All of the aforementioned ethical principles come up when considering the quandaries that arise during the processes involved in ART.  This list explores many ethical dilemmas, but by no means covers every one:

• What is the debate surrounding posthumous reproduction?
• Are we ever too old to receive treatment?
• What about the problem of multiple gestation?
• Genetic Discrimination -- Is our genetic information safe?
• Frozen Embryos -- What will happen to unused embryos?

Posthumous Reproduction
Once it became known that it was possible to cryopreserve (or freeze) sperm for later use, people began to implement this technology for many purposes beyond the sperm bank.  Today, the death of a husband or partner before procreation is less devastating for a wife or significant other because it is possible to procure sperm posthumously.   Techniques such as stimulated ejaculation, microsurgical epididymal sperm aspiration (MESA), or testicular sperm extraction (TSE) can be employed to procure sperm from a dead or brain dead individual.  Technology is also being developed so that ova may be cryopreserved as well.  These techniques are also very useful for couples where the husband is undergoing chemotherapy and wishes to preserve his sperm beforehand in case of sterility.  However, once they are used to bring the child of a dead partner into the world, the legal borders become very blurred.

• Many wives give birth to the children of deceased husbands in hopes that this child will be considered an heir.  However, a child born from conception and pregnancy after a father's death may not always be attributed to him for purposes of inheritance and legitimacy.

 
• According to a University of Pennsylvania Center for Bioethics, 14 clinics in 11 states had retrieved sperm from 45 dead males.  In these cases, the sperm must be harvested within 24 hours of death.  Not only is this a difficult time for a loved-one to make a rational decision about whether or not she wants the sperm of a dead husband to be harvested, but there is no informed consent on the part of the deceased spouse, which poses a problem in the case of performing a medical procedure.

 
• All of these issues also apply to cases in which a husband or partner conceives a child with the frozen ova of a dead wife or partner.  However, in these cases, the issue of surrogacy also plays a role.  Thus, in cases such as these, the questions of motherhood and rearing parents come up.

 
• The United States Supreme Court is clear that comatose individuals cannot be forced to accept life-sustaining treatments.  Can they be forced to contribute to life-creating ones?

• Existing law does not provide clear guidance on when, or whether, sperm should be retrieved after a man is incapacitated or dead.  In January of 1999, State Senator Roy Goodman of NY introduced a bill, now pending in the NY Legislature, banning posthumous sperm collection unless informed consent was given before death.  But until such a bill is passed, a wide range of conflicting precedents -- governing organ transplants, custody over frozen embryos and fetal tissue transplants -- are being consulted to provide guidance for this new means of parenting.
• Under the Uniform Anatomical Gift Act -- the organ donor law in each state -- a wife or other relative can donate the deceased's organs or tissue and can choose the recipient.  Technically, then, a wife could donate the sperm to herself. Thus, even if she wanted a child and her husband didn't, the existing law wouldn't protect his desires after death.

Oocyte Donation to Postmenopausal Women
The central ethical issue in this case is whether the interests of women and children are served by technology that allows women to conceive postmenopausally.  In many cases, a woman who has lost a child or who has never had a child will wish to have a child late in life.  There are mixed opinions on whether or not this is ethically sound.

THE ARGUMENTS:

• Pro

Those who argue that this technology should be made available to women cite evidence of societal practices, gender equality, and reproductive freedom to make their cases.  It is not uncommon in our society for grandparents to raise children and contribute meaningfully and powerfully to the child-rearing process.  If this is the case, then it is no different for a postmenopausal woman to give birth as well.

1)  Men are able to have children very late in life and so women should not be denied this opportunity -- that
      would be sexist and prejudicial, especially as women generally live longer than men. be sexist and prejudicial,
      especially as women generally live longer than men.

2)  Our society places the utmost importance on respecting the rights of individuals to make reproductive choices.
      Thus, a terminally-ill person would not be looked down upon for procreating even though he/she has a
      shortened lifespan.  Likewise, older women should be given this same opportunity.
 

• Con

Opponents of postmenopausal birth argue mainly that there is a "natural" limit in reproductive capacity that is intrinsic to being human, and to try to extend this limit is "unnatural."  Thus, if nature has taken the ability to procreate away from women of a certain age, there is a reason for it and there are certain risks involved in pushing mother nature past her limits.

1)  Parenting is highly stressful both emotionally and physically, and there is an age at which people are more fit to
     be parents.  Older women and their partners may not be able to meet the overwhelming demands of rearing a
     young child, or even a teenager.

2)  Children are also being successfully raised by teenage mothers, this does not mean that teenage pregnancy
     should be encouraged for physicians.

3)  In postmenopausal pregnancy a woman faces greatly increased medical risk of hypertension, diabetes, multiple
     gestation, preterm labor, preeclampsia and other complications associated with pregnancy and childbirth.
     There are no tests to detect the propensity of an older woman to develop hypertension.

4)  The possibility of multiple gestation as the result of IVF or GIFT also poses great ethical and physical
     difficulties.

Multiple Gestation

There are many situations in ART that call for administering drugs that cause superovulation (the release of a large number of eggs during the monthly cycle), and this often brings with it associated moral dilemmas.  Sometimes, when fertilization cannot be achieved naturally, a large number of eggs are deliberately released in order to provide greater probability of success for in vitro fertilization or GIFT. Suddenly, prospective parents may be faced with the problem of either what to do with the many fertilized eggs awaiting implantation, or how to deal with  carrying eight or nine fetuses.

