Il social freezing : la posizione dell ESHRE

Transcript

1 Il social freezing : la posizione dell ESHRE Anna Pia Ferraretti - Luca Gianaroli S.I.S.Me.R - Bologna La preservazione della fertilità Padova 29 Marzo 2014

2 Definizioni Social freezing Oocyte cryopreservation for non medical reasons Oocyte cryopreservation for age-related fertility loss

3 La posizione dell ESHRE Aspetti Socio-culturali e demografici (social facts ) Fatti nella PMA ( evidenza) Aspetti Etici

4 Progressivo ritardo con cui si arriva al primo figlio: Europa 4

5 Ritardo con cui si arriva al primo figlio Dopo i 30 : la maggior parte di donne che iniziano il progetto riproduttivo dopo questa età fanno un solo figlio. Dopo i 35 anni : aumenta rischio di infertilità involontaria Ritardo

6 Età al matrimonio e rischio infertilità Menken et al, 1986 Età (aa) Infertilità % % % % >40 64%

7 In EUROPA: MENO FIGLI PER DONNA Francia Grecia Italia Portogallo Spagna

8 Riduzione del tasso di fertilità Rivoluzione del ruolo delle donne negli ultimi 30 anni: desiderio crescente di autonomia, personale ed economica. Si manifesta con l aumento dell istruzione e la partecipazione al mercato del lavoro. 8

9 Nuovo ruolo della donna: Istruzione % di donne fra i 30 e 34 anni con titulo di studio universitario IT 9 Fonte: Eurostat

10 Nuovo ruolo della donna: Occupazione Tasso di occupazione femminile (Svezia, Danimarca, Germania, UK, Francia, Italia, Grecia, Spagna e Portogallo, Europa27) 10

11 Tasso di fecondità totale Numero di figli per donna Francia Italia 11 Fonte: Eurostat

12 Numero medio di figli per donna per area geografica - Anni Numero medio di figli per donna * 2009* ITALIA 1,35 1,37 1,42 1,41 Nord 1,38 1,41 1,45 1,46 Centro 1,31 Mezzogior 1,33 no Sud 1,33 1,32 1,41 1,38 1,34 1,36 1,35 1,35 1,36 1,35 1,32 1,36 1,37 Isole 1,32

13 Nuovo ruolo della donna Rivoluzione del ruolo delle donne negli ultimi 30 anni: desiderio crescente di autonomia, personale ed economica. Negli ultimi 10 anni, la fecondità e il nuovo ruolo della donna, sono legati in direzione contraria rispetto al passato: dove la donna è cambiata di più, la fertilità è più elevata. Dove i ruoli di genere e la strutture familiari tradizionali sono ancora la norma, le donne hanno meno figli (soprattutto secondi o terzi figli) Modelli di politiche pubbliche incentrati ancora su un idea tradizionale di famiglia e di divisioni di ruoli tradizionali hanno un effetto paradosso di ridurre il tasso di fertilità. 13

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16 La posizione dell ESHRE Aspetti Socio-culturali e demografici Fatti nella PMA (evidenza) Aspetti Etici

17 ART World collaborative report ( ICMART) Cycle/ year Estimation million cycles / year babies born per year - Total babies born > 5 millions

18 Età pazienti che si sottopongono a PMA (Dati 2009 dei registri internazionali) % di cicli %

19 IVF/ICSI in Europa Distribuzione per età

20 Age and outcome in the world PR/aspiration-2009 Eta (anni) % di gravidanze a termine 40 7%- 10%

21 USA

22 ART and age > 40 years Women > 40 should have access to infertility treatments?

23 Example Age of the women usually determines access to infertility treatments Germany Germany Reimbursement level Italy² Italy Spain¹ Spain UK¹ UK 50%* 100% 99% Interventions reimbursed IVF/ICSI IVF/ICSI IVF/ICSI IVF/ICSI IVF/ICSI Which patients have access <41 yrs - <41 yrs <40 yrs *private insurance: 80% - 100% 100% France² France 100% <43 yrs

24 Number of egg donation cycles in Europe and USA

25 Oocytes donation (PR/ET)

26 Problematiche della ovodonazione Reclutamento Donatrici Ricevente Ovociti non geneticamente propri

27 Legislazioni in Europa : divieto alla donazione di ovociti Italia Germania Svizzera Austria Turchia Croazia Donazioni di ovociti è la causa più frequente di migrazione per problemi riproduttivi

28 La posizione dell ESHRE Aspetti Socio-culturali e demografici Fatti nella PMA ( evidenza) Aspetti Etici Aumento della efficacia e sicurezza della crioconservazione di ovociti grazie alla vitrificazione

29 Non medical gamete s cryopreservation for men and women Male : little debate Female: more debate Less decline in fertility.ovarian reserve Increased genetic risk for offspring (less) few «principled» objections (funding) challenges. Age-increased genetic risk for offspring

30 La posizione dell ESHRE Aspetti Socio-culturali e demografici Fatti nella PMA ( evidenza) Aspetti Etici

31 Female age and fertility : messages Professions in the field of human reproduction should promote and contribute to efforts aimed at raising awareness of agerelated fertility decline The first message must remain that women s best change of having an healthy child are through natural conception at a relative early age. However, in the light of social facts and new scientific developments, oocytes cryopreservation should also be available to improve prospects of future child.

