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Where am I now? Lawlink > Law Reform Commission > Publications > 1. An Overview
Discussion Paper 15 (1987) - Artificial Conception: In Vitro Fertilization
1. An Overview
I. IN VITRO FERTILIZATION AND INFERTILITY
1.1 In vitro fertilization (IVF) and embryo transfer (ET) are the terms typically applied to a medical procedure of two stages, the first being the fertilization of a human ovum outside the human body and the second its transfer into a woman’s uterus. The first stage is preceded by surgical removal of the ovum from a woman’s ovary, and fertilization is effected by human sperm in a laboratory dish. Subsequent transfer of the fertilized ovum to the uterus takes place in the expectation that it will thereafter implant and develop as in a normal pregnancy. The procedure and its techniques depend for success upon many factors including careful monitoring of the patient’s hormonal levels, and the timing both of the ovum removal and its transfer after fertilization. The procedure will be described in greater detail in Chapter 2.
1.2 The development of IVF has been a medical response to human infertility. Over the past two decades pressure to improve methods of overcoming infertility has increased. This pressure is due in part to the substantial decline, in the Western world, in the number of children available for adoption.1 For the infertile couple, adoption is no longer an assured or likely solution to childlessness.
1.3 The increasing interest in methods of dealing with fertility disorders may also be related to accounts of increased infertility in Western nations. Reports indicate that human sperm counts have been falling in industrialised countries for some time. Research undertaken in the United States suggests that the average American male produces less than half the sperm produced by his counterpart 50 years ago.2 There have also been suggestions of reduced female fertility.3 Accurate statistics on rates of infertility are not available, and although there is evidence of increased numbers of people presenting for infertility treatment,4 this may simply be a function of growing community awareness of infertility, and less willingness to live with the consequences of it.
1.4 Infertility has been defined as “the failure to conceive after a year of unprotected intercourse”.5 Applying this definition, there is an acceptance by experts that between 10 and 15 per cent of all couples are infertile.6 In New South Wales alone, it has been estimated by one official committee that between 30,000 and 50,000 couples of reproductive age are infertile.7 However, if the estimates cited (10 to 15%) are correct, the actual number of couples of reproductive age who are infertile is considerably greater. Without any doubt, the problem is a substantial one.
II. TREATMENT OF TUBAL INFERTILITY AND DEVELOPMENT OF IVF
A. Introduction
1.5 The patients originally selected for IVF treatment were women who lacked normal fallopian tubes through damage wrought by “chronic infection, attempts at surgical repair of the tube, or surgical removal of the tube”.8 The techniques of IVF allow the ovum to “bypass” damaged, obstructed or absent tubes.
1.6 In normal reproduction, fertilization of an ovum by sperm takes place in a woman’s fallopian tube. When an ovum is released from one of the two ovaries, an event which occurs each month, it is swept into the nearby fallopian tube and transported down that tube towards the uterus. After sexual intercourse, sperm travels up the female genital tract through the uterus and into the fallopian tubes. If an ovum is present in the tube at the same time, one of the sperm may fertilize the ovum. A fertilized ovum will continue to travel down the fallopian tube and upon arrival in the uterus may implant itself in the endometrium or lining. With implantation, pregnancy is said to be established. If an ovum cannot travel down either of the two fallopian tubes due to some obstruction or damage then fertilization, and hence pregnancy, cannot take place “naturally.”
1.7 Tubal disorders account for between 20 and 35 per cent of all female infertility,9 and the most common cause of tubal damage is infection.10 Causes of infection are many:
While legalized... abortion has reduced the incidence of severe pelvic infection and tuberculous pelvic disease is less common, the incidence of tubal infection has been sustained by the persistence of post-abortal and pregnancy infections of a mild type and by the increase in incidence of venereal disease.11
1.8 Other reports, however, estimate that venereal disease is in fact only responsible for about 1 per cent of all infertility.12 Tubal damage may also result from pelvic infection due to use of certain contraceptive devices (IUDs), pelvic peritonitis in association with appendicitis, or ectopic pregnancy.
