Reproductive Technology OLD News

Extracts from EEIN 1991-1994. Latest news is at the bottom. Provided by Eubios Ethics Institute , at http://eubios.info/index.html.

The need for knowledge about contraception and reducing population growth are stressed by King, M. (1990) "Health is a sustainable state", Lancet 336: 664-667. The population problem is a root cause of many of the global problems, and we must solve it for the benefit of future generations (Lancet 336 (1990), 681-2, 1312-3). We need to view health as a longterm and broad concern, no longer focusing only on the individual.
Another paper by Potts, M. & Rosenfield, A. (1990) "The fifth freedom revisited: I, background and exisiting programmes", Lancet 336: 1227-1231; looks at the current contraceptive access for people of different countries. The major progress has been the establishment of family planning programmes, and the knowledge about contraception and provision of contraceptives, and the practise of safe abortion. In different countries the reduction in birth rate has been very dramatic, but more progress is required in providing reproductive choice to families in many countries.

Surrogacy
There have been several recent court decisions in the USA regarding IVF techniques. The Davis case where the divorced couple argued over the ownership of frozen embryos went to Appeal court. The Appeals court has judged that there should be joint ownership of the embryos. Another case was a surrogacy case in California, where the surrogate mother, Johnson, wanted to keep the baby. The court decided that the child would be sent to a foster home, so the surrogate mother gave the child to the genetic parents to look after (Angell, M. (1990) "New ways to get pregnant," NEJM 323: 1200-1202; BMJ 301 (1990), 1062-3). The case is being appealled, and is getting information support from the US National Coalition Against Surrogacy.
Many believe that the surrogate mother should be able to keep the child, including the laws of many countries, and although it is a difficult decision, the ethical arguments would support the surrogate mother's claim to keep the child. Selling organs is illegal in the USA, but selling gametes or wombs is not. There will continue to be some cases where the poor are exploited, society should protect people from this type of exploitation. There will be continued pressure by rich couples who are infertile, by doctors and lawyers who are involved in such arrangements, and from women who are willing to be surrogates, but protection of the surrogate mother is especially important. In Germany surrogacy has been recently outlawed altogether (BMJ 301 (1990), 1063), not just commercial surrogacy.
A report in Australia by the National Bioethics Consultative Committee recommended that surrogacy should be either "allowed and controlled" or "discouraged but strictly controlled". Other Australian reports, by the Family Law Council and some States were strongly against surrogacy (Thomas, A. (1990) "Human embryo experimentation and surrogacy", Med. J. Australia 153: 369-371). There needs to be study of the psychological effects upon the children, and studies should followup those children who have been born from surrogate mothers to investigate any harmful effects of the surrogacy, however, this paper also stresses the lack of study of the psychological stress that infertile couples undergo during treatment. There needs to be continues study and improvement of the counseling of the people involved.

IVF and Embryo Transfer
The commonly used procedure of cryopreservation of human embryos is used in many IVF clinics for surplus embryos. A study by Levran, D. et al. (1990) "Pregnancy potential of human oocytes - the effect of cryopreservation", NEJM 323: 1153-1156, compared the pregnancy rate of fresh with frozen oocytes. Normally visual selection of the embryos is made, only those that look healthy are chosen to be implanted immediately. In this study no selection was used, they were randomly separated, and the frozen embryos had a substantially lower rate of success than the fresh embryos. They recommend that the three best embryos should be transferred fresh, and only surplus embryos frozen.
A study of the success rate of embryo transfer to women over 40 years of age indicated that age is not a barrier to successful pregnancy (even if at later stages there may be higher risks) (Sauer, M.V. et al (1990) "A preliminary report on oocyte donation extending reproductive potential to women over 40," NEJM 323: 1157-1160). The practise of selective fetal reduction is increasing, and it is accepted by many for the treatment of multiple pregnancies. To reduce the need for it, there should be tight limits on the number of embryos that are replanted in embryo transfer (Poplawski, N.K. (1990) "An ethical issue for reproductive technologies," Asia-Oceania J. Obstet. Gynaecol. 16: 291-296). There are also concerns about the selctive reduction when one of the fetuses has a genetic abnormality (Zaner et al. (1990) "Selective termination in multiple pregnancies: ethical considerations", Fertility & Sterility 54: 203-205).
The success of the preimplantation diagnosis of embryos in Britain (SG 244-5) has led to worldwide research on methods of genetic biopsy. Besides using PCR, other detection methods may also be used in the future (BMJ 301 (1990), 894-5, 1277).
Earlier in 1990 the American Fertility Society Ethical Committee released their extensive (100+ page) report Ethical Considerations of the New Reproductive Technologies, in Fertility & Sterility 53, suppl. 2 (June 1990). It discusses the use of IVF and associated techniques, and embryo research, and supports their continued use.

One of the most basic types of reproductive control is the use of the contraceptive pill. A survey of mothers in Britain reported by A.Fleissig (1991) "Unintended pregnancies and the use of contraception: changes from 1984 to 1989", Lancet 302 (19 Jan 1991), 147, reports that the incidence of unintended pregnancies among users of the contraceptive pill was higher in 1989 than in 1984. The suggested reasons for this include the lower doses used and the errors of using them properly. This indicates that greater education may be required when contraceptives are issued. There was also a greater number of unintended pregnancies in women not using contraceptives.
The USA is expected to approve the use of the implantable contraceptive 'Norplant' in the near future (Lancet 337 (1991), 228-9). This report also comments on the legal decisions made regarding surrogacy in the Californian case 1990. Other comments on the role of the law in reproductive decisions are in Fertility & Sterility 54 (1990), 955-6, and by G.J.Annas, "Crazy making: embryos and gestational mothers", Hastings Center Report 21 (Jan/Feb 1991), 35-8. The later paper also looks at the nature/nurture debate in addressing the question of whose child such babies should be.
A review article on gonadotropin is R.M.Conn & W.F.Crowley (1991) "Gonadotropin-releasing hormone and its analogues", NEJM 324: 93-103.
The results of two surveys in 1982 and in 1988 on the fertility of Chinese households is presented by A.J.Cole et al. (1991), "Recent trends in fertility and nuptiality in China", Science 251: 389-393. The survey sizes were covering several million people, and are useful in accessing the affects of the Chinese government policy on restricted reproduction. The effects of the removal of many local marriage age limits in 1980 was to lower the average age from what it had become, and the overall fertility has increased since 1980 when this occured. A related paper is L.G.Martin (1991) "Population agng policies in East Asia and the United States", Science 251: 527-531. The pace at which population structure is changing in some Asian countries is greater than in Western developed countries.
There is a theory on the hormonal control of the human sex ratio developed by W.H.James (Fertility & Sterility 54 (1990), 956-7; J. Theoretical Biology, in press). It is based on observations over a number of diseases where the sex ratio of children is affected, and will be interesting for future research. It suggests that there are specific receptors or molecules on sperm that are sex-dependent, and would have future potential application in agriculture and in medicine.
The mechanism of X-inactivation, how certain genes are inactivated in one of the X-chromosomes in females (XX) is discussed in several articles in Nature 349 (1991), 15, 38-43, 82-4, and in Cell 61 (1990), 1205-18. It is also of relation to Turner's syndrome.
We need to distinguish ethical questions from conceptual questions when looking at the use of new reproductive technologies, especially when they make us think about our concepts of parenthood and the family. This is discussed by R.Macklin, "Artificial means of reproduction and our understanding of the family", Hastings Center Report 21 (Jan/Feb 1991), 5-11. The concepts of family that are seen in the traditions and laws of different countries are different, and we need to think further about the changing concept of family. A recent book is Larry Gostin, ed., Surrogate Motherhood: Politics and Privacy (Indiana University Press 1990). Another recent paper discussing surrogacy and gifts is by J.G.Raymond, "Reproductive gifts and gift giving: the altruistic woman", Hastings Center Report 20 (Nov/Dec 1990), 7-11. A review of the Australian Bioethics Consultative Committee's report on Surrogacy is by J.Funder (1990) "Surrogacy", Med.J. Australia 153: 641-3.
A paper by M.Yoon (1990) "The Uniform Status of Children of Assisted Conception Act: Does it protect the best interests of the child in a surrogate arrangement?" AJLM XVI: 525-53, suggests improvements to the mentioned proposed unifrom law. The Act will make void any surrogacy contract, Yoon contends that this may not protect the child's best interests. The Act is similar to the laws in some other countries, in that the surrogate can keep the child if she becomes attached to them during pregnancy. It is a difficult area, but there are problems about whether the surrogate mother will be able to care for the child as well as the gamete donors, versus the surrogate's rights to keep the child that she bore. Yoon suggests that legislation should be enacted to regulate surrogacy so that it can only be used for infertile couples who plan to raise the child, which would meet broad support. It would also prevent commercial surrogacy, and what many see as potential exploitation of women. There will need to be attention given to the use of surrogacy, and we should not assume that the existing laws or absense of laws are the best.
The question of when couples using infertility treatments should give up trying to have a child is a question that faces many users of the new technology. The role of the physician in this process is important, and this is discussed in P.J.Taylor (1990) "When is enough enough?" Fertility & Sterility 54: 772-4. The end point should be discussed , and time limits may be suggested.
A paper that contradicts an earlier report (see EEIN 1: 8), A.S.Penzias et al. (1991) "Successful use of gamete intrafallopian transfer does not reverse the decline in fertility in women over 40 years of age", Obstetrics & Gynecology 77: 37-39. Further study is important because many women are delaying child birth until later age.
There are two techniques being used for preimplantation diagnosis (SG 244-5). One technique used at Hammersmith hospital in London involves embryo biopsy, and has given rise to births. Another approach being used used in Illinois which involves removing the polar body from the oocyte (Lancet 336 (1990), 306-7). Other approaches will be used, and it has recently been found that a single cell from a human 4-cell embryo will divide to produce an apparently normal embryo (JAMA 264 (1990), 3113-4; N.G.Verlinski et al. (1990) "Analysis of the first polar body: preconception genetic diagnosis", Human Reproduction 5: 826-9). The list of diseases is being expanded, and the techniques further improved, while being clinically applied for genetic screening.

