Q1] A married couple of 40 years of age experience difficulty in conceiving natural and

after a year of unsuccessful attempts they decide to seek medical advice. Upon consulting
a fertility specialist, the specialist recommends a medical procedure of fertilizing an egg
with sperm outside of the body in a laboratory setting, followed by implantation of the
embryo. However, Kriza is hesitant due to cultural and religious beliefs that influence her
views on reproductive technologies. Outline the cultural, religious or ethical
considerations associated with the medical procedure suggested in the above scenario.
Give a step-wise detailed account on the medical procedure and include a note on the
possible risk and complications involved. Add a note on potential benefits and drawbacks
of pre-implantation genetic testing.

Since the couple belongs to an age group where the chances of conceiving naturally are low,
Kriza and her partner may have been suggested to go for artificial reproductive techniques
(ART) such as in-vitro fertilisation (IVF) or Zygote intra fallopian transfer (ZIFT) which require
fertilization to occur outside the body followed by implantation inside the body. However, there
are several cultural, religious and ethical beliefs on such techniques.

Cultural Beliefs and the Use ART

Cultural beliefs play a crucial role in determining attitudes toward in vitro fertilization (IVF).
Different cultures perceive fertility, assisted reproductive technologies, and family structures in
unique ways, affecting the acceptance, accessibility, and ethical considerations of IVF.

Europe

In Europe, cultural acceptance of ART varies significantly. Countries with a higher proportion of
Protestants tend to have increased ART utilization, with Protestant-majority countries showing
a 25% higher take-up rate. Conversely, regions with strong Catholic or Orthodox influences may
exhibit more conservative attitudes toward ART, potentially leading to lower utilization rates
(Präg & Mills, 2017; University of Oxford, 2017).

Middle East

In the Middle East, cultural and religious beliefs have historically posed challenges to the
acceptance of ART. Islamic perspectives on ART vary, but a general consensus among
contemporary Sunni scholars permits IVF procedures involving only the husband and wife,
conducted within the bounds of marriage. The introduction of a third-party donor is prohibited,
as it is considered equivalent to adultery. These religious frameworks influence the availability
and practice of IVF in Muslim-majority countries (Gad El-Hak, 2003).

Asia

In Asia, cultural norms and legal frameworks significantly impact ART access. For example, in
China, single women are prohibited from accessing fertility treatments like egg freezing,
reflecting societal expectations that prioritize childbearing within marriage. This legal
restriction underscores the influence of traditional cultural norms on reproductive rights and
ART utilization (Wee, 2024).

United States

In the United States, cultural beliefs and legal considerations intersect to influence ART
practices. Some Christian couples face ethical dilemmas with traditional IVF, as it often involves
creating and potentially discarding excess embryos, which they view as human lives. This has
led to the development of alternative practices, such as minimal-stimulation IVF and no-discard
policies, aligning reproductive technologies with specific religious convictions (Zhang, 2024).
Additionally, legal decisions granting embryos legal rights in certain states have introduced
complexities, potentially restricting access to IVF and influencing clinical practices (Ducharme,
2024).

Religious Beliefs and the Use ART

Religious beliefs play a crucial role in shaping attitudes toward in vitro fertilization (IVF) across
different faith traditions. The Catholic Church opposes IVF due to concerns about embryo
destruction and the separation of procreation from marital intercourse (Centre for IVF, 2024).
Protestant views vary, with many denominations supporting IVF as long as it respects the
sanctity of life (Centre for IVF, 2024). In Islam, IVF is permitted only within marriage, while
third-party donors are strictly prohibited (Centre for IVF, 2024). Judaism generally supports IVF
as a means of fulfilling the commandment to "be fruitful and multiply," though opinions on
embryo disposition and donor gametes differ among denominations (Centre for IVF, 2024).
Hinduism views IVF favourably as a way to fulfil one's dharma, while Buddhism remains neutral,
focusing on ethical considerations like non-harm (ahimsa) (Centre for IVF, 2024). Sikhism and
Jainism emphasize ethical reflection and alignment with non-harm principles, with Jainism
particularly concerned about potential harm to embryos (Centre for IVF, 2024).

Ethical Considerations

Autonomy and Informed Consent: Respecting patient autonomy requires comprehensive

informed consent processes. Prospective parents must be fully aware of the medical, legal, and
ethical implications of ART procedures to make decisions aligned with their values (American
Medical Association, 2018).

Embryo Ethics: The handling of embryos presents ethical dilemmas, particularly concerning
their creation, selection, storage, and potential destruction. These issues are deeply intertwined
with personal, cultural, and religious beliefs about the moral status of embryos (PubMed
Central, 2016).

