Artificial Intelligence in Reproductive Medicine - An Ethical Perspective

Artificial intelligence is steadily being integrated into all areas of medicine. In reproductive medicine, artificial intelligence methods can be utilized to improve the selection and prediction of sperm cells, oocytes, and embryos and to generate better predictive models for in vitro fertilization. The use of artificial intelligence in this field is justified by the suffering of persons or couples who wish to have children but are unable to conceive. However, research into the use of artificial intelligence in reproductive medicine is still in the early experimental stage and furthermore raises complex normative questions. There are ethical research challenges because evidence of the efficacy of certain pertinent systems is often lacking and because of the increased difficulty of ensuring informed consent on the part of the affected persons. Other ethically relevant issues include the potential risks for offspring and the difficulty of providing sufficient information. The opportunity to fulfill the desire to have children affects the welfare of patients and their reproductive autonomy. Ultimately, ensuring more accurate predictions and allowing physicians to devote more time to their patients will have a positive effect. Nevertheless, clinicians must be able to process patient data conscientiously. When using artificial intelligence, numerous actors are involved in making the diagnosis and deciding on the appropriate therapy, raising questions about who is ultimately responsible when mistakes occur. Questions of fairness arise with regard to resource allocation and cost reimbursement. Thus, before implementing artificial intelligence in clinical practice, it is necessary to critically examine the quantity and quality of the data used and to address issues of transparency. In the medium and long term, it would be necessary to confront the undesirable impact and social dynamics that may accompany the use of artificial intelligence in reproductive medicine.

[Capable or incapable of giving consent? Assessing a patient's capacity to consent: Procedures and challenges in daily clinical practice]

BACKGROUND/OBJECTIVES

The capacity of patients to give consent (CTC) is an indispensable prerequisite for informed consent to medical measures. When there is doubt about a patient's CTC, careful assessment is therefore required. Despite a broad theoretical discussion about the conception of CTC and possible procedures for its assessment, there is often a lack of orientation towards binding standardized procedural guidelines in everyday clinical practice. As a consequence, the results of CTC assessments are inconsistent, revealing both interdisciplinary and interindividual variability. In order to improve the quality of CTC assessment, more detailed knowledge about the procedures as well as the problems of CTC testing is needed. Therefore, the aim of this explorative telephone survey was to get an impression of the actual procedures that clinicians apply when in doubt about a patient's CTC. In particular, participants in the survey were asked about the weighting of individual CTC criteria and the difficulties with their application.

METHODS

Based on structured questionnaires, telephone interviews with 26 physicians working in German hospitals in the fields of neurology, anaesthesiology, surgery, internal medicine, gynaecology, and reconstructive/aesthetic surgery were conducted. The answers were documented using the paper-and-pencil method, and answers to open questions were summarized with the help of a qualitative data analysis software and a thematic coding scheme.

RESULTS

The majority of respondents reported that "sometimes to very often" they had doubts about their patients' CTC, with the examination being mostly conducted in an individual approach without formalized, standardized specifications. Regarding the question about the weighting of the seven assessment criteria proposed in the questionnaire, their importance was predominantly evaluated as being in the range of "partially important" to "very important". Difficulties in the clinical assessment were indicated in relation to the patients themselves, the relationship between physicians and patients, and the assessment situation. The perception of difficulties in the examination of CTC is apparently independent of the relevance attributed to the specific criterion for CTC.

DISCUSSION AND CONCLUSION

Overall, the results show a high level of agreement with the relevance of the seven CTC criteria included in the survey, but at the same time revealed various verification difficulties. Some of the respondents would like to have more support in determining their patients' CTC. The survey results suggest that precise training and adequate time resources are paramount to this sensitive medical context.

In vitro gametogenesis: A benefit for women at advanced and very advanced age? An ethical perspective

Assisted reproductive technologies (ART) may be supplemented with in vitro gametogenesis (IVG). Although IVG is still experimental the question arises whether IVG offers any moral advantages compared to implemented methods. The aim of the paper is to present the landscape of ethical arguments in favour or against IVG. ART-related ethical issues in relation to reproductive autonomy, health risks for the woman and foetus, the welfare of the future child, the adverse effects of advanced motherhood, gender equality, and justice are similar for IVG, oocyte cryopreservation, and oocyte donation. IVG may have the following advantages: (I) the psychological and physical burden of stimulation and puncture of the oocyte could be avoided; (II) women do not necessarily have to cope with motherhood at young age; (III) ethical doubts associated with oocyte donation would be eliminated; (IV) by using IVG in combination with preimplantation diagnostics, it is more likely to find suitable oocytes or embryos to increase the probability of pregnancy; (V) women would have the opportunity to decide how many oocytes should be generated and how often an attempt should be made to achieve pregnancy. Simultaneously, however, the advent of IVG may lead to new moral disadvantages: pressure on women to give birth at an advanced age or pressure on women to follow 'male' career structures. Additionally, the reimbursement of costs related to IVG is an open question, especially if equal opportunities regarding motherhood are linked to demands for equal access to ART. An early discussion about the ethical, legal, and social consequences for IVG is necessary.