1.9 Another major cause of tubal damage is previous sterilization, involving interruption of the usual function of fallopian tubes by a variety of techniques including clipping, cauterizing or surgical excision. A United States study on fecundity carried out by the National Centre f o r Health Statistics has found that of 54 million American women of child-bearing age, 13.6 million have been sterilized.13 In a recent survey carried out in Australia by the National Perinatal Statistics Unit and the Fertility Society of Australia, sterilization was a stated cause of infertility in 22 of 309 IVF pregnancies in Australia, or 7.1 per cent.14
B. Development of IVF and ET
1.10 Blocked fallopian tubes have been recognised as a cause of infertility since the early 19th century, even though at that time the physiology of conception was not fully understood. 15 The first surgical attempt to unblock obstructed fallopian tubes was undertaken in the mid 19th century.16
1.11 However, the foundations for the successful use of IVF to alleviate tubal infertility were laid before its application to human fertility problems was even considered. The technique of embryo transfer (ET) was first demonstrated by Walter Heape in 1890.17 He showed that fertilized rabbit ova could be flushed from a doe’s fallopian tube and transferred to a surrogate mother.
1.12 The first attempts to fertilize mammalian ova in vitro were made in 1878, but were not successful.18 In 1930, Gregory Pincus published a description of his experiments with in vitro fertilization of rabbit ova.19 In 1934, he claimed to have successfully fertilized rabbit ova in vitro, but the results of his experiment were equivocal,20 and it was not until 194721 that the first unambiguous fertilization of mammalian ova in vitro took place. In vitro fertilization of human ova proved even more elusive.
C. The Recent Past
1. United Kingdom
1.13 The British partnership of Robert Edwards (scientist) and Patrick Steptoe (gynaecologist) was the first to achieve a continuing pregnancy in a woman without functional fallopian tubes, following IVF and ET. The two men began working together in 1968, and by February 1969 were in a position to publish irrefutable proof of successful fertilization of human ova in vitro.22 In 1975, they achieved a pregnancy in a woman following IVF and ET, but the pregnancy was ectopic.23 Finally, in late 1977 they achieved a normal pregnancy following IVF and ET, and on 25 July 1978 the world’s first “test-tube” baby, Louise Joy Brown, was born.
2. Australia
1.14 Australia’s first IVF baby, Candice Reid, was born on 23 June 1980. Her birth was the result of the work of Professor Carl Wood and his colleagues at Monash University and the Queen Victoria Medical Centre, Melbourne. Of the world’s first 16 IVF babies, three were born in the United Kingdom, one in the United States and 12 in Melbourne.24 The Melbourne group was also responsible for the first birth following implantation of an IVF conceptus which had been frozen and thawed.25
1.15 To date, there have been over 1400 live births in Australia following IVF and ET,26 and there are IVF clinics operating in all States, and in the Australian Capital Territory. In New South Wales, IVF clinics are conducted at Royal North Shore Hospital (Sydney), Royal Prince Alfred Hospital (Sydney), St. George Hospital (Sydney), Westmead Hospital (Sydney) and Lingard Hospital (Newcastle). Recently a private IVF clinic has been established in Macquarie Street, Sydney.27
III. CURRENT INDICATIONS FOR IVF
1.16 As has already been indicated, IVF was originally developed as a treatment f or tubal infertility. It is now evident that the technique has wider applications. IVF may be successfully applied to alleviate the effects of a number of different types of infertility affecting couples, including:
- oligospermia (a form of male infertility);28
- infertility caused by immunological factors;29
- infertility as a result of ovarian disorders;30
- inherited genetic disease; and
- unexplained or “idiopathic” infertility, which accounts for a substantial proportion of all cases.31
1.17 One expert commentator has seen the role of IVF in the treatment of human infertility as follows:
... IVF is not a panacea, and will not supplant established methods such as ovulation induction in the anovulatory patient, or surgery for certain forms of tubal damage. It is likely, however, that in the near future, IVF and ET will be regarded widely as a valuable infertility treatment that complements existing procedures, as well as a means of obtaining important information about the earliest stages of human development.32
Footnotes
1. Total adoptions in Australia fell from 6773 in 1969 to 3337 in 1980, and the decline in traditional “non-relative” adoption was proportionally even more dramatic. See P Harper “Changing Laws for Changing Families”, paper delivered at seminar entitled Creating Families in the 1980’s (Victorian Standing Committee on Adoption, March 1982).