A multi-fetal pregnancy creates a physical danger to both the mother and future children. The larger the number of embryos, the greater the likelihood that the pregnancy will terminate prematurely, leaving the babies in danger of physical and mental damage.  If some of the embryos are aborted the others stand a better chance of surviving, developing normally, and being carried to term. But, if fertilization is to occur in vitro, successful implantation often requires fertilizing many embryos, implanting a number of the healthy ones (not all will implant), and facing the problem of what to do with the "excess" others.

Current medical practice is to implement a multi-fetal pregnancy reduction (MPR). In this procedure (originally called selective abortion or selective termination), a needle is inserted into the mother's womb early in the pregnancy and, guided by ultra-sound, some of the fetuses are killed. It is impossible to "select" the most viable or healthy of the embryos at this early stage of the pregnancy, and the selection is indeed a matter of chance.  How this process effects the parents emotionally should also be factored in when thinking about the ethical implications of this procedure.  As with all other cases of abortion, even if the children that result from this procedure are everything the parents ever dreamed of, those fetuses that never came to term will always pose the question of "what if?"

CURRENT POLICY

The American Society for Reproductive Medicine issued new recommendations for embryo transfer in IVF procedures.  The ASRM Practice Committee report recommends that in patients with the most favorable prognosis, no more than two high-quality embryos should be tranferred during IVF.  The number of embryos recommended to transfer increases for patients with worsening prognosis because they have a higher likelihood of miscarriage.

Genetic Discrimination

Advances in medical technology help to predict genetic predisposition for disease; however, results of genetic tests can also be used for purposes of discrimination.  The more we are able to tell about a person's genetic makeup, the more we are able to discriminate against.  In the past, genetics was focused on discovering those single-allele genetic diseases that could be diagnosed with certainty.  These are diseases like Huntingtonís, Cystic Fibrosis, certain forms of Alzheimerís, Sickle Cell Anemia, and Duchenne Muscular Dystrophy.

Today, we have reached a point where we are able to test for multiple-allele genetic diseases that are much more common, such as asthma, arthritis, diabetes and many forms of cancer.  The difficulty with these tests is that they do not give a 100% positive result, but instead show the probability of developing the disease.  Many of these diseases have either no treatment or, in the case of cancer, very expensive treatments.  Thus many patients are reluctant to get tested for these more common diseases for fear that the results will be used against them.  Many insurance companies or employers will discriminate against people based on how much their conditions might cost many years down the line, even if they are healthy today.

Many infertile couples would be able to bypass this issue by using pre-implantation genetic testing to determine whether a fetus has a genetic defect and only implanting those fetuses that were unaffected.  A routine practice with IVF is to create multiple embryos in a lab, perform biopsies on them, and then implant only those with no indication of a genetic defect. This practice has elements of eugenics, the science of creating or breeding genetically superior humans. Eugenics was what spurred the genocide of the Holocaust.

Discriminating against disabled embryos is ethically murky because the severity and nature of a genetic disease cannot truly be realized until a person has been allowed to develop.  However, if parents are going to worry about genetic defects of fetuses conceived using donor eggs and sperm, then donors should be screened before they are allowed to donate.  That, in itself, is a form of discrimination.  It's a never-ending cycle.

CURRENT POLICY

• On the topic of genetic discrimination, President Bill Clinton signed an Executive Order that said that the federal government and its agencies may not use genetic testing in any employment decision.  It also said that federal employers may not request or require that employees undergo genetic tests of any kind and they are strictly forbidden from using genetic information to classify employees in such a way that deprives them of advancement opportunities.

 
• Senator Daschle and Reperesentative Slaughter have also introduced bills in the Senate and House respectively called the Genetic Non-Discrimination in Health Insurance and Employment Acts.  This legislation extends the employment protections contained in the President's Executive Order to all private sector employees and also ensures that people in all health plans will have full confidence that genetic research will be used solely to improve and never deny them care.

Frozen Embryos
Often couples will leave the "extra" embryos that result from the early stages of IVF treatment cryopreserved for later use or will choose to donate them to other couples.  This is a good idea in theory, but many couples will leave their embryos stored indefinitely and this brings up the ethical question of to whom these embryos belong.  Often a couple will leave the frozen embryos in storage for inordinate lengths of time.  In these cases, do the fertility programs have the right to dispose of the embryos?  Also, what guidelines exist for the donation of frozen embryos to other couples who are attempting to conceive?

Disposing:

• Often couples have not stated their wishes and cannot be contacted to make their wishes known.

 
• A program's willingness to store embryos does not imply an ethical obligation to store them indefinitely.  A couple that has not given written instruction for disposition, has not been in contact with the program for a substantial period of time, and has not provided a current address and telephone number cannot reasonably claim injury if the program treats the embryos as abandoned and disposes of them.

 
• There is also the ethical quandary of disposing of material that has the potential to become human life.  Although the embryos are simply frozen matter at the point at which they are being disposed, if implanted in the right environment, they can grow into human beings.  Does that make them different from other biohazard material?  Some would say yes.

 
• The Tennessee Supreme Court, in a dispute over frozen embryose that had been created through in vitro fertilization, held that a divorcing man's right not to be a father allowed him the right to order that the frozen embryos he helped to create be destroyed. He argued that his changed circumstances -- divorce -- made his previous consent to in vitro fertilization invalid.

• screened for infectious diseases and blood typing and
• provide a medical history.
• give up the right to control the embryo once it comes up for donation