning and hope in their suffering. This article reviews the literature on religion/spirituality and infertility using Medline, CINAHL, PBSC, IBSS and ISI Web of Knowledge from 1985 to the present. It focuses on religious and spiritual care as one aspect of holistic care of women with fertility problems, and draws attention to the religious perspectives of infertility and reproductive technologies. It highlights the spiritual dimension of the infertility experience in previous research, and concludes with a discussion on the gaps in the literature and the implications of including religious and spiritual issues in infertile women's care.

"Public" perceptions of gamete donation: a research review

This paper reviews the literature on "public" perceptions of the practice of gamete (egg and sperm) donation in the treatment of infertility. Despite regular "consultation" exercises in the UK on the manner in which infertility treatments should be regulated, there is little sense of how a range of public groups respond to developments in this area. The key themes from thirty-three articles, chapters and reports are discussed. The review reveals the limited nature of our current knowledge of public understandings of and attitudes towards gamete donation as a form of infertility treatment which has been readily available and widely practiced for many years. The review is critical of the methodological and epistemological basis of much of the work in this area and argues that there is a strong case for social scientific research to attempt to capture the perceptions of a wider range of people who are rarely included in formal public consultations and often similarly excluded from research studies.