2. Sydney Morning Herald, 15 June 1985 at 40.
3. See eg C Wood and A Westmore Test-Tube Conception (1984) at 17; Sydney Morning Herald, 12 April 1985 at 13.
4. See Wood and Westmore, note 3 at 17 ; Ontario Report Vol 1 at 11; IVF Working Group of New South Wales Department of Health In Vitro Fertilization in New South Wales - Policy Guidelines (December 1984) at 10-11.
5. N Pfeffer and A Woollett The Experience of Infertility (1983) at 27; see also R J Pepperell et al (eds) The Infertile Couple (1980)at 1; S Suchy and S Cahill The Infertility Resources Handbook (1981) at 13.
6. S Suchy and S Cahill, see note S at 11-12; C Wood and A Trounson (eds) Clinical In Vitro Fertilization (1984) at 183; J Kraus and P E Quinn “Human Artificial Insemination: Some Social and Legal Issues” (1977)1 Medical Journal of Australia at 710.
7. IVF Working Group of New South Wales Department of Health, see note 4 at 10.
8. R J Pepperell et al (eds), note 5, at 211.
9. Id at 43; S Suchy and S Cahill, note 5, at 18.
10. R J Pepperell et al (eds), note 5, at 44.
11. Id at 43.
12. S Suchy and S Cahill, note 5, at 13.
13. Sydney Morning Herald, 7 June 1985 at 10.
14. National Perinatal Statistics Unit Report (1984) at 10.
15. A Trounson and C Wood (eds) In Vitro Fertilization and Embryo Transfer (1984) at 35.
16. Id at 4, 5.
17. A Trounson and C Wood (eds), note 15, at 8.
18. Ibid.
19. Id at 9.
20. Ibid.
21. L B Andrews New Conceptions (1984) at 121.
22. R Edwards and P Steptoe A Matter of Life (1980) at 78-86.
23. Id at 125-133.
24. D Overduin and J Fleming Life in a Test Tube (1982) at 63.
25. Australian, 11 April 1984 at 1; Sun, 11 April 1984 at 13; Age, 12 April 1984 at 3.
26. National Perinatal Statistics Unit Report (1987) at 18, table 4.
27. The clinic has complied with NHMRC guidelines relating to the conduct of IVF clinics including obtaining approval by an institutional ethics committee to all aspects of the program.
28. Fertility in the male depends upon his ability to produce an adequate number of normal, live and “motile” (capable of spontaneous movement) sperm. A sperm count of 20 million per ml of ejaculate is considered the lower limit of fertility. When a man has a low sperm count he is said to be oligospermic. See R J Pepperell et al (eds), note 5, at 84.
29. Sometimes, a woman may develop an allergy to her partner’s sperm. This means that her body produces antibodies which attack and kill any sperm which make their way into the woman’s genital tract. The antibodies may be present in the woman’s cervical mucus, in the uterus and fallopian tubes or even in the blood stream. The process of IVF involves washing of ovum prior to any attempt at fertilization. Washing removes body fluids which may contain the sperm antibodies and increases the likelihood of successful fertilization.
30. Where a woman is not producing ova, or when her ovaries are inaccessible, it is possible to create a pregnancy using donated ova which have been fertilized with her partner’s sperm.
31. When conception fails to occur after one or two years has elapsed and no major or minor abnormality can be detected in either partner, their infertility is unexplained. See R J Pepperell et al (eds), note 5, at 164.
32. C Wood and A Trounson (eds), note 6, at 9.
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