Evaluation of the Biomedicine Agency
On 29th January 2008, the Biomedicine Agency drew up a balance sheet of the
medically assisted procreation (MAP) in France. In 2005, 19,026 children
were born with a MAP, which represents 1 child out of 40. 1,293 of them were
conceived with a third donor. In other respects, at the end of 2005, we
registered 141,460 frozen embryos conceived in vitro for 38,274
couples; 58% of them were subject to a parental project. The success rate of
a MAP, in terms of births, is still around 20% per attempt.
Oocyte and sperm shortage
The Biomedicine Agency is worried about the “shortage” of gamete donation
which generates sometimes the travel of some couples abroad. With this
shortage, François Thépot, professor of embryology and cytogenetics and
assistant to medical director of the agency, indicates that it authorised
the oocyte direct donation and not obligatorily frozen. An information
campaign will be launched in spring for the oocyte donation and in autumn
for the spermatozoid donation.
Extending the access to MAP?
Today, the “physician for infertility” are faced with new demands coming
from non planned social situations, due to disruption of the traditional
family, to “the improvement of techniques (…) which opens the
field of possibilities” and to “a different apprehension of the
position of the patient who, particularly since the law of 4th March 2002,
has more words to say”, explains Nicolas Foureur, physician in the
clinical ethics Centre in Paris. These new demands (late, coming from
homosexual couples, single women, from couples in which the man is a
transsexual…) rise news questions regarding bioethics laws which governed
the “treatment” of heterosexual couple sterility. Today, legal texts do not
always clearly answer this question. The law of 6th August 2004 foresees
that the MAP is accessible to a couple formed by man and woman, alive and in
age to procreate. How to determine the limit age, for instance? Since a few
years, an increasing number of men ask to freeze their sperm around 60 or 65
years-old, to “have a second life”. What to answer? For some physicians,
like René Frydman, “the dominant element is the risk that presents a
possible pregnancy, particularly after a certain age”. “As for the
rest, I refrain from entering in what makes the desire of a child.”
Others ask the opinion of the clinical ethics Centre or refer to a collegial
decision. The question concerning the access to medically assisted
procreation has to be discussed during the revision of the bioethics laws,
foreseen in 2009.
Setting an approval?
Sophie Marinopoulos, psychoanalyst at the University Hospital of Nantes,
estimates that “we will not have the choice to oppose such an enlargement
because it is already possible, beyond the boundaries, for who wants it, to
obtain a MAP”. Then she proposes to set a form of approval, like for
adoption.
Globalisation of the MAP
In other respects, in various countries, the gametes and all the MAP
techniques are freely sold, constituting a child market, already globalised.
There is a large number of examples: in the USA, sperm (USD 275,000 per
dose), oocytes (from USD 2,500 to 50,000, according to morphological and
racial criteria of the “salesman”) can be bought; in Ukraine, a surrogate
mother rents her uterus between USD 25,000 and 45,000… This market is
estimated to USD 3 billions per year in the USA, without taking into account
the rest of the world.
Should the MAP be financed?
Véronique Fournier, physician and director of the Cochin Centre for clinical
studies, interviewed by the newspaper La Croix on 29th January 2008,
wonders: “if we largely open the access to MAP, will this mean that the
society supports this opening and that it is ready to finance it?”. ”The
question is to know what it is “fair” to spend at the ethical level for the
MAP, compared to other health expenses.”
Sexuality and procreation
Since 1987, in the encyclical Donum Vitae, the Catholic Church was
worried about the dissociation between sexuality and procreation generated
by MAP. “By substituting a technical act to the embrace of bodies, we
pervert the relation to the child: this one is not anymore a donation but
something due”, explains Mgr Jean-Louis Bruguès, secretary of the Roman
congregation for catholic education.
Another dissociation denounced by the Church: the one of kinship, when we
resort to a third donor of sexual cells. Artificial insemination by donor
(AID) “prejudices the rights of children, deprives them of the filial
relation to their parental origin and can be an obstacle to the maturation
of their personal identity”.
Loss in value of the embryo
The Church warns against the loss in value of the embryo, due to embryonic
reduction and the use of “supernumerary” embryos. “All happen as if the
embryo which has no parental project has no value”, says Father of
Malherbe, professor of bioethics in the Cathedral School. Nevertheless, the
embryo is a fully human being and from his conception, “we have to
recognise the right of the person among which the inviolable right to life”.