Individual risk assessment of adverse pregnancy outcome by multivariate regression analysis may serve as basis for drug intervention studies: retrospective analysis of 426 high-risk patients including ethical aspects

OBJECTIVE

To identify patients at very high risk for adverse pregnancy outcome (APO) at the 20- to 23-week scan and to assess the effectiveness of Aspirin (ASS) and low molecular weight heparin (LMWH) starting after this examination.

PATIENTS AND METHODS

By applying an algorithm based on multivariate logistic regression analysis using the parameters maternal age, parity, body mass index (BMI), mean pulsatility index of both uterine arteries (meanPI), presence of uni- or bilateral notch, and depth of notch (mean notch index (meanNI), we retrospectively calculated the individual risk for APO of 21,302 singleton pregnancies. We isolated a subgroup of 426 patients with the highest calculated probability for APO (cpAPO > 27.8 %). 147 had been treated with ASS; 73 with LMWH, 15 patients with a combination of ASS and LMWH, and 191 patients had not received anticoagulants.

RESULTS

Administration of ASS starting after 20 gestational weeks in comparison to non-treated patients significantly reduced the frequency of intrauterine/neonatal death (IUD/NND), preeclampsia <33 weeks (PE < 33), and preterm delivery <33 weeks (PD < 33), while the frequency of IUGR showed a tendency to be elevated (P = 0.061). The subgroup of high-risk patients treated with LMWH was characterised by a higher a priori risk for APO and showed no significant reduction of any form of APO but an increased frequency of PE.

CONCLUSION

Individual assessment of risk for APO by applying a simple algorithm based on biometrical/biographical as well as sonographic parameters may serve as basis for drug intervention studies. The administration of ASS in high-risk patients starting after 20 gestational weeks reduced the frequency of most of the severe forms of adverse pregnancy outcome in high-risk patients. A complication-reducing effect of LMWH starting after 20 weeks of gestation in patients could not be proven. From an ethical point of view, it may not be justified any more to preclude high-risk patients from administration of ASS or to perform studies of ASS against placebo.

An ethical assessment of postmenopausal motherhood against the backdrop of successful antiaging medicine

By creating fertility reserves, women are now able to become pregnant using their own eggs, even after menopause. Multiple arguments already exist against postmenopausal motherhood, most of which stress the potential risk of damage involved due to the mother's advanced age. Consequently, the question arises: Can successful antiaging medicine be applied to preserve or enhance cognitive and physical capacity at an advanced age and invalidate these objections? In this article, we shall explore this issue further and come to three main conclusions: (1) Until now, enabling postmenopausal women to become pregnant has not been a specific objective of antiaging medicine. (2) Postmenopausal motherhood can find legitimacy through the development and success of antiaging medicine. (3) The acceptance of postmenopausal motherhoods in our society first requires that antiaging medicine itself find some sort of ethical legitimacy. To evaluate the arguments for and against antiaging medicine and postmenopausal motherhood, it is important to take into consideration two points more in depth, which are constantly being impacted by both medical arguments alike: (1) The identity and role of medicine itself as well as (2) the normative role of our body`s natural boundaries.

[Technological intervention in the self? An ethical evaluation of deep brain stimulation relating to patient narratives]

Technological interventions into the brain raise a number of ethical questions, particularly, questions of personality change and control or manipulation of the human mind. Taking patients undergoing deep brain stimulation as an example, the authors analyse the possible impact of neurotechnologies on human self-perception in individual cases as well as in general. Following the concept of narrative-based medicine and ethics patients' narrations are presented in order to discuss the value of this approach for developing normative considerations as well as for deriving practical consequences regarding the physician-patient-relationship.

[Digital multilayer tomography. A description of the method and initial clinical results]

A set of projection images is acquired during longitudinal tomography with an image intensifier TV system. Reconstruction of tomograms in each desired plane is achieved by shifting and summing up of the digitalized projection images. Digital multilayer and conventional film tomograms mainly of the respiratory tract and skeleton have been compared in 100 patients. Image quality is comparable with both methods. Disadvantage of digital tomography is lower spatial resolution (512 x 512 matrix size); advantages include lower radiation dose, shorter study time, and facilities of digital imaging.