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SUM,
mis stay was p~*ed by a cordon that, Muse of a policy that
~ effect prohibits the ~~~ of federal furls for ~ involving human
embryos, the mini practice of in vitro fertilization arm embryo
transfer (IVFE:r) was pi to the limit of its scientific formations.
In avocation, there was a perception that animal science had made
substantial progress in the development of rVFET but, because of a lack of
communication among those working to further human clinical IVFET and
those working in the animal science area, the knowledge developed in one
sector was not being conveyed to the other. AS a result progress in each
sector was seen as being slowed.
An Institute of Medicine committee was appointed to examine the Chic
science foundations of medically assisted conception, to develop an agenda
for basic science research that could contribute to ads in the
clinical and agrialltural practice of IVIES, to sagest aniJre1 systems
dot provide useful m~els for pacific research areas, ~ identify ways
of diminishing barriers to pr~ess, and to red ways of bringing
together the veterinary and human repr~ti~re research workers.
lhe oer~tarpi~r~ of the s ~ y As a workshop at which clinicians and
investigators reviewed the stab ~ of assisted conception and The relater
basic research in humans a ~ animals, and suggested productive areas for
future research. This workshop brought together representatives from the
human and animal research worlds to enable them to exchange ideas, enhance
their understanding of ways in which they can contribute to each others
work, and participate in a joint activity that ~d establish contir~uir~
ties.
Social Concerns what Can be dress By IVFET
Joseph dirt at Chid forward the frontiers of helically
assists conception has the potential to provide benefits beyond the
limited nabber of couples whose infertility may be solved by IVES. m ere
are expectations that such research would enable practitioners to identify
genetic defects in embryos without damaging them, and to determine the sex
of embryos without damaging them, so that those with sex-linked genetic
diseases can be identified at a very early stage. Major areas to which
advances in basic reproductive biology would make large contributions
include:
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0 Infertility. Me magnitude of the problem of human infertility
is reflex by the number of wan with "impairs flits" 4.4
million or 8.2 percent of In of childbearing age in 1982 (National
Center for HF1A1th Statistics, 1985~. E'y one estimate, Ire than half of
the 4.2 million warren so have been surgically sterilized for
Ron oontrac~ptive reasons, arm half of Me 4.4 million s~ibf":ur~ In
wculc} like to He pregnant. Ore, ox million Warren between He
ages of 15 arm 44 who were or had been married Or at let one
Spiral visit for infertility in 1982 (fixes and] Pe~ault, 1986).
Alpha data coot describe He emotional toll of infertility, the
nications Apia are beginning to portray sax of the distress. He
lengths to which cables will go in attempting to conceive arm the
formation of nationwide suborn groups for c~ilcil~= people are indicators
of ache pain of childlessness. Al~h Iv~r ~ a solution for only
limited ~ of infertile Apples, r~rdl Hat advarx:~ the practice
of IVEFT also has ache pcrtential of advancing cipher fond of infertility
treatment.
Numercus infertility treatments exist, including education to give
Ccupl~= sufficient knowledge of reproductive biology, surgical repair,
artificial insemination, and the use of drugs to induce ovulation. Two
major new technologies are [VFET and gamete Any afallopian transfer
(GIFT). mese are complicated technologies. m e simple description that
follows will facilitate understanlinq of the research agenda developed by
the committee.
For IVFET, eggs are removed from the woman either during a natural
cycle or after growth and maturation of occytes has been stimulated by
such drugs as human Mensa gonadotrophin. This latter method has the
advantage of allowing more than one oocyte to be harvested. The egg is
placed in a petri dish together with washed sperm that have been treated
to ensure capacitation. If fertilization is achieved, the process of
cleavage starts, and somewhere between the 2- and 16-cel1 stage, the
embryo is transferred to the uterus. Pregnancy is established when the
developing embryo implants itself into the wall of the uterus. Mare than
one embryo may be transferred to the uterus.
For GIFT, growth and retrieval of eggs are performed in a manner
similar to that used for [VFET. Semen is collected and placed in a
catheter with the eggs, and they are then transferred to the fallopian
tube. Fertilization takes place in viva.