Third-Party Involvement: The use of donor gametes or surrogates introduces complexities

related to parentage, identity, and the rights of all parties involved, including the resulting
children. Ethical considerations include the potential for exploitation and the child's right to
know their genetic origins ([Link], 2014).

Epigenetic Concerns: Emerging research into the epigenetic effects of ART raises questions
about potential long-term impacts on offspring. Balancing the desire for parenthood with the
principle of non-maleficence requires careful consideration of these possible risks (NHMRC,
2023).

Steps involved in In-Vitro Fertilisation (IVF)

1. Ovarian Stimulation – Hormonal medications stimulate the ovaries to produce

multiple eggs, increasing the chances of fertilization (American Society for
Reproductive Medicine.
2. Egg Retrieval – A minor surgical procedure called follicular aspiration is
performed under ultrasound guidance to collect mature eggs from the ovaries.
 3. Sperm Collection and Preparation – A semen sample is collected from the
male partner or a donor, and the healthiest sperm are selected for fertilization.
4. Fertilization – The eggs and sperm are combined in a laboratory dish for natural
fertilization or injected directly via intracytoplasmic sperm injection (ICSI)
(Centers for Disease Control and Prevention.
5. Embryo Culture – Fertilized eggs develop into embryos over several days, and
their growth is monitored to select the healthiest ones for transfer.
6. Embryo Transfer – A selected embryo is transferred into the uterus using a thin
catheter, typically without anaesthesia.
7. Luteal Phase Support – Hormonal medications, such as progesterone, are given
to support implantation and early pregnancy.
8. Pregnancy Test – About two weeks after embryo transfer, a blood test
determines whether implantation was successful (Mayo Clinic, 2023).

Risks and complications

 Ovarian Hyperstimulation Syndrome (OHSS) – The use of hormonal medications

to stimulate the ovaries can sometimes lead to OHSS, causing swollen ovaries,
abdominal pain, nausea, and, in severe cases, blood clots or fluid buildup in the
abdomen (ASRM, 2022).

 Multiple Pregnancies – If multiple embryos are transferred, there is a higher

chance of twins or triplets, which increases the risk of premature birth, low birth
weight, and pregnancy complications like preeclampsia (CDC, 2023).

 Ectopic Pregnancy – In some cases, an embryo may implant outside the uterus,
typically in a fallopian tube, leading to an ectopic pregnancy, which is a medical
emergency requiring intervention (Mayo Clinic, 2023).

 Miscarriage and Birth Defects – The risk of miscarriage in IVF pregnancies is

similar to natural conception, but some studies suggest a slightly higher risk of birth
defects, although this may be linked to underlying infertility rather than the IVF
process itself (CDC, 2023).

 Emotional and Psychological Stress – The financial cost, repeated treatments, and
uncertainty of success can lead to significant emotional distress, anxiety, and
depression for individuals undergoing IVF (ASRM, 2022).

 Egg Retrieval Complications – The procedure to collect eggs involves a needle

inserted into the ovaries, which carries risks such as bleeding, infection, or damage
to surrounding organs (Mayo Clinic, 2023).

Potential Benefits and Drawbacks of Pre-Implantation Genetic Testing.

Potential Benefits

 Reduces Genetic Disorders – PGT helps identify embryos with genetic abnormalities,
reducing the risk of passing on inherited conditions (Instituto Bernabeu, n.d.).
  Improves IVF Success Rates – Selecting genetically healthy embryos can increase the
chances of a successful pregnancy and reduce the risk of miscarriage.

 Reduces Multiple Pregnancy Risks – Since PGT allows the selection of a single, healthy
embryo, it reduces the need to transfer multiple embryos, lowering the risk of twins or
triplets and associated complications (Giuliano et al., 2023).

Potential Drawbacks

 False Positives or False Negatives – No genetic test is 100% accurate, and errors in
embryo screening can lead to the rejection of viable embryos or the selection of embryos
with undetected condition.

 Higher Costs – PGT adds significant financial burden to IVF, making it inaccessible for
many couples without insurance coverage (Instituto Bernabeu, n.d.).

 Potential Embryo Damage – The biopsy procedure to extract cells for testing may
impact embryo viability, although advancements in techniques have minimized this risk.

 Ethical and Social Concerns – The use of PGT raises ethical debates about embryo
selection, potential discrimination against individuals with disabilities, and concerns
over the possibility of "designer babies" (Giuliano et al., 2023).

Q2] A 32-year-old woman presents with a two-year history of infertility, despite regular,
unprotected intercourse. Her menstrual cycles are irregular, occurring every 35 to 45
days. She reports occasional pelvic discomfort and has a history of pelvic inflammatory
disease (PID) treated five years ago. Her medical history is otherwise unremarkable, and
she maintains a healthy lifestyle. Examine the impact of pelvic inflammatory disease
(PID) on fertility, including possible complications that could contribute to infertility.
Propose a comprehensive management plan, including both medical and lifestyle
interventions, to address the identified causes of infertility in this patient. Discuss other
causes of infertility seen in women with similar symptoms.