The U.K. Fertilisation and Embryology law will come into full effect on August 1, including a conscientious objection to participation in any of the activities covered in that Act. In September inspections of about 160 centres will begin in the U.K., and there is a call for a limit of 3 embryos to be a legal limit for embryo transfer; NS (30 March 1991), 7. For comments on the high incidence of multiple births following infertility treatment see Lancet 337: 797; BMJ 302: 740-1. The Human Fertilisation and Embryology Authority (HFEA) has also outlined a code of practice for infertility centres; Lancet 337: 786; BMJ 302: 746. Many British couples who have used infertility services have said that their GPs were unsympathetic, and the telephone helpline is being expanded; BMJ 302: 676. A Norwegian report entitled Man and Biotechnology contains recommendations to the Norwegian government, and a list of these is in the BME 66 (March 1991), 6-7. It covers medical "biotechnology" and medical ethics, rather than the environmental issues.
An extensive paper on the legal aspects of the techniques is M.M.Shultz, "Reproductive technology and intent-based parenthood: an opportunity for gender neutrality", Wisconsin Law Review (1990), 297-398. It considers the traditional and emerging views of parenthood, and how the number of reproductive options is expanded, and the current law, before moving on to consider the policy for intent-based legal parenthood. There is considerable space given to questions of surrogacy and contracts. Another paper is S.F.Appleton, "Surrogacy arrangements and the conflict of laws", Wisconsin Law Review (1990), 399-482. This addresses the legal issues when cases cross different jurisdictions.
A paper on the more social side of surrogate mothering from the results of interviews with American women involved in such programmes is D.MacPhee & K.Forest (1990) "Surrogacy: programme comparisons and policy implications", International J. Law & the Family 4: 308-17. The misadventures of some should prepare better others who want to use surrogacy and be considered by the regulators. There are some things that may be very difficult to regulate, for example a woman in Britain caused a recent controversy by wanting to become pregnant while remaining a virgin; NS (16 March 1991), 5; NS (6 April 1991), 48-9; Nature 350 (1991), 96. It is common practice in many countries to be a soloparent, and people can find ways around a law; though clinics could have a policy not to treat soloparents. A comment from a sociologist on gamete donation and anonymity is in the BME 66 (March 1991), 25-7.
A positive book review of Robert Winston's book Getting Pregnant (Anaya, pp.252, 9) is in NS (23 Feb 1991), 52. It explains in layman's terms the infertility aids that are available, and that their actual success rates are often low. A short introduction to IVF techniques is in Laboratory Practice 40 (1991), 17-8. A more technical book that contains papers presented at a conference in Aberdeen in 1990 is A.A.Templeton & D.Cusine, editors, Reproductive Medicine and the Law (Edinburgh: Churchill Livingstone 1990, pp. 167, 30). It is reviewed in Lancet 337 (1991), 541.

New Swiss IVF law - Very Restrictive On June 11th, the two chambers of the Swiss Federal Parliament ironed out their differences over the regulation of assisted procreation. In a striking display of conservative feeling, they decided to prohibit the storage of embryos produced by in vitro fertilisation and allow only the production of such embryos as can be reimplanted immediately. Although this controversial decision is final as far as the Parliament is concerned, it is not the last word on IVF in Switzerland: a nation-wide referendum will be held on this and related issues around the end of the year. Should however the parliamentary ruling become the law of the land, it would make Switzerland one of the most restrictive countries as far as IVF is concerned. If intepreted strictly, it would make IVF all but impractical. In reality, it is not clear how the new law would be implemented. Firstly, it contradicts the widely respected guidelines of the Swiss Academy of Medicial Sciences, which are legally enforceable in several cantons. Furthermore, it remains an open question whether a fertilised egg whose pronuclei have not yet fused counts as an "embryo". If not, this would provide a loophole through which IVF could continue without imposing on women the burden of repeated oocyte retrieval.
communicated by Dr. Alex Mauron, Fondation Louis Jeantet de Médicine, P.O.Box 277, CH-1211 Geneva 17, Switzerland.