Sometimes donated sperm, eggs, or fertilized zygotes are used in
assisted conception. For example, excess zygotes collected fmn a patient
urxiergoing IVAN can be fertilized and implanted in a recipient uterus
that has been sync~zed with the donor's cycle.
O Contraception. hi in the - -tic science that weld ingrate
the clinical practice of ~~;cist~ Luxation wcAllcI, at the Sam tin—, help
in the search for better contra~cive teleologies. Despite widespread
use of such ~ntra~ptive methods as sponges, surgical sterilization,
intrauterine devise, and birth Sol pills, there remain unresolved
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problems of safety are efficacy. ~ sear for implored for of
contraction ~ sparred not only by the desire of individuals to gain
conch aver their repressive lives, he alto by the social cost of
up prelacies arc the problems caused }fly fast~gr~ir~g populations
in Injuries unable to provide an Hate stanzas of living for the
present predation.
o Agriculture. He application of Hiss connation Unit;
has made rapid inroads in ache tic cape ir~try. Artificial
insemination is the norm, with 70 percent of dairy cows oonaeivir~ In this
Urn In 1985. In IF~c than ~ cheep;, a n~timillion clollar IVES
bovir~e ir~cry has c~velc~. Abet 25 pert of embryo transfer In
1984 wet of frozen embryos. Artificial ~r~tian has rat In
genetic i~prov~rents in daisy cattle that have crabbed mill production per
can In thirty years (First, Crister, are P0l, 1985~. Embryo transfer
Homology ir~reases the rate of prounion of Valerie cows. Ire
auction of new r~r~uctive ~nologie~ to Charge the pinion of
foc~-pr~x3ucing animals has the potential for Inhering the cost of food and
Sickening the process by High anions genetically suite ~ cliffi~t
clime ~ ~ ~~
0 Biodiversity. Is in reproductive t~rx)1ogies may sustain
biodiversi~r by improving He r~uctive efficiency of ~ng~
Elegies.
O Primates for Prearm. A limited ~ of primal—C are In
captivity and available for z~`, art there is a possibility Cat He
capture of more may be hall becalms= of Urn: for the future of the
species. It will be increasingly important to maximize the r~pr~tive
capabilities= of the pry;: available to science.
Barriers ~ Ens in In Vitro Fertilization and Embryo Transfer
since the birth of Twin Brown in E ~ lard in 1978, in vitro:,
fertilization with embryo replacement has become an established method of
treatment for certa ~ types of infertility that do nck respond to
alternative methods of treatment. However, the chances of Quoters in IVF
are relatively low. In 1985, 14.1 percent of stimulation cycles resulted
in clinical pregnancies. In 1986 this figure rose to 16.9 percent
(Fertility and Sterility, 1988). But, the proportion of women entering
treatment who attain a live birth is far lower ~ only 8.9 percent of
oocybe retrievals ended in live birth (Journal of the American Medical
Association, 1988). Why are the ~~= for suro~cful IVFET so low? The
state of clinical practice of IVFET today is limited by lack of knowledge
of some of the basic reproductive biology involved. This is caused, In
part, by the many ethical questions raised by research in pursuit of the
needed information. Difficulties in resolver these issues have cat
the reseat h to be deprived of federal f~i~.
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Ethical arm Social Issues
Sare of the ethical or social ~c that arise fray the variants
form of mist correction are unrelated to decisions a}xxIt the promos
of rearm. E~nples of these are ~i~ am the promotion of the
rights of gamete donors, g~tati~al parents, and social par~ts; the
Rip of cryc~preserved mbryos; arm the sale of gamy= arm embryos.
sane ethical question have a dim Ring on i, and have
had important consumers; for ache few of ~arch. me major
questions fees on ~ sta—~= of the embryo at each stage of itch
develc~rent. Hcm ache embryo ~ rearm dictate that Is Orally
arable to do to it.