Impact of PID on Fertility in This Situation

PID, particularly when untreated or recurrent, can lead to tubal factor infertility, which is a
common cause of infertility. Even though the PID was treated five years ago, the long-term
consequences of PID on reproductive health may still be affecting her fertility.

Possible Complications Contributing to Infertility:

1. Fallopian Tube Damage

o PID can cause scarring or blockage of the fallopian tubes. In this patient’s case,
PID could have led to tubal adhesions, which may be impairing the normal
passage of sperm to the egg or preventing the fertilized egg from reaching the
uterus.

o Hydrosalpinx, or fluid-filled fallopian tubes, may develop, which can decrease the
chances of natural conception by toxic fluid interfering with the implantation
 process. Even though her PID was treated, the long-term scarring may still affect
the tubes' function (Apari, de Sousa, & Müller, 2014).

2. Endometrial Damage

o Chronic inflammation from PID could lead to endometritis, which affects the
endometrial lining and reduces its ability to support embryo implantation. This
could be a contributing factor to recurrent implantation failure if she attempts to
conceive (Atena Editora, 2024).

3. Ovarian Involvement & Ovulation Problems

o PID can cause tubo-ovarian abscesses or scarring around the ovaries, which may
affect normal ovulation or lead to disrupted ovarian function. Her irregular
menstrual cycles (35-45 days) could indicate an underlying ovulatory disorder,
possibly related to PID-induced damage to the ovaries or disrupted hormonal
regulation (Owhonda et al., 2023).

4. Chronic Pelvic Pain

o Occasional pelvic discomfort could suggest pelvic adhesions, a common

complication after PID. These adhesions may distort the anatomy of the
reproductive organs, making it harder for the sperm to reach the egg or for the
fertilized egg to implant. Chronic pelvic pain might also suggest ongoing
inflammation or adhesions, contributing to infertility (Apari, de Sousa, & Müller,
2014).

5. Increased Risk of Ectopic Pregnancy

o Although not explicitly mentioned in the case, PID significantly increases the risk
of ectopic pregnancy due to fallopian tube damage. If she does conceive, there is
a higher likelihood that the fertilized egg could implant in the tube rather than
the uterus, which requires immediate medical intervention (Atena Editora,
2024).

Comprehensive Management Plan for Infertility

1. Diagnostic Evaluation

Before initiating treatment, a thorough fertility workup is essential to identify the exact cause of
infertility.

A. Hormonal & Ovulatory Assessment

Since the patient has irregular cycles (35–45 days), an assessment of ovulatory function is
essential. Serum FSH, LH, and Estradiol levels help evaluate ovarian reserve and ovulatory
function, while AMH provides insights into ovarian reserve and predicts response to stimulation.
Thyroid function tests (TSH, Free T4) are necessary to rule out hypothyroidism, which can
contribute to irregular cycles and ovulatory dysfunction. Additionally, mid-luteal phase
progesterone levels, adjusted for longer cycles, help confirm whether ovulation is occurring
(Aziz, 2019).

B. Imaging & Structural Assessment

To assess fallopian tube patency and identify possible pelvic causes of infertility, a
hysterosalpingography (HSG) is performed to check for tubal blockages, hydrosalpinx, or
adhesions due to prior PID. If tubal blockage is confirmed, tubal surgery or IVF may be required.
A pelvic ultrasound (transvaginal scan) is also essential to evaluate for conditions such as PCOS,
abnormal endometrial thickness, ovarian cysts, uterine fibroids, or pelvic adhesions that could
impact fertility (Smith, 2020).

C. Infection & Endometrial Evaluation

An endometrial biopsy may be performed to rule out chronic endometritis, which can impair
implantation and reduce fertility. Additionally, screening for sexually transmitted infections
(STIs) like Chlamydia, Gonorrhea, Mycoplasma, Ureaplasma, and Trichomonas is necessary to
ensure there is no persistent infection affecting the reproductive system (Jones et al., 2018).

2. Medical Treatment & Fertility Enhancement

A. Ovulation Induction (if ovulatory dysfunction is present)

If the patient has irregular cycles, ovulation induction is the first step. Letrozole (2.5–5 mg daily
for 5 days starting on Day 3–5 of the cycle) is preferred due to higher ovulation rates and a
lower risk of multiple pregnancies compared to Clomiphene Citrate (50–100 mg for 5 days),
which requires monitoring to prevent ovarian hyperstimulation (Brown et al., 2017).