As mentioned in the last issue of EEIN (1:37), the British Human fertilisation and Embryology Authority has released draft guidelines as a code of practice. Parts of this code are presented in BME (April 1991), 17-21. The relative funding of IVF or tubal surgery or ovulation induction, is being discussed in Britain, see Lancet 337: 888-9, 1096, 1291-2. The call is made for greater use of tubal surgery, which can restore fertility, and can be quite successful when suitable patients are selected for treatment. A letter on the elective transfer of only two embryos for IVF is in Lancet 337: 975. Letters commenting on a recent UK television report on assisted conception appear in BMJ 302: 1078, 1204.
For the practice of IVF and AID in a Moslem country see M.A. Aboulghar et al., "Some ethical and legal aspects of medically assisted reproduction in Egypt", IJB 1 (Dec 1990), 265-268.
On the general topic of infertility see J.Randal, "Trying to outsmart infertility", FDA Consumer (May 1991), 22-29. It looks at the different methods, including surgery, drugs, and AID, IVF etc. The emotional problems of infertility see BMJ 302: 1159.
A paper on the use of embryo reduction in multiple pregnancies following infertility treatment is in Fertility and Sterility 55: 805-11. See also a letter in BMJ 302: 1079.
The use of cesarian operations for low birth weight babies has not been found to increase the survival rate of such babies in a study of 1765 cases in the USA; Obstetrics & Gynecology 77: 495-503. These results question the continued use of cesarian for low birth weight criteria. See also D.Gordon et al., "Advanced maternal age as a risk factor for cesarean deleivery", Obstetrics & Gynecology 77: 493-7; and K.D.Pierre et al., "Obstetrical attitudes and practices before and after the Canadian consensus conference statement on cesarean birth", Social Science & Medicine 32: 1283-9. On nonclinical factors and the use of cesarians see also JAMA 265: 2338. A letter on the general subject of technology in obstetrics is in Lancet 337: 1095. On the ethical quesions see F.A.Chervenak & L.B.McCullough, "Justified limits on refusing intervention", HCR (March/April 1991), 12-18. The positive effect of emotional support during pregnancy is described in J.Kennell et al., "Continuous emotional support during labor in a US Hospital. A randomised controlled trial", JAMA 265: 2197-2201, 2236-7. Their results suggest that the presence of a Doula, to give support may be significant even in modern American hospitals. A letter on homebirths in Australia is in MJA 154: 367.
Another birth technique that may become increasingly common is the use of fetal surgery. A discussion on the ethical obligations of mothers is K.A.Knopoff, "Can a pregnant woman morally refuse fetal surgery?", California Law Review 79: 499-540. A scientific review on the use of growth factors in wound healing, including after fetal surgery is in Science 252; 1064-6.
Surrogacy is the topic of a paper by S.Franklin in the BME (Feb 1991), 13-18. In particular it discusses the New York State Task Force report, the Australian Bioethics Consultative Committee Report, and the British Medical Association Report. The main medical dilemmas are social, the priority should be given to the wellfare of the offspring. The question of divorce and the disposal of cryo-preserved sperm is addressed by J.Robertson in Fertility & Sterility 55: 681-3.
Important for the use of AID is a paper H.Yavetz et al., "Prerequisites for successful human sperm cryobanking: spoerm quality and prefreezing holding time", Fertility & Sterility 55: 812-6. A procedure for freezing sperm is described. Also on the topic of AID see Lancet 337: 1048.
Related to the use of donor gametes is the question of the right of access of children to information about their genetic parents. The American Society of Human Genetics has made a statement on this issue as it applies to adoption; AJHG 48: 1009-10. Some of the points are related to newer techiniques, and genetic histories are urged to be recorded. The statement includes that "Every person should have a right to gain access to his or her medical record, including genetic data that may reside therein". Although it also stresses privacy of people's genetic information, it urges that genetic information be stored and made available. See also an earlier article AJHG 46 (1990), 208-214.

There are fears that the UK ILA actions may be compromised by bureaucracy; NS (29 June 1991), 16. GIFT is not under the control of the regulations. A comment on the IVF consent forms that are being used, and the question of whether they are too complicated, see BME (June 1991), 28-31. A comment on the UK Human and Embryology Act by J. Montgomery is in The Modern Law Review 54: 524-34. The ILA released a code of practice and consultation document earlier in the year and is now considering submissions it received (EEIN 1: 51).
A letter on how to reduce the incidence of triplet pregnancies following IVF and embryo transfer is in Lancet 337: 1543-4. They provide data suggesting that only two embryos need to be implanted to ensure reasonable success rates, and is by the team at Hammersmith Hospital, London. Other letters on embryo transfer are in Lancet 337: 1413; BMJ 303: 185. Another paper is D. Navot et al., "Poor oocyte quality rather than implantation failure as a cause of age-related decline in female fertility", Lancet 337: 1375-7. The uterus can sustain pregnancies when oocyte donation is used, well into the late-40s.
A registry on the use and success of IVF in the USA is reported in a paper in JAMA 265: 3139-41. In 1989 8230 deliveries are recorded for the USA, and the level of the number of procedures (55300 retrieval cycles) is plateauing. No extra risk has been detected from the use of IVF.
A mini-review on the management of tubal infertility is in British J. Obst. & Gynecol. 98: 619-23. The use of infertility management in HIV positive couples is discussed in BMJ 302: 1447-50. On the funding of IVF in the UK see BMJ 303: 244.
A major study on the effects of divorce on children is summarised in A.J. Cherlin, et al., "Longitudinal studies of effects of divorce on children in Great Britain and the United States", Science 252: 1386-9. This study is also of interest in predicting the effects of children being brought up in family situations different to the traditional two parent family. They found that much of what is normally considered the behavioural problems after a divorce, is actually present before the divorce, possibly due to the bad family situation.
The review of a new book, Elaine Sutherland & A. McCall Smith, eds., Family Rights: Family Law and Medical Advances (135pp, 25, Edinburgh University Press 1991), is in Nature 351: 707. It is a collection of essays on the subject. A letter on trends in cesarian section in the UK is in Lancet 337: 1481-2. Comments on the situation in the UK regarding the increasing number of legal claims against obstetricians is in Lancet 337: 1597; BMJ 302: 1487; see also JAMA 265: 2992-4. See also F.C. Barros et al., "Epidemic of caesarean sections in Brazil", Lancet 338: 167-9, where a very high rate is reported (maybe close to 50% of births now).

The Human Fertilisation and Embryology Authority (HFEA) has taken over the monitoring of IVF clinics in the U.K., replacing the Interim Licensing Authority (ILA). The costs of the HFEA are estimated to be 1.7 million during its first full year, while the annual costs of the ILA were less than 100,000! The ILA records will not be generally available to the public, and data on individual clinics is not available, except to the sponsoring bodies of the ILA (the MRC, Royal College of Obstetricians and Gynaecologists, and Department of Health); BME (Aug 1991), 4-5, 8. It also presents some of the findings from the final ILA report, which were figures from 1989. The live birth rate per treatment cycle was 11.1%, but large size clinics had significantly better results than smaller size clinics. The number of eggs/embryos transferred in GIFT/IVF is also regarded to be too high, and should be limited to 3. An interview with Dame Mary Donaldson, former chairperson of the ILA, entitled "Does voluntary licensing work best?" is in BME (Aug 1991), 13-5. On the issue of embryo research under the HFEA see Lancet 338: 888. A letter from the HFEA on charges for infertility services is in BMJ 303: 713-4. The HFEA has also said that clinicians can not seek legal advice on particular cases because of patient confidentiality; BMJ 303: 851-2; see also NS (24 Aug 1991), 8.
On the situation in the USA see Fertility & Sterility 56: 192-7, for comment and the new American Fertility Society guidelines on IVF and GIFT. On women's reproductive health see JAMA 266: 1846-7. On the use of human chorionic gonadotropin for pregnancy testing see JMA 154: 718-9. See also T. Levy et al., "The prognostic value and significance of preclinical abortions in in vitro fertilisation-embryo transfer programs", Fertility & Sterility 56: 71-4.
There are various factors that improve chances of successful pregnancy during infertility treatment. One new factor is described in R.G. Edwards et al., "High fecundity of amenorrhoiec women in embryo-transfer programmes", Lancet 338: 292-4. Women that have irregular menstrual cycles are more likely to obtain a pregnancy and live birth. A letter on oocyte donation and older women is in Lancet 338: 319-20, see also an editorial in Lancet 338: 285-6. See also NEJM 325: 1043-5. In Aberdeen, South Dakota, a surrogate mother is now the genetic grandmother of twins, which her daughter will raise. A letter on sperm competition is in Nature 352: 671-2, and on the fecundity of plant pollen in male-male competition; Nature 352: 796-7. On female antisperm antibodies effect on pregnancy outcome in IVF clinics; Fertility & Sterility 56: 84-8.
A paper showing that longer oocyte maturation increases fertilisation rate is M.E. Jamieson et al., "In vivo and in vitro maturation of human oocytes: effects on embryo development and polyspermic fertilisation", Fertility & Sterility 56: 93-7. On the use of cocultures in embryo growth for infertility services see Fertility & Sterility 56: 179-91. A report finding high levels of chromosome abnormalities in fragmented embryos is in Fertility & Sterility 56: 66-70.
On the subject of reproductive liberty see several letters in the HCR (Jul/Aug 1991), 38-40. A book review of Regulating Reproduction , by Robert Blank (New York: Columbia 1990, 272pp., US$27.50) is in NEJM 325: 366-7. Another book is In Vitro Fertilisation , by Andrea L. Bonnicksen (NY: Columbia 1991, 194pp., US$12). See comments on the ethics debate at the recent world congress on IVF in the HCR (Sept/Oct 1991), 3. See also J.M. Aragona, "Dangerous relations: doctors and extracorporal embryos, the need for new limits to medical inquiry", J. Contemporary Health Law & Policy 7: 307-37. On the practice of artificial insemination see articles in the Millbank Quarterly 69: 5-50.
On parenthood, and children who want to have children; Science 253: 1215. On homosexuality and parenthood; BMJ 303: 295-7. A letter on divorce and children is in Science 253: 952, see also Archives of Diseases in Childhood 66: 915-6. Of related interest, but focusing more on medical diseases that can be screened for, is M.K. Hostetter et al., "Medical evaluation of internationally adopted children", NEJM 325: 479-85.
Comments on preventing preterm birth are in NEJM 325: 727-9, and a new test for predicting the development of preterm labour is described in NEJM 325: 669-74.