At one end of this ~bn~ of Fought Is me position yawn by the
Pecan Catholic Churl. me Vatican's Suction on Pi for mean
Life state that "freon the first at of its existence until birth . . .
no moral distinction is oonsider~ between zygotes, pr~ryos, erdbry~
or fetuses" (cited ~ Fertility are Sterility, 1988b). Therefore, the
absolute sanctity that is accord to p~-nat~l human life begins with
the zygote. Ihis arc makes it impossible ~ discard spare embryo or
use them for Ryan Arm. At the cipher end of we Rho Is me
position that an embryo Is merely biological material like any other group
of living cells. The special value that might be attached to that
Merriam rats frog the Rations or aspirations of others (Office of
Ethnology Assessment, 1988) .
Midway between th~;c too positions is one that holds Bat "~e hen
embryo is entitled to profane respect; but this ~c does no
r~ssarily ~a~ the full legal arm ~~ rights acrid to a
person" (Department of Health, Education, arm Welfare, 1979~. Holding
this position, the Elite; Advisory Bard (established by the ~r~nt of
Health, Education am Welfare (~) in 1979) concluded that rearm was
actable on embryos up to 14 days after fertilization.
the Feds Goverrment arm Embryo drub
Policy conic rewarm on human subjects has Ben sickly evolving
singe the 1960s. A sty gnmp was convened atNIH to develop guidelines'
arm a National Advisory Fission on Health Science arx] Society was
prod by Senator Walter Mondale ~ 1968 to examine develc~nts in
Rival regears. Follcxving reports of the infants Gee syphilis
experiments, mEW Rae Bat is establish a ~rrra~t bcxty to
regulate federally furred Rae using hogan subjects.
In the 1970s the abortion issue ~ lime ~ the issue of embryo
reseat. After the Roe v. Wade Schick legalized abortion User Canaan
conditions, concern develops that wan weld be pressure into having
abortions arm the awe of aborts ~ryo6 might aver. In 1974, Me
fevers government cravat the National fission for the Lion of
— 4 —
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Human Subjects (P.L. 93-348). Until this commissiQn reported to Congress,
research on the living fetus was prchibited unlay= it was used to help
that ferric survive. In 1975, DHEW issued regulations hasps on the
findings of the commission. Id-== regulations did not cover embryo
research. The commission also recommended establishing an Ethics Advisory
Board (EAB) to review requests for research on embryos and in vitro
fertilization. However, in 1980, the Secretary of CHHS allowed the EAB
charter to expire. mus, no research could be approved, and federal
funding of embryo research was de facto prohibited. As a result, embryo
research has relied on private funding from patient care revenues,
pharmaceutical companies, and university budgets.
Since 1985, efforts have been made that, if mYY~es~ful, ~ ght
establish some rules under which embryo research could proceed. However,
the chances of such an outcome ~ the near future appears to be slim. A
Congressional Biomedical Ethimc Board, composed of six senators and six
representatives, has been appointed. This group established a Biomedical
Ethics Advisory Committee. In 1988 the Department of Health and Human
Spavins at its intention to revive the Ethics Advisory Record and
publish a proposed tar en A final Farber is awaits.
Domestic ~ Foreign Decisions Concerning Embryo Research
The two professional societies ~ the United Stats that represent
the physicians most involved in hymen IVFEr have considered ethical
questions abort the practice of IVES art - 3ryo research. In 1986 the
Remittee on Ethics of the American Cabs - e of C~etricians and
Gynecologists (AaDG) (1986) issued a statement that acl~ledged the
ethical issues pos ~ by the creation of embryos outside a uterus, the
dilemma of surplus embryos, and the acceptability of research using early
human embryos. The ACOG committee recommended that human embryos should
be used only if nonhuman embryos could not provide the needed knowledge.
It also recommended banning resee rch on embryos that had reached the age
of 14 days. The American Fertility Society (AFS) also issued a report in
1986, approving experiments on embryos up to 14 days (Fertility and
Sterility, 1986~. A year later, after consideration of the Vatican's
Instruction for Human Life in its origin and on the Dignity of
Procreation, issued by The Congregation for the DccUrine of Faith, the ADS
issued another report. This report stated that progressive degrees of
respect are *ue with progressive development of embryos, and that
experimentation can be justified and is neat if the human condition
is to be improved (Fertility and Stern ity, 1988b).