B. Surgical Intervention (if necessary)

If HSG confirms significant tubal damage, surgical correction may be attempted. If hydrosalpinx
is present, laparoscopic salpingectomy can improve IVF success rates (Singh & Patel, 2021).

C. Assisted Reproductive Technologies (ART)

If ovulation induction fails or tubal repair is unsuccessful, ART is considered. Intrauterine

Insemination (IUI) can be attempted for mild tubal disease or ovulatory dysfunction, while In
Vitro Fertilization (IVF) is recommended for severe tubal damage, failed ovulation induction
after 3–6 cycles, or significant endometrial damage (Lopez & Martinez, 2022).

3. Lifestyle & Supportive Interventions

A. Nutritional & Lifestyle Modifications

Maintaining a healthy BMI (18.5–24.9) is crucial, as weight loss (if overweight) improves
ovulation and IVF success. A diet rich in antioxidants, omega-3 fatty acids, and minimal
processed foods helps reproductive health. Moderate exercise (150 minutes/week), avoiding
smoking and alcohol, and managing stress through yoga, meditation, or therapy further support
fertility (Anderson et al., 2010).

B. Sexual Health & Timing of Intercourse

Timed intercourse every 2–3 days around ovulation maximizes conception chances. Ovulation
tracking using basal body temperature (BBT), cervical mucus monitoring, or ovulation predictor
kits (LH kits) aids in optimizing fertility.

4. Follow-Up & Monitoring

Regular gynecologic visits every 3–6 months help track progress and adjust treatment. Repeat
ultrasound and hormonal testing are required if ovulation induction is used. If conception does
not occur within six months, referral for IVF evaluation is recommended (Practice Committee of
the American Society for Reproductive Medicine, 2013).

Management & Treatment Options:

1. Ovulation Induction

o If ovulatory dysfunction is diagnosed, Clomiphene citrate or letrozole can be

used to stimulate ovulation, especially if the cause is PCOS or anovulation
(Brown et al., 2017).

2. Surgical Intervention

o Surgical correction of tubal blockages or adhesions may be considered if HSG

or laparoscopy reveals significant tubal damage. However, the success of such
procedures depends on the severity of the scarring and adhesions.

3. In Vitro Fertilization (IVF)

o If there is significant tubal damage (e.g., hydrosalpinx) or scarring, IVF might be

the most effective option to bypass the fallopian tubes and directly implant the
embryo in the uterus (Lopez & Martinez, 2022).

Other Causes of Infertility in Women with Similar Symptoms

1. Ovulatory Disorders
Women with irregular cycles may have ovulatory dysfunction, reducing their
chances of conception. Polycystic Ovary Syndrome (PCOS) is the most common
cause, characterized by irregular periods, anovulation, and hyperandrogenism (acne,
hirsutism). It is often linked to insulin resistance, leading to metabolic complications.
Hypothalamic Dysfunction results from stress, excessive exercise, or low body
weight, suppressing GnRH and causing ovulatory failure. Thyroid Disorders,
including hypothyroidism and hyperthyroidism, disrupt hormone balance, affecting
ovulation. Hyperprolactinemia, due to prolactin-secreting tumors, stress, or
medication use, suppresses GnRH, leading to irregular periods and infertility (Legro
et al., 2013).

2. Tubal & Pelvic Disorders

Given the history of PID, tubal factor infertility is a strong possibility, but other pelvic
conditions may also contribute. Endometriosis, characterized by ectopic endometrial
tissue growth, causes pelvic pain, painful periods, and infertility due to adhesions.
Pelvic Adhesions, often resulting from PID, surgeries, or infections, can block egg
transport. Hydrosalpinx, a condition where the fallopian tubes are filled with toxic
fluid, reduces implantation success and lowers IVF outcomes (Macer & Taylor, 2012).

3. Uterine Causes
Structural abnormalities of the uterus can also contribute to infertility. Uterine
Fibroids (Leiomyomas) are benign tumors that distort the uterine cavity, leading to
implantation failure and pregnancy complications. Endometrial Polyps are
 overgrowths in the uterine lining that interfere with embryo attachment and cause
irregular bleeding. Asherman’s Syndrome, characterized by intrauterine adhesions
from infections or surgical procedures, can lead to recurrent miscarriages and
infertility due to scarring.

4. Immune & Genetic Causes

Certain immune and genetic factors can also impair fertility. Antiphospholipid
Syndrome (APS) is an autoimmune disorder linked to im plantation failure and
recurrent pregnancy loss. Genetic abnormalities, such as chromosomal
translocations or Turner Syndrome mosaicism, can result in poor ovarian function or
increased miscarriage risk (Branch et al., 2010).
References

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Meeting report

Date Topic

10/ 02/2025 Questions was discussed

13/02/2025 Finalisation of answers and compilation