32 Human Reproduction, 2012 Oocyte cryopreservation for age-related fertility loss ESHRE Task Force on Ethics and Law, including, W. Dondorp1,*, G. de Wert1, G. Pennings2, F. Shenfield3, P. Devroey4, B. Tarlatzis5, P. Barri6, and K. Diedrich7

33 Social freezing is in line with the ethical principles Beneficence Non maleficence Autonomy Justice Arguments against allowing this application of the technology are not convincing and imposing one view on others is morally unacceptable

34 Beneficence Medicine understood as preventing and curing disease and caring for the hill The first objections : social freezing fall outside the scope of the medical model

35 Objections to social freezing Fertility preservation is a typical instance of medicalization : the tendency to seek medical answers to societal problems. Offering fertility preservation to healthy women will lead to undermining efforts aimed at addressing the societal cause of the high maternity age, thus only reinforcing and perpetuating the problem.

36 Age and fertility The social facts in the field of reproduction:. Voluntary or involuntary postponement of childbearing is not a new phenomenon that only comes into play with the possibility to cryopreserve oocytes and it results in : - increased involuntary childlessness - increased request of IVF in advanced age - increase request of egg donation and need of CBRC

37 ART and age The medical facts in the field of reproduction : - ART does not cure infertility ( women remain infertile after ART pregnancy) but overcomes the factors inducing infertility - Among the factors related to fecundity, age is the most important single factor - We already treat socially induced infertility ( ART in age+, egg donation) - Stored «younger», «better quality»( with If onegametes accept will to be treat deliberate postponers health theone mother and the child ) them to withbenefits IVF orfor ED, should also help save their oocytes at an early age.

38 Oocyte freezing benefits ( for mother and children) Vs IVF in older age Vs Egg donation - more effective - own s genetical child treatment - lower rate of chromosomal abnormality in the offspring - no donor information dilemma

39 Beneficence ( medicine understood as preventing and curing disease and caring for the hill) Social freezing or freezing for non medical reasons is an health- related choice

40 Autonomy ( respect for reproductive autonomy) Motives for fertility preservation : Women who want to have child but are still without a partner at the age of 35. Women who deliberately choose to postpone childbearing while giving temporary priority to other life plans and goals such as build-up a career. Fertility specialist should refrain from passing judgment on a woman s motives for postponing childbearing and should leave to the women themselves to make their own informed decision about the nedd of fertility preservation.

41 Social freezing and respect for reproductive autonomy Benefits for the autonomy of the mother: Oocytes cryopreservation at an early age as a form of prevention for age related fertility loss Lower dependency on the use of donor oocytes and on the need of less effective IVF in older age Welfare of the child: - lower rate of chromosomal abnormality - no donor information dilemma

42 Justice Given the many demands calling for simultaneous realization in a relatively short period of their life ( new female roles in modern societies), many women who want to have children feel to be under considerable pressure. The option of oocyte cryopreservation may give them more breathing time to combine motherhood with other life plans ( like is for men)

43 Objections to social freezing The primary role of the women is reproduction ( traditional and religious presuppositions ) Against nature ( naturalistic presuppositions)

44 Diritto alla Salute Riproduttiva Articolata come concetto nella Conferenza Internazionale del Cairo sulla Popolazione e Sviluppo del 1994 ( ripresa da Conferenza di Pechino nel 1995 ) Inserita dall ONU tra gli Otto Obiettivi di sviluppo per il nuovo Millennio Definita come Stato di completo benessere fisico, mentale e sociale che non è solo la assenza di malattia, ma che riguarda tutte le varie fasi del sistema riproduttivo e delle sue funzioni (sia femminili che maschili). Implica quindi che ciascuno abbia la possibilità di riprodursi e la libertà di decidere se, quando e quante volte, e senza rischi per la madre ed il nascituro.

45 Non-maleficence ( first do no harm) The medical procedure to obtain oocytes ( ovarian stimulation and egg retrieval) are not entirely without risks of complications. However the risks are extremely small and some (OHSS) almost fully avoidable when no pregnancy occurs. Health of the future child : so far there is no evidence of increased risks for the children born from oocyte vitrification, but the number is still low. More data on short and long-term follow-up of children is needed. Welfare of the child: lower rate of chromosomal abnormality no donor information dilemma

46 Additional benefits ( for individual and society) Left over oocytes from young women ( either because they reproduce naturally at later age or because they decide not to have children) can be used for donation to other infertile women or for scientific reasearch.

47 Recommendations Centres offering this service must have the necessary expertise to employ oocyte cryopreservation efficiently. Fertility specialists should be careful not to raise false hopes. Women interested in oocyte cryopreservation for age-related fertility loss should be told that their best chances of having a child are through natural reproduction. Interested women should be adequately informed about all relevant aspects of the procedure for obtaining the oocytes, should be provided with a personalized and evidence-based estimate of the number of oocytes (and cycles) they would need for the highest possibility of pregnancy, but success is not guaranteed. Interested women should be informed that oocyte cryopreservation is a relatively new technology, that the number of children born from such oocytes is still limited and that long-term safety is still to be proved.

48 Specific ethical considerations under debate Age limits for preservation (35 yrs?) and use (50 yrs like for egg donation? ) Coverage : Who should pay? Women? Society? Which part of the procedure? ( storage/ use in IVF) Donation of left-over oocytes

49 Recommendations As data about long-term safety are still lacking, centres also have a responsibility to contribute to the collection of these data. More data are needed about the psychosocial aspects of fertility preservation for ovarian ageing, including women s motives for choosing this option, what it means for women to have a stored reserve and the choices they make regarding the use of this reserve.

50 ESHRE special interest groups (SIGs) New SIG : Socio-cultural aspects of (in)fertility To gather evidence and increase insight social freezing ( as a new development symptom of societal changes) and its possible impact on mentality and attitudes in the population