The government of the United Scats=, since 1979, has not followed the
lead of nations that have systematically examined issues related to human
[VFET. Since 1979, at least 85 statements have been prepared by
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Representative terms from entire chapter:
clinical practice
cc~nittees representing at least 2S vestries. Fair A~alian Remittee;
fat r~ on early (prei~lalTtation) embryos to be ethically
urm~:able. Eleven canmi~ees arrived at least saw kinds
of early embryo r~. Six of these adept sub relearn only oar
embryos left aver frown clinical activities. Five c~ni~ee sta~:s
(include ache 1979 MEW Ethics Advisory army wed allay the
communication to allow cross-fert~ ization of ideas and development of
ongoing relations hips among investigators pursuing similar approaches to
problems.
sources of Research Material for Experiments with Humans and Other
Primates The committee's workshop provided many excellent examples of
instances in which information about reproductive physiology derived from
animal models has keen 1,CPfU1 in unlerstandlnq human physiology. However,
animal mantis cannot suffice for investigating all central questions;
progress ~ some areas requires the ,~== of human tissue. An example of
this is investigation of reasons for developmental failure of human
embryos.
Although specific primates are good masons for some aspects of human
reproductive physiology, there are only a limited number of monkeys of
desirable species ~ captivity and many of them are presently being used
for AIDS research.
A workshop was held August 21-23, 1988 at the Arnold and Maker
Beckman Center in Irvine, California. Overviews of the experience gained
by the clinical practice of rVFET and of the practice of aniseed
conception in food-prc~ucing animals directed attention to unanswered
questions that will ~ basic science research for their resolution.
These questions reflect important gaps in our knowledge of the biology of
all the stages of reproduction from the develcpment of male and female
gametes to the process of embryo implantation. The topics listed below
are areas ~ which further research was recommended by workshop
participants and committee members. Work ~ thence areas is expected to
increase understanding of the biology of reproduction with the hope That
increased knowledge will eventually lead to improvements ~ the practice
of IVFET in humans and ckher animals, or to advances in oontracepkion.
Rr search areas are listed here in summary form and apply bath to lower
animals and human beings unfed= specifically noted. me complete summary
of the workshop is contained in Chapter Two of the full report.
chic Science
Male Gametogenesis
o Definition of the role of cell adhesion molecules in interactions
between Sertoli cells and developing sperm cells.
O Understanding the function of differential protein synthesis in
different stages of sperm develcpment.
— 7 —
o Determination office role,of pa~crine factors incl~i~
fibr~last grew factor, Stalin C, epidermal grchrth factor, and
ir~rl~kin-1 on the ~velc~: arm cliffer~iation of male gamete.
O Structural analysis to identify normal arm abnormal Opens and the
develc~rent of marker'; for a~r~1 sperm.
0~ Ur~tar~ir~ of we bi~istry of Berm capacitation.
Fee Ga~genesis
o Analysis of the effects of ~vvulation or hormonal stimulation
p~x:ols on He develc~nt and maturation. His work Child also
ermine cliff~rKxs been species.
O Develc~nt of ways to marry of; in vitro.
O IrIvestigation of ways to naturally stimulate Byte and
follia~ar development.
O Investigation into the biodh~nistry of Tneiotic arrow and the
factors, such as cyclic Am, purines, Scion, and ma~ration-prcr~ing
factor, that may mediate this process.
o Devel~nt of ways to produce or synopsize hones frmn
non-h~nan primates to be used in ovarian stimulation.
O Definition of the role of Croatian estrogen In ocx~e maturation
and ovulation are the interactions been estrogen and paracrine factors
incl~ir~ fibrdblast ant ppidermal Huh factors, insulin-like! growth
factor, transforming growth factor, and ir~ibin.