On IVF see P.A. Stephenson & M.G. Wagner, "The place of IVF in infertility care", IJB 3: 255-262. It looks at the worldwide situation of IVF, and includes a summary report from a meeting held by the WHO European Office in Copenhagen in June 1990. On IVF in Australia, from a feminist view see Issues in Reproductive and Genetic Engineering 4: 143-54. Ovarian hyperstimulation syndrome is discussed in Lancet 338: 1111-2. On the Canadian Royal Commission on Reproductive Technology see CMAJ 145: 1371. See also J. Medical Genetics 28: 808 for a book review of Teresa Iglesias, IVF and Justice: Moral, Social and Legal Issues Related to IVF (London: Linacre Centre: 175pp., 10). On a confidentiality trap in the British IVF legislation see Lancet 338: 11449-50.
The Japanese Society of Obstetrics and Gynecology has approved the procedure of oocyte drilling for treatment of infertility; Asahi Newspaper (1 Dec 1991). Up to ten clinics may be registered to perform this technique, which has led to the births of about 100 children worldwide.
On the effect of embryo quality on pregnancy rates after IVF see Fertility & Sterility 56: 707-11.
Looking at the other end of pregnancy, on home monitoring of uterine activity and the opinions of the FDA to such tests, to monitor premature births, see NEJM 325: 1374-8. A paper looking at the time of gestation in humans is N. Sauders & C. Paterson, "Effect of gestational age on obstetric performance: when is "term" over?", Lancet 338: 1190-4. On cesarian sections and litigation see Lancet 338: 1462.
Discussion of the American Fertility Society guidelines for sperm donors, is in Fertility & Sterility 56: 396, in context of a finding that there is increasing numbers of mutations in sperm from older sperm donors; B.L. Bordson & V.S. Leonardo, "The appropriate upper limit for semen donors: a review of the genetic effects of paternal age", Fertility & Sterility 56: 397-401. On the attitudes of sperm donors see P.P. Mahlstedt & K.A. Probasco, "Sperm donors: their attitudes toward providing medical and psychosocial information for recipient couples and donor offspring", Fertility & Sterility 56: 747-53. The donors were found to be willing to give in depth information for families, that was not-identifying, and permanent files should be established to keep this information. Also on sperm banking for males undergoing cancer treatment is discussed in Nursing Times 87 (20 Nov 1991), 38-40.
The NIH intends a major study of women's health looking at postmenopausal women; Science 254: 792.

Fetal Environment
A survey of British statistics has found no link between birth weight and the effect of social class on postneonatal mortality; "Influence of birth weight on differences in social mortality by social class and legitimacy", BMJ 303: 964-7. Reduced growth in early life is linked with impaired glucose tolerance and non-insulin dependent diabetes; C.N. Hales et al., "Fetal and infant growth and impaired glucose tolerance at age 64", BMJ 303: 1019.
On the importance of neonatal vitamin K; BMJ 303: 1083-4, and on calcium see NEJM 325: 1399-405. A call for a look at any link between high prenatal lead levels and congenital abnormalities is AJMG 41: 388.

The Canadian Royal Commission on Reproductive Technologies has had some internal problems, with 4 of the 9 members being dismissed by the government after they launched a legal action to change the internal arrangements of the commission; Canadian Bioethics Report 1 (Dec 1991), 1.
A recent Californian court decision in the Johnson surrogacy case is criticised in A.M. Capron, "Whose child is this?", Hastings Center Report (Nov 1991), 37-8. As is argued, the decision to give custody to the genetic parents rather than the mother who bore the child, is disturbing, ethically, legally and socially. See also a book review in Bioethics 5: 353-8. On the UK confidentiality issue in IVF see Lancet 338: 1599.
On treatment of ectopic pregnancies see JAMA 267: 534-7. On low risk maternity care in the UK and providing patients with more choice see BMJ 303: 1487-8.
The number of cycles that IVF treatment was the reason given for a study of the IVF records in Yale School of Medicine; A. Hershlag et al., "Heterogeniety in patient populations explains differences in in vitro fertilization programs", Fertility & Sterility 56 (1991), 913-7. The conclude that different patients should be treated using different models of fertility, and that treatment should be stopped after a certain number of cycles. This is the policy of some clinics already. Concerns about a link between IVF and hypospadias from a study of births in a British Columbian clinic are reported; Fertility & Sterility 56 (1991), 918-22. Two of 53 male infants born suffered from hypospadias.
A study on the survival of embryos after freezing is reported in Fertility & Sterility 56 (1991), 1111-6. On improving the chances of pregnancy in older IVF patients see Fertility & Sterility 56 (1991), 1095-1103. See also letters in Amer. J. Obstetrics & Gynecology 165: 1896-7; Lancet 339: 122-3. The establishment of pregnancy after the removal of sperm antibodies in vitro is reported in BMJ 304: 292-3.
On the use of sperm injection see S.-C. Ng et al., "Microinjection of human oocytes: a technique for severe oligoasthenoteratozoospermia", Fertility & Sterility 56 (1991), 1117-23. They obtained five pregnancies among 165 patients with only one delivery, after a lot of zonal drilling. One can hope that the efficiency improves with practice!
There have been pregnancies established following the donation of both sperm and oocytes, and a letter from the London Fertility Centre in Lancet 339: 307-8, reports six pregnancies at their centre following this approach.
On the use of sperm donation, and the effects of two methods of sperm preparation see Fertility & Sterility 56 (1991), 939-45.