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A recent study by P. Revidi and B. Beauquier-Maccotta,
child psychiatrists, one in the CECOS of Cochin, the other at Necker
Hospital, took stock of the actual situation of the medically assisted
procreation (MAP) and psychic problems it generates1. It proposes
orientations to understand the construction of the link within the new
totally or partially non-genetic filial status modes and tackles the psychic
pain due to sterility as well as the important stress and anxiety generated
by the resort to MAP (linked to techniques, waiting period, the fear to be
not adapted to the child and to major sexual disturbances induced by
technical restrictions).
Insufficient studies
International studies on the psychological development of children up to 12
years old are relatively reassuring and methodologically questionable
because they treat about few children and these are not directly assessed.
Gaps persist in the knowledge of the psychological development of children
at the adolescence and at the adult age. One of the fundamental problems to
assess will be the accession to the parenthood of these children and the
conflicts or questions that this development step could raise. It is
advisable to also assess the consequences of the oocyte and embryo
donations.
Secret of origins
The disclosure of the “secret of origins” is subject to a debate. Some
people reproach CECOS for preventing the children, who would want it, to
know the identity of the gamete donor they biologically come from. This
secret of origins would generate psychological pains. Nevertheless, the
requests from young people regarding CECOS to know the identity of the donor
are very rare (less than ten in Paris). The rate of disclosure by the
parents does not exceed 20% of children born by artificial insemination by
donor (AID), to protect the child and the father’s position. Finally, the
relationship between a psychological pain and the non-knowledge of the
identity of the donor is difficult to establish. The relationship between
the parents and the child can be at the origin of the problem. Others
reasons can also been researched. This question has to been dealt with
prudence.
1 - Revidi P.,
Beauquier-Maccotta B., Problématiques psychiques dans les aides médicales à
la procréation, EMC (Elsevier Masson SAS, Paris),
Psychiatrie/Pédopsychiatrie, 37-204-G-40, 2008 |
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From 31st January to 2nd February 2008, the first international congress
about human embryonic stem cells took place at the Genopole of Evry. This
congress was sponsored by the Genopole of Évry, the national institute for
health and medical research (INSERM), the conseil general of Ile de France,
the institute of stem cells for the treatment and study of monogenic
diseases (ISTEM), the university Paris-Sud and the French Association
against myopathies (AFM).
The researchers underlined the capacity of human embryonic stem cells to
multiply in hundreds of cell generation (from 100 to 500). Then it is not
necessary to immortalize these cells, this technique results in introducing
viral particles in the cells.
Most of the cell cultures were conducted using animal serum (usually foetal
calf serum), but this addition of animal proteins is incompatible with the
administration in human.
Now, various cultures can be performed in synthetic medium, under
development, in order to circumvent the obstacle.
Obtaining pure lines is long and difficult. Several very complex techniques
are implemented to isolate the stem cells in one embryo.
The reprogrammed cells (induced pluripotent stem cells – iPS) - like
Shinya Yamanaka’s (adult cells reprogrammed into pluripotent cells) – today
require the introduction of genes into the cells by introducing viral DNA,
which makes them clinically unusable. To do so, other means have to be found
to block the target genes. Regarding this point, everything has to be done.
No therapeutic study
If the therapeutic aspect of the human embryonic stem cells was omnipresent
during the congress, no study in man was presented. The only clinical study
presented was Marc Peschanki’s study on Huntington’s chorea, conducted with
human foetal cells.
For Philippe Menasché, the absence of results in man is linked to the fact
that it is only possible to work on human embryonic stem cells for two years,
in France (reminding that in Great Britain, the research on embryonic stem
cells is authorised since 1990).
One of the important characteristics of human embryonic stem cells is their
high carcinogenic power (teratomas), so much so that this characteristic is
considered as a quality criterion of the line. After the differentiation,
the removal of undifferentiated human embryonic stem cells is then a major
stake: two human embryonic stem cells in one million differentiated cells
are sufficient to trigger a teratoma.
The differentiation of human embryonic stem cells is still difficult to
obtain and arriving to a “useful” stage is not evident.
Finally, human embryonic stem cells raise problems of histocompatibility,
like any graft tissue.
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