O Definition of the point at which offs become sensitive t:o
factors that influence their development.
O Elucidation of ache pro that underlie oocy~ce depletion, to
determine By cables are lost at a predictable rate ~roughaxt life.
O Investigation into ways to augment natural hormone rml-A-~.
o Investigation into the biochemistry of protein synthesis and
modification in ovarian calls.
Fertilization
.
0 Investigation into the biophysics of m=1l membranes as it relates
to sperm and egg interactions at fertilization.
— 8 —
0 Confirmed irnrestigation to identify the germ; for zone proteins
in variants sp~ies, especially hogans.
O Earth delineation' of Me role of zone proteins, Medially ZP2
are] ZP3, In Sperm birding.
O ~star~ of ~ bi~istry of the modification of zeta
proteins in preventing popery.
O Elucidation of Me Mogul ar mirier of antibody formation
to zone proteins arm ~ r Forcible ale in c~r~tra~ive strategies.
O Definition of Me bi~emi~a' Mania of the cortical reaction
the egg arm the effects of this reaction on zeta proteins.
O ~ination of the ~ysiologi~a1 significant of germinal
vesicle breakdown and the bi~ist.~ of sperm urinate decorxiensation.
o Definition of the molecular events associated with formation of
the male and female pronuclei.
O Definition of the molecular events *tiring zygote formation and
the first cleavage.
Preimplantation Deve~gement
o Definition of The metabolic requirements of early embryos at
different stages. -
0 Determination of embryonic gene expression.
o Assessing the potential of individual embryonic cells and
defining the point at which embryonic calls are committed to particular
fates.
0 Identification of substances produced by early embryos that
signal changes in the uterus prior to implantation.
O Improvements in embryo multiplication and embryo splitting,
especially for food producing animals.
Implantation
o Definition of the biochemical events that make the uterus
permissive to implantation.
_ 9 _
o Definition of the factors rearm by embryos that cause
trial changes at the since of i~plar~ation.
O Identification of the role of ~ry~r~ factors
suppressing the ire responses of me Other.
O Isolation am analysis of Stan release by Serial
delis and ~ r effects oat IBM;.
O Continue work with In vitro navels of Man inplantati~ to
sway the biochemists and ~i~ of ~ry~anetrial interactions,
especially the rule of extra~lular matrix proteins arm the bic~nistry
of to - `iblast invasion of ~ er~a~rium.
T~ic~ ~
0 depraved cry~p~servation te~niq~, incoming freezing arm
thawing protocols for eggs arm embryos.
o Improved resolution of ultrasonography for localization and
nonInvasive harvest of oocytes, eggs, embryos--would have particular
usefuinRss for non-human primates and food prosaic mg animals.
O Development of new couture media and methoic for in vitro
maturation of oocytes.
O Development of safe methods of biopsy of early embryos for
pre~mplantation diagnosis of genetic dic-~cpc.
Clinical Research Opportunities
lee founding areas are those In which a ooordinated data collection
effort across IVAN centers weld help improve the quality arm
success rate= of IVES nationally arm, possibly, internationally.
O Evaluation of hormonal stimulation protocols in teens of Or
of oopytes }vested, quality of oocytes, arm rate of fertilization
s~c~cc .
o Documentation on the incident_ of abnormal implantation rates in
IVFET practice and correlation of incidence with particular stimulation
Pal ad.
O Collection of information regarding the incidence of abnormal
zygotes and embryos, failed fealty ization, and developmental arrest of
embryos.
O Analysis of data pertaining to synchronization of embryonic stage
with endcmetrial stage and development of methods to improve
synchronization.
o Collection of information on sharing of spare eggs and arres teed
embryos for research purposes.