Two major reviews of the performance of assisted reproduction based on statistical results have been published, which increase the expected success rates from IVF. M.G.R. Hull et al., "Expectations of assisted conception for infertility", BMJ 304: 1465-9. The results of the Bristol IVF unit in 1991 were that a 29% live birth rate per cycle was obtained using IVF, a 26% rate for GIFT and a 16% rate for intrauterine insemination. After 4 cycles of IVF or GIFT the pregnancy rate was 78%. They conclude that the prognosis for couples using assisted reproduction is as good as for fertile couples, except for women over 40 and men with sperm dysfunction. The second is S.L. Tan, "Cumulative conception and livebirth rates after in vitro fertilisation", Lancet 339: 1390-4. Their success rates were somewhat lower because they are based on results obtained over many years, not just on the performance during the latest year, but they also say that the rate of success of IVF is close to natural conception rates, especially in younger women.
The case of a Spanish court decision to allow the use of artificial insemination techniques to favour a girl, for a mother of five boys, led to much discussion of the issue of sex selection in Spain. The issue is discussed in IJB 3: 5-12 (in French). On gamete donation and disclosure of parents see Fertility & Sterility 57: 943-5. The successful use of subzonal insemination, based on 225 cases, is reported in Fertility & Sterility 57: 840-9. Arguing about suurogacy see papers; D. Staz, "Markets in women's reproductive labor", Philosophy & Public Affairs 21: 107-31; R.J. Arneson, "Commodifi-cation and commercial surrogacy", Philosophy & Public Affairs 21: 132-64.
The U.K. Human Fertility and Embryology Act has been criticised with regard to its confidentiality clauses, and further discussion of this is in BME (April 1992), 10-11, and of the new government debate to amend the clauses, BME (May 1992), 2. In Tennessee, USA, the Supreme Court has held that an 8-cell blastomere is not advanced enough to be xconsidered a person; Nature 357: 425-6. It may be the final decision in the davis case, overturning the lower court decision saying that legally life started at conception. A paper on ethical issues of embryo research is M. Warnock, "Ethical challenges in embryo manipulation", BMJ 304: 1045-9, with comment in BMJ 304: 1446.
The results of a public refenredum in Switzerland on genetic manipulation were positive, as is outlined in the following letter. The wording of the referendum is reproduced in BME (May 1992), 8-11, together with the currently used guidelines for assisted reproduction in Switzerland. See also Nature 357: 181; Lancet 339: 1345.

Letter from Switzerland
On May 17th, the Swiss people voted to accept, by overwhelming majority of 73.8%, the constitutional article about genetic engineering and assisted procreation passed last summer by the Swiss Parliament (EEIN 1: 50). This bill regulates the use of genetic enginering in both humans and other organisms. In humans, for instance, it prohibits germ-line gene therapy. However, the most controverisal part of the bill is an obscurely-worded provision that appears to prohibit obtaining and storing spare embryos. This would make IVF considerably less practical as embryos could not be saved from one cycle of treatment for the next one. However, since the embryo has not been legally defined so far, the practical consequences for IVF are not really clear and sevral observers now think that the status-quo for practitioners of IVF will not change in the immediate future.
The bill had been frought against from two opposite quarters. On the one hand, many reproved it as an illiberal attempt to restrict IVF and thought that the whole project should be revamped by Parliament. On the other hand, opponents to all forms of assisted procreation (on grounds of religious fundamentalism, fear of reproductive technology in general or some versions of feminism) also campaigned against it. To them, anything short of an explicit prohibition of IVF was unacceptable. Industry and the official bodies of the medical profession supported the bill with varying degrees of enthusiam, as being an acceptable compromise and providing some protection against more extreme law proposals (however, such proposals are in the pipeline anyway).
Dr Alex Mauron,
Fondation Louis Jeantet de Medecine, P.O. Box 277,
1211 Geneve 17, Switzerland.

There is a surrogacy trade between Japan and the USA, care of Noel Keane's agency, the Infertility Center of America (based in Larkspar, California). It is reported that 11 Japanese couples are in surrogacy contracts with US surrogate mothers, and there are reported to be at least 5 births so far. These surrogacy arrangements involve sperm from Japanese men inseminated into American women; Yomiuri Shimbun (31 Aug 1992), 31; Japan Times (1 Sept 1992), 3. Another 15 couples are on the waiting list, including surrogacy using IVF. Opinion polls suggest Japanese women prefer to use their own eggs in surrogacy arrangements, as would be expected. The cost of each baby is about US$80,000 - somebody is making a lot of money. Such arrangements are not allowed in Japan. Is it desirable to have international trade in wombs? The number of Germans using surrogacy services is actually higher. The number of Japanese is the same as those from France, Italy and Britain. In New York State, a law restricting commercial surrogacy, and making any contract unenforcable was passed; Lancet 340: 361.
Attempts to look at the extent of oocyte donation in the USA are reported in F&S 58: 16-8, which give some measure on the extent of the procedures. A report on defective oocytes is in F&S 58: 24-7. On the use of fresh sperm in insemination instead of frozen sperm, see AJOG 166: 1597-606. A legal paper on parental responsibility is G. Douglas & N.V. Lowe, "Becoming a parent in English Law", Law Quarterly Review 108: 415-32. Letters on motherhood are in NEJM 327: 286-8.
The views of the pressure group PROGRESS are expressed in a paper, V. Bolton et al., "The Human Fertilisation and Embryology Act 1990 - A British case history for legislation on bioethical issues", IJB 3: 95-101. A review of the German fetal protection law is E. Deutsch, "Fetus in Germany. The Fetus Protection Law of 12.13.1990", IJB 3: 85-93. It is a rather strict law. A law of more intermediate standing with regard to the use of reproductive technology is in Austria, E. Bernat, "Regulating 'the artificial family', an Austrian compromise", IJB 3: 103-8.
A paper reporting on opposition to reproductive techniques in Australia is L. Woll, "The effect of feminist opposition to reproductive technology: A case study in Victoria, Australia; IR&GE 5: 21-38. See also Lancet 340: 362. The use of behaviour treatment in IVF programs is discussed in A.D. Domar et al., "Psychological improvement in infertile women after behavioural treatment: a replication", F&S 58: 144-7. The stress undergone in IVF clinics is reported in F.M. Andrews et al., "Is fertility-problem stress different? The dynamics of stress in fertile and infertile couples", F&S 57: 1247-53. In a medical mistake in Royal Free Hospital in London, a woman entering the hospital for fertility treatment was mistakenly sterilised; Times (29 Aug 1992), 3.
A survey of European legislation in the area of reproductive technologies was reported at the Toronto Health Law and Ethics Conference, by D. Morgan and L. Nielsen. The laws vary, as known, and for information on their work contact Dr. Linda Nielsen, University of Copenhagen, Institute of Legal Science, Denmark. The UK Human Fertilisation and Embryology Act is being modified; BMJ 305: 77.
On technical issues see H. Strohmer & W. Feichtinger, "Successful clinical application of laser for micromanipulation in an in vitro fertilisation program", F&S 58: 212-4; G. Palermo et al., "Pregnancies after intracytoplasmic injection of single spermatozoon into an oocyte", Lancet 340: 17-8; C.R. Kingsland et al., "Transport in vitro fertilisation - a novel scheme for community-based treatment", F&S 58: 153-8; on male factor infertility see F&S 58: 187-9; and on risks associated with assisted conception, BMJ 305: 50-1.
At several conferences recently I have still noticed the use of the term "artificial reproduction". Let us dispense completely with this word to "assisted reproduction", which has a much stronger scientific basis (at least if we are talking of biological reproduction of cells), and also lessens the danger of stigmatising families who use assisted reproduction.
On the question of enforced contraception see L.B. McCullough et al., "Ethically justified guidelines for family planning interventions to prevent pregnancy in female patients with chronic mental illness", AJOG 167: 19-25. A review of events on obstetrics and gynecology is in JAMA 268: 384-5.