— 10
Elusions and ~atiorm
Developing Beards Polisher
Tack of a Mania for dealing with ethical clisag~ement aver ache
use of embryos ~ losers he sled the rate of progress In ram }by,
In effect, placing a moratoria on He `~ of farad furls for eight
year';. This h?= had undesirable results: Be human clinical practice of
Iv~r is To effective En it might have been had reseal pi at
a fester pace; other socially~irable goals such as improved
con Erosion, better nines to preserve endangers Bier;, and Are
c=;t-effective methods of producing food have develc~ed at a pace sicker
Can c~timal.
me recent aft of the Biro—teal Advisory C~nitt~ by the
Bic~i~a' Ethics Bard, to report to Era by November 1990 cm embryo
issues, cc~c3 be a step End a solution. Ike cranmi~
applaud the intention to revive ache Ethics Derisory Board of
lit of Health and Ran Ser~ri~c to rule on the ethical
adoptability of red relating to human embryos, Rich is Bill
before federal furring of sum a rearm Grit can be consign.
However, until these go ~ fully fictional and straw evicler~ of
pros, their impact must remain In question.
If these groups can an leadership roles In resolving the
difficult issues of reproductive r~, arx] develop guidelines for
~ a ~ that are teas ~ on information provided by sci ~ x, and on
concepts that a ~ ethically a ~ ble to society, research in
reproduction will be able to move forward. But if these grcup6 become
paralyzed because of political considerations or an inability to develop a
framework for the resolution of differences of Opinion, another
organization should take over the role. The committee recommends that, if
the grc ups currently being formed fail to come to conclusions concerning
embryo am fetal research. a non-govarn=ental organization should be
established to develop guidelines for embryo and fetal research that are
based on the Ret advanced knowledge that science can her. and with
scrims consideration of ache expr~d values of society. Ihe group
shculd be cc of individuals with expertise in the relevant
scientific disciplines, representatives of Be lay public, and exerts In
the legal, ethical, and social issues. He organization shculd be housed
an institution that would allow it to c~rxtuct its deliberations free
from any undue pressures fern political and special interest cargos. A
Eel for such activities can
Authority of Goat Britain.
found in the Voluntary Licensing
— 11 —
Relic science Formations
me rammer arm range of topics include in me relearn agenda
indicate the exciting po~ial for Rive scientific exploration.
me cammi~ee believes At fatal Farm ~ enhance me Eric
scier~e formations of repr~:ive biology ~d be stimulated and
Sparta. this incur sties of human beings, laboratory animal
dels, and foa3=pr~ducing animals. ~ e kr ~ ledge that ~ id be generated
is fundamental to an understanding of how to reverse infertility, to new
approaches in the area of contraception, and to increasing the world's
food supply.
It is important that male as well as female reproductive biology be
studied and that investigators make lace of some opportunities that are
largely ignored tc day. mese opportunities occur as a result of clinical
activities as well as research activities.
me ccmmitt== reccrmen~s that a vigorous program of funding for a
basic science agenda in reproductive biology be maintained in a
coordinated fashion by an appropriate office In the National Institutes of
Health.
Applied Research
Research needs to be stimulated cone rning technologies And In
medically assisted conception in food producing animals and in human
beings. Lack of support in these areas is leading to inadequate
scientific underpinnings for safe and effective clinical ~pn~ctice. Art
example of a technique used, but not carefully evaluated for possible
detrimental effects, is freezing eggs or zygotes. Further experiments
should be conducted to Chic the effects on safety and viability of this
technology which is standard practice in many [VFET clinics. Other areas
of technology that need to be developed include 1~= invasive ways to
retrieve oocytes, ways to mature oocytes in vitro, and ways to accpcc the
quality of spermatozoa or eggs to be n=~ for fertilization.
The committee recommends that applied research into technologies used
in medic~lly-assisted conception be undertaken to provide a firm
foundation for the safe and effective practice of in vitro fertilization
and embryo transfer. Such applied research should be coordinated by the
appropriate office at the National Institutes of Health.
Clinical Research Opportunities
Perhaps the most obvious mussed opportunity is the failure to learn
from the diverse experiences of the approximat=1y 160 clinical programs
that provide IVFET. In addition to scientific questions, there are
_ ~ _
questions to c30 with the organization of clinics and ~e ~ of
Inures, Me answers ~ which ~d enable practitiar~; to work Ire
effectively, arm polity Mars to make decisions on the Isis of the best
avail able information.