Some data from an Australian study on the social effects of IVF for families is J. Monro et al., "Successful parents of in vitro fertilisation: The social repercussions", J. Assisted Reproduction & Genetics 9: 170-6. A medical risk of assisted reproduction is reported with an association between Creutzfeldt-Jakob disease and human pituitary gonadotropin (hPG), which is used for inducing ovulation. It has been claimed that hPG is linked to two cases in Australia; NS (10 Oct 1992), 4. Most countries use human menopausal gonadotropin, obtained from urine, so should not face the danger of using the pituitary gland extracted material. The infectious agent for the disease (also associated with pituitary growth hormone extractions) has a long (maybe 20 year) incubation period in humans, and can be transferred by extractions from brain tissue.
The New York law, to go into effect from July 1993, which will make commercial surrogacy a crime , is in contrast to Californian attempts to develop regulations on commercial surrogacy; HCR (Sept.-October), 22: 48. A philosophical essay on surrogacy is A. Wertheimer, "Two questions about surrogacy and exploitation", Phil. & Public Affairs 21: 211-39.
The 1990 results of assisted reproduction in Britain have been released by the Human Embryology and Fertilisation Authority. There were 11583 treatment cycles in 64 centres, with an overall live birth rate of 12.5% , with 74.4% singleton, 21.9% twin and 3.6% triplet pregnancies; BME (July-Aug 1992), 8. The incidence of multiple births in the UK as a proportion of total births has increased from 1.00% in 1982, to 1.21% in 1991; BME (Sept 1992), 2. The obstetric risks of IVF from a British study are discussed in S.-L. Tan et al., "Obstetric outcome of in vitro fertilization pregnancies compared with normally conceived pregnancies", Amer. J. Obs & Gyn 167: 778-84. A trial of zygote intrafallopian transfer ( ZIFT ) and IVF found no advantage of ZIFT; Fertility & Sterility 58: 344-50.
A study of human semen quality in Britain has shown that the quality of human semen is decreasing; BMJ 305: 609-13. A literature comparison suggests that the mean sperm count has dropped from 113 million per ml in 1940 to 66 million per ml in 1992. There is evidence that smoking may damage sperm, as well as drinking or chemicals; NS (17 Oct 1992), 13-4. Both men and women are recommended to avoid them when they are pregnant. Damage to sperm by cancer therapy is reported in NS (26 Sept 1992), 5. Radiation exposure of father's is said not to cause any damage to children in a new study; Science 258: 31. A negative effect on women's reproduction in dental workers who used nitrous oxide anaesthetic is reported in A.S. Rowland et al., "Reduced fertility among women employed as dental assistants exposed to high levels of nitrous oxide", NEJM 327: 993-7.
Letters on whether assisted conception should be available under public health funding, the NHS in the UK are in BMJ 305: 521, 771-2. Legal aspects in the UK are discussed in Dispatches 3 (1) (Autumn), 7-11. The costs per baby from IVF are similar to tubal surgery operations. In Thailand there is currently a lack of control on infertility services, and calls have been made for strict controls; BMJ 305: 669. The Health Council of the Netherlands has called for restraint in the use of assisted reproduction. There may also be a Fertilisation Techniques Act enacted in the Netherlands; Network (Aug 1992), 5. The Canadian law Reform Commission (which recently has had to close down due to financial troubles) published a report, Medically Assisted Procreation. The key recommendations on medically assisted procreation are listed in BME (Sept 1992), 8-11, with a commentary by D. Morgan in BME (Sept 1992), 13-5.
A legal view on recent trends in US courts on embryo status and assisted reproductive technology is A.M. Capron, "Parenthood and frozen embryos More than property and privacy", HCR (Sept.-Oct 1992), 22: 32-3. Legal cases and accidents in obstetrics and gynecology are discussed in Lancet 340: 720-1, 783-4. trends in obstetrics in the USA are reported in AJPH 82: 1332-9; 1340-4. More on obstetrics in C. Strong et al., "A conference on ethics for obstetric and gynaecological clerkship students", Medical Education 26: 354-9. On attitudes to embryo research see J. Assisted Reproduction & Genetics 9: 90-93.
The results of a clinical trial of oocyte donation to older women in the USA is reported in M.V. Sauer et al., "Reversing the natural decline in human fertility. An extended clinical trial of oocyte donation to women of advanced reproductive age", JAMA 268: 1275-9, 1320-1. The studies 100 cases at a Southern California clinic and found that oocyte donation could reverse the age-related decline in fertility. A paper on the social unacceptibility of AID in Cameroon is O.M.N. Savage, "Artificial donor insemination in Yaounde: Some socio-cultural considerations", SSM 35: 907-13. Despite 14% infertility, only 33% of infertile respondents were aware of AID, and half of the infertile respondents accepted it compared to 38% of fertile adults. However, only 20% would apply it personally. The effect of various community characteristics on marital and non-marital fertility in the USA is surveyed and reported in Social Forces 70: 977-1011.
Scientific papers include M.T. Zenzes et al., "Chromosome status of untransferred (spare) embryos and probability of pregnancy after in vitro fertilisation", Lancet 340: 391-4; M. Alkani & J. Cohen, "Micromanipulation of cleaved embryos cultured in protein-free medium: a mouse model for assisted hatching", J. Expt. Zoology 263: 458-63. The impact of developmental biology on medicine is discussed in Lancet 340: 760-1.

A discussion of surrogacy in the case when the surrogate mother is only motivated by love to help the infertile couple is J. Oakley, "Altruistic surrogacy and informed consent", Bioethics 6: 269-87. A paper arguing for the support of reproductive technology based on the benefits to the new person is T. Tannsjo, "Who are the beneficiaries?", Bioethics 6: 288-96. Embryo donation is suggested as one way to lessen the growing number of frozen embryos in Australasia; MJA 157: 148-9. Since Nov. 1990, most of the patient costs of IVF in Australia were paid for by Medicare. For the Japanese position on surrogacy see the letter by Y. Shirai on p.3 of this issue. The Japan Society for Infertility has called on the Gynecology Society and lawyers to consider surrogacy. The funding of assisted conception under the NHS in the UK is discussed in BMJ 305: 1368.
A critique of new reproductive technologies from a Catholic perspective, which notes the similarity to feminist opposition to overuse of technology is in Trends in Bioethics (Nov 1992), 1-6. The Canadian Royal Commission on New Reproductive Technologies has announced that it will be reporting to the Government by July 15, 1993, not as originally planned in Oct. 1992 (and in Oct. 1991); Lancet 340: 1214-5. However, it has already produced an impressive number of interesting documents; contact the Commission for copies at P.O. Box 1566, Station "B", Ottawa, Canada K1P 5R5. A book review of A. Liu, Artificial Reproduction and Reproductive Rights is in Int. Digest of Health Legislation 43: 672-5; for other book reviews of related recent books see BMJ 305: 1104. On 9 December a Los Angeles judge ruled that a man could not will his frozen sperm to his girlfriend after his death - it may be appealed, and the sperm destroyed after that if it is not successful. A new method for preserving sperm cells in a liquid state for artificial insemination has been used to give rise to a baby in Maebashi, Gumma, Japan; Japan Times (26 Oct 1992).
Smoking increases infertility also for those using IVF; Lancet 340: 1195-6. Letters on the apparently decreasing sperm quality in the last 50 years are in BMJ 305: 1228-9. A simplified procedure for IVF at one third the cost of current IVF is M.L. Taymor et al., "Natural oocyte retrieval with intravaginal fertilisation: A simplified approach to in vitro fertilisation", Obs. & Gyn. 80: 881-91. Treating azoospermia is discussed in MJA 157: 149-52. Also on techniques see Lancet 340: 983, 1097-8; F&S 58: 674-9. Guidelines for embryology and andrology labs by the American Fertility Society are in an October supplement to the journal Fertility & Sterility 58 (1-22S).
On 12 October, the first court-ordered cesarian section occured in the UK; BME (Oct 1992), 3-4; BMJ 305: 978; Lancet 340: 1029-30. It was justified on the grounds of urgent serious danger to the life of both mother and fetus. In Germany , the brain dead pregnant woman who had been kept on life-support (EEIN 2: 83; BMJ 305: 1047-8) in the hopes that her fetus might be born, was disconnected from life support. The fetus was stillborn at 18 weeks gestational age. This follows much criticism of the experiment, which may have had bad effects on the fetus.