Clinical IVFEr chances can prc~vide unique Opportunities for important
s ~ ies. For example, human oo ~ ; ~ at fat to fertilize in vitro cculd
be used to investigate the pbencmenon of fat ed fertilization. Research
that seeks to understand the basis of reproductive failure, and its
relationship to hyperstimLlation should be encouraged. Coordinated
studies utilizing the Marc of material and experience frmu rVFET centers
could begin to answer these and other questions.
me committee applauds the activities of the various prof-=cicnal
societies that have issued n ~ binding stat~n~cs about the quality of
practice of IVF. The American Fertility ~ ciety has also provided a
voluntary registry for centers.
The committee believes that a mechanism is needed to monitor and
evaluate clinical practice so that existing information that is relatively
easy an] in expensive to collect can be disseminated. This would enable
clinicians to build on the broadly heaps experience of the community and
help ensure that patients have access to information about developments in
IVFET and to well-informed physicians. The committee recommends that a
mechanism for mwlti-centered data collection be established to monitor and
evaluate human and veterinary practices of medically assisted conooption
in order to imp ~ e the safety, effectiveness, and quality of clinical
practice. A cooperative group composed of the Mel ~ nt profe~ciona,
societies should be established to fund and initiate data collection under
the direction of an inter-society council composed of representatives of
each participating organization.
Improving Communications
The IBM Workshop on Medically Assisted Conception brought together
researchers from basic science, clinical practice, and animal sciences.
The resulting interaction was viewed as extremely helpful by investigators
face each of these communities. The committee recommends that a mechanism
(or multiple mechanisms) be found for fostering continued communication
between researchers in diverse areas of reproductive science. m e
initiative should come both from NIH research ado mistrators who cculd
sponsor additional workshop opportunities, as well as from the
professional societies, either individually or through an ~ntersocie~y
council.
— 13 —
REGENCY
Anerican college of Obstetricians arm Gemologists. 1986. Emit Issues
~ mean In Vitro Fertilization arm Embryo Placerent. CXamni~ on
Ethics AGOG Unit Opinion Namer 47. Walton, D.C.
t of Walsh, Formation and Welfare. 1979. HEW Short of
Involving Oman In Vim Fertilization art Embryo Transfer. Part
arm Oor~clusions. May 4. Ship, D.C., U.S. Gcr~rerrment Printing
Office.
Fertilizer and Sterility. l98Sa. Anvils Fertilizatior~ryo Transfer In
the United Static: 1985 arm 1986 Results flora the National IVF/Er
P - ivory. 49(2) :212-215.
Fertili~rar~Sterili~r. 1988b. Ethical considerations of the row
r~pr~ctive theologies. py the Ethics Remittee (1986-7) of the
American Fertility &'cie¢,r In light of Instruction on the ~ t for
Human Life in its Orig ~ and on the Dignity of Procreation issued by
the Congregation for The Doctrine of the Faith. Feb;49(2 Sup pi
1):I-7S
Fertility and Sterility. 1986. Ethical Considerations of the New
RRprc~uctive Technologies. The Ethics Committee of The American
Fertility Society. Sep;46(3 Suppl 1):IS-94S.
First, N.L., Critser, E.S., and Robl, J.M. 1985. Boving Embryo:
Development, Cloning, Sexing and Transfer of Genes for Immunology of
Reproduction and Contraception, P. Talwas, ed. FUsevier, 1985.
Fuchs, V.R. and Perreault, L. 1986. Expenditures for
Reprc~uction-Related Health Care. Journal of the American Medical
Association. Vol. 225, No.1. January 3:76-81.
Journal of the American Medical Association. 1988. IVF Registry Notes more
Centers, More Births, slightly Improved Odds. 259~13~:1920-1921.
National Institutes of Health. Undated. Inventory and Analysis of Federal
Population Research. Fiscal year 1986. U.S. Department of Health and
Human Services, Public Health Service, Nations Institutes of Health.
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