In Britain a clinic offering sex selection services has caused media attention back on this issue. Called the London Gender Clinic, it charges 650. Technically, sex selection for male sperm is about 70% successful; NS (30 Jan 1993), 4, but the success rate for female sperm is very high. This has made newspapers in Japan also. At Sugiyama Women's Hospital in Tokyo, over the last five years they report performing 100 cases for selecting female babies with a 90% success rate; Yomuiri Shinbun (15 Feb 1993), 30. They use the Percol method, and about 10% were for desire of parents who only had male children. The majority were for patients at risk of sexually-transmitted disease. The cost is about 20-40,000 (US$150-300), and about 20-40 clinics are doing sex selection.
India plans to ban prenatal sex determination, and wants to punish offenders by fines and imprisonment; BMJ 306: 353. There are several thousand cases suspected each year. However, as in the letter from Dr Kurian last issue (EEIN 3:3), and in a recent communication, at the ordinary level it is very difficult to control. In Tamil Nadu the provincial and national governments have revamped a programme to stop female infanticide, but it still requires local action at the community level to solve the problem.
In the UK the HFEA is seeking public comment to determine whether they should allow the licensing of sex selection clinics; Lancet 341: 299; Nature 361: 283. A paper looking at how gender division is reinforced in statements and policy about gamete donation is E. Haimes, "Issues of gender in gamete donation", SSM 36: 85-93. The legal definition of motherhood and surrogacy is discussed in geneWATCH (Nov 92), 4-5. Positive results from oocyte donation to women over 50 years old are reported in M.V. Sauer et al., "Pregnancy after age 50: application of oocyte donation to women after natural menopause", Lancet 341: 321-3, 344-5.
People interested in joining the International Network of Feminists Interested in Reproductive Health and Ethics ( IN/FIRE ) should contact the secretariat at 1436 U St., N.W., Suite 301, Washington D.C. 20009-3916, USA (Fax 1-202-332-7995). They publish a quarterly newsletter called "Ethics". A general paper on women and bioethics and rights, in French, is in IJB 3 (1992), 163-7. A new book looking at the concept of kinship in society using new reproductive technologies is Jeanette Edwards et al., Technologies of procreation: kinship in the age of assisted conception (Manchester University Press 1993). Abuses in fertility programs, such as the sperm donating Dr Jacobson in the USA, have prompted calls for more control in the USA; Hospital Ethics (Sept/Oct 1992), 6-8. See also Sociology of Health & Illness 14 (1992), 111-32.
Austria has passed a law to regulate assisted reproduction, the Act on Procreative Medicine, No. 275; BME (Nov 1992), 13-6. There are 22 IVF centers in Austria, second to Israel in the ratio of centres per population. Many more clinics offer AID, though only in vivo donation of gametes is permitted. Storage of embryos is limited to one year, and research is banned. Single women are not permitted to use IVF.
A review of the first year of the UK Human Fertilisation and Embryology Authority is in BME (Nov 1992), 17-8. The "Recommend-ations of the French College of Obstetricians and Gynaecologists for the diagnosis, treatment, cost and results of the treatment of infertility in the health services", are in Human Reproduction 7 (1992), 1335-7.
Results from the Bourn Hill clinic in Cambridge on 63 couples treated for endometriosis using a mean number of 3 cycles of IVF were very successful, with a clinical pregnancy rate of 65% and a 45% take home baby rate; ESHRE meeting abstract 68 (The Hague 1992); Human Reproduction 7 (No. 9, 1992). In a counseling study there (abstract 70), the main causes of stress in couples using IVF were: 25% treatment, 23% failure, 18% emotional; 8% relatives, 4% family, 10% ST (?) and 12% other causes.
The role of physicians in helping subfertile couples is discussed in BMJ 305 (1992), 1376-7; JAMA 269: 46. Some assays of sperm that can predict fertilisation ability exist; AJOG 167 (1992), 1760-7.
The negative effects on fertility of exposure to nitrous oxide may be due to either lowered ovulation or sperm production and/or increased spontaneous abortion; NEJM 328: 284-5.

The Japanese IVF statistics show a large increase in the use of IVF; Yomiuri Newspaper (15 April 1993), 30. The total number of children born from 1983-1991 is 3408, and in 1991, over 1700 babies were reported born, compared to 1418 in 1990. There are 199 registered clinics (although it is not legally required to register, and the total number of births may be somewhat higher). 21.5% of the 1991 births were multiple, including 50 triplets, seven cases of 4 babies and one case of five. Calls for limiting the number of embryos to three continue to be made.
A review of R. Rowland, Living Laboratories: Women and reproductive technologies , is in Bioethics Research Notes 5 (March 1992), 7. It is a feminist critique of reproductive technology. A paper examining public policy is W. Kymlicka, "Moral philosophy and public policy: The case of the new reproductive technologies", Bioethics 7: 1-26. A critical appraisal of assisted reproductive techniques is in Human Reproduction Update 8: 168-74. A new technique being tried in the UK is ovary transplants: which could present another approach to infertility.
The Scottish and UK funding of IVF is discussed in BMJ 306: 741, following a rejection of a centrally funded IVF clinic in Scotland.
An editorial on the use of surrogacy by elderly mothers is in Bioethics 7 (Jan 1993), iii-v. A paper on parental rights and gestational surrogacy is in Columbia Human Rights Law Review 23: 525-54. In North Carolina, USA, the sister of an infertile couple used a turkey baster to inseminate herself with semen from the man of the couple, and is expected to give birth in early May. They had tried for 6 years with doctors, and decided it was too expensive! A letter on the fees that should be given to egg donors is in NEJM 328: 737-8. It argues that it takes about 56 hours to provide an egg, much more effort than providing sperm, and the current US fees of US$1-2,000 are justified. A French surrogacy aid organisation is discussed in Nature 362: 200; and French consent laws and psychological studies of AID in Nature 362: 102.
A paper on the relevance of embryo transfer technology in animals to humans in a Canadian context is in Human Reproduction Update 8: 147-67. A third woman has died from Creutzfeldt-Jakob disease due to pituitary gonadotrophin in Australia, NS (13 Feb 1993), 11.
In Canada there is a preference for male children as shown by increased use of contraception by women who have two sons compared to women who have two daughters; J. Biosocial Science 25: 213-21. A letter on attitudes to sex selection in Cambridge, U.K. indicates that there is no sex preference among women; Lancet 341: 564-5. 62% said that they did not want to know the sex of their child before birth. See also Lancet 341: 727-8, 762.
Letters on pregnancy in post-menopausal women are in Lancet 341: 697. A survey of women over 30 years old suggests that older women have increased chance of adverse pregnancy outcomes for their first birth; O&G 81: 512-6. The use of lasers to make holes in the egg for sperm to enter through has been used in animals; NS (20 Feb 1993), 20. The risks of sperm damage due to chemotherapy are discussed in Human Reproduction 8: 8-10. An increased waist-hip ratio, due to fat, makes it harder to conceive a child; BMJ 306: 484-7.
A letter on the use of caesarians in a Hong Kong hospital, 14% of the deliveries, is in Lancet 341: 763. Figures from the UK are in BMJ 306: 494-5. A legal paper asking in whose interests court-ordered caesarians are is in Modern law Review 56: 238-43.

Sex selection issues and problems are debated in NS (1 May 1993), 12-3; Lancet 341: 1145. The UK has issued a consultation document on the subject. India and China have been using sex selection at different levels for many years and the population sex ratios are changing. Other countries should not follow their path, even if the technical methods are more acceptable, the consequences are similar. The technical use of FISH for sex determination (for sex-linked disease) following preimplantation diagnosis is in BMJ 306: 1382.
A report and list of conclusions from the first conference on "Bioethics in Human Reproduction Research in the Muslim World" is in IJB 4: 22-3. They recommended an urgent need for Ethical Committees to review such research, and that all the research should be in keeping with the teaching of Islam.
One of the classic legal cases in embryo status and ownership of embryos, the Davis case in Tennessee, was over whether the father could prevent the mother from implanting the embryos, following their divorce. The court and appeals led to custody going to the father, and all the embryos have been destroyed by the father in June.
The California law on surrogacy , recognising the contracts even if the birth mother changes her mind, is called an "experiment" (and criticised) in Lancet 341: 1469. A general background to the ethics of IVF by L. Gillam is in Bioethics News 12 (3), 49-59.
A review of the issues of science involved in improving IVF and preimplantation diagnosis is R.M.L. Winston & A.H. Handyside, "New challenges in human in vitro fertilisation", Science 260: 932-6. They also list the problem of financial resources as being the most serious issue. The issue of rationing of IVF is debated in BMJ 306: 1521-4. In the UK a study reports that access to IVF is by chance, and half the infertile couples do not have access to clinics; BMJ 306: 1290. Also in the UK simplified procedures are being drafted for confering legal parenthood in cases of comissioned surrogacy; BME (May 1993), 3; Lancet 341: 1274.
A Finnish study shows that sperm counts do cycle, being lowest in summer; Science 260: 1592-3. Another study there shows that semen quality is declining; BMJ 306: 1579. A paper hypothesing a link between oestrogens and falling sperm counts is in Lancet 341: 1392-5. A letter on technical improvements to IVF for cases where the technique fails is Lancet 341: 1213.
An inquiry into the possible link between Creutzfeld-Jacob disease and human pituitary gonadotropin is being launched; NS (29 May 1993), 10; BMJ 306: 1128-9. The use of recombinant human follicale stimulating hormone instead of IVF is reported in Lancet 341: 1101. The fear of human fertility drugs is discussed in US News & World Report (3 May 1993).
Claims that hysterectomies are inappropriately recommended in the USA are in JAMA 269: 2398-402. The high cesarian rate in the USA continues in 1991, with 23.5% of deliveries involving cesarian; JAMA 269: 2360. In California the rate of cesarians has declined from 1988 to 1990, AJOG 168: 1297-302. Debate over what the correct cesarian rate is, and international comparisons, are in Br. J. Obstetrics & Gynaecology 100: 303-6, 310-5, 403-4, 493-6.

A paper on autonomy and commercial surrogacy is in IJB 4: 137-41. Legal issues of surrogacy are in R.B. Oxman, "Maternal-fetal relationship and nongenetic surrogates", Jurimetrics J. 33: 387-426. Also on surrogacy, AJOG 168: 1858-63.
The Canadian Royal Commission on New Reproductive Technologies has completed its report, which is to be given to the government on 15 November.
Psychological factors involved in infertility are surveyed in Human Reproduction 8: 1039-46. Positive factors for fertile couples were the wives' level of positive expectations related to motherhood, and the husbands' quality of integration between the wish for a child and sexual relationships. A paper on the psychological and social impacts of infertility in Greek couples is Human Reproduction 8: 396-401. There are obvious psychological consequences for a second reported case in the UK of an abortion of an embryo implanted after IVF, due to the wrong embryo being implanted.
UK clinical guidelines may increase the quality of care of infertile couples; BMJ 306: 1728-31. The WHO recommendations on IVF are reviewed in Lancet 341: 1648-9. On sex selection and eugenics, BMJ 306: 1704-5, 307: 133, 451. The BMA has rejected social reasons for sex selection. In a survey in Japan just conducted, 76% said that if they had only one child they would want a girl , suggesting that traditional ideas of family inheritance are discounted by many people. On who should pay for IVF and rationing it, BMJ 307: 324; Lancet 342: 251-2.
In the UK about 10% of people coming for donor insemination are due to vasectomies, SSM 37: 263-6. On male infertility, BJOG 100: 612-4; and on the NIH Consensus panel report on impotence, JAMA 270: 83-90. The issue of secrecy in donor insemination is debated in AJOG 168: 1846-51. On compensating egg donors , NEJM 329: 278-9; and on egg donation to older women, AJOG 168: 1803-9; Lancet 341: 1668.
Higher success is reported for intracytoplasmic sperm injection than subzonal insemination; Human Reproduction 8: 1055-60, 1061-66. On the use of failed human oocytes in research, Human Reproduction 8: 503-7. The mechanism of chromosomal abnormalities is suggested to be due to generation of single chromatids at the second meiotic metaphase by precocious division of single chromatids at anaphase I (predivision) in Human Reproduction 8: 1047-54.

The recent report from the UK Human Fertilisation and Embryology Authority ( HFEA ) shows further increase in the success rate of IVF. The live birth rate per cycle in 1991 was 13.8%, from 12.5% in 1990. The range between centres was 10.5% to 20.8%, generally being better in larger centres. On other recent comments from the HFEA; BME (Sept 1993), 3-5.
In Denmark recently, a woman became pregnant with nine embryos at a private clinic. This has led to strong calls for regulation of the private infertility clinics there; BMJ 307: 643-4. A letter on the WHO guidelines for IVF is Lancet 342: 867. There is a rumour that the Victorian (Australia) law on surrogacy will be relaxed in 1994 to allow sisters and female cousins of a woman to be surrogates, and possibility also close friends. It would maintain a ban on commercial surrogacy; Bioethics News 12(4), 3.
A report in the New York Times (24 Oct 1993) of the " cloning " of humans was repeated in Japanese and other newspapers. Of course, it was only making identical twins using embryo splitting, something which could have been done for years, and identical twins are quite natural. The research at George Washington University in Washington D.C., USA, led to destruction of both embryos. The case has been discussed in ethics before, and suggested many years ago by R. Edwards as a way to increase the chances of a baby following IVF. Is it safe? In many mammals it has already been done, with no evidence of harm.
A review of R.G. Edwards, ed., Preconception and Preimplantation Diagnosis of Human Genetic Disease (Cambridge University Press 1993, 340pp, 60) is BMJ 307: 691.
A paper that was not reported on cover pages (I think) was a paper associating mutagenic effects in mouse embryos with freezing - which should be of more concern; M. Bouquet et al., "Cryopreservation of mouse oocytes: Mutagenic effects in the embryo?", Biology of Reproduction 49: 764-9.

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