The reproductive medicine is concerned with the propagation , the fundamentals and the control of human fertility and its disorders. As an interdisciplinary field of medicine , reproductive medicine also touches the fields of andrology , urology , gynecology and genetics as well as the disciplines of forensic medicine , medical law and bioethics . At the center of modern reproductive medicine is helping with involuntary childlessness .
The word reproduction is taken from biological reproduction : It describes the creation of new, identical or largely similar individuals of living beings. The specialty arose out of the interests of gynecologists and andrologists who have them for diagnosis, therapy and research into reproductive processes in men and women. Carl Schirren is one of the founders of andrology in Germany . In 1983 he set up the first center for reproductive medicine in Hamburg and was its director until his retirement in 1987.
In human medicine, the birth of Louise Brown in 1978 is considered the beginning of modern reproductive medicine . In vitro fertilization (as a form of assisted reproduction ), used for the first time , was developed by Robert Edwards and Patrick Steptoe . A boy born on April 16, 1982 in the University Hospital Erlangen is considered to be Germany's first so-called test tube baby .
Since then, the theoretical knowledge has grown and the methods of diagnosis and therapy have been refined. A variety of techniques are now available. A wealth of ethical, legal and psychological consequences and discussions have emerged from this.
In Germany, legal norms are regulated in the Embryo Protection Act (ESchG) of December 13, 1990. Ethical discussions have been held in the German Ethics Council since June 8, 2001 . It is discussed whether Germany needs a new reproductive medicine law, based on the example of Switzerland, with which the ESchG, which is no longer perceived as contemporary in its basic biomedical and legal assumptions, could be replaced.
In most cases, sterility is the reason for consulting a reproductive medicine doctor. A sterile couple is when, after at least one year of regular sexual intercourse without contraception, no pregnancy results. The causes of a lack of fertility are 30% in men, 30% in women, 30% in both partners, and 10% is an idiopathic infertility .
The anamnesis has the task of finding out the type of disorder: In men, for example, it can be disorders in spermatogenesis that are determined by a function test of the sperm . Overall, andrology has developed for the diagnosis of male fertility disorders . In women, there is typically an ovulation disorder , mainly caused by polycystic ovary syndrome , an occlusion of the fallopian tube, or endometriosis .
The aim of reproductive medicine techniques is to assist in successful conception . For this purpose, various assisted reproductive technology (ART) procedures have been developed over the past decades:
- Intrauterine Insemination (IUI)
- Intratubar Insemination (ITI)
- Gamete-Intra-Fallopian Transfer (GIFT)
- Cervical-Intra-Fallopian Transfer (ZIFT)
- In Vitro Fertilization (IVF)
- Intracytoplasmic Sperm Injection (ICSI)
- Intracytoplasmic Morphologically Selected Sperm Injection (IMSI).
In addition, there are now diagnostic methods for recognizing genetic defects and gender:
Current research projects particularly relate to artificial insemination methods. The University Hospital Carl Gustav Carus Dresden mentions the following topics:
- Morphological analysis of preselected spermatozoa using high-magnification microscopy to optimize intracytoplasmic sperm injection (ICSI).
- Development of a non-invasive rapid test to assess the development potential of human oocytes during in vitro fertilization.
- Development of a laboratory method for the detection of glycodelin on the spermatozoa membrane as a possible cause of sterility in men.
The research also includes problems from the field of hormonal contraceptive methods and the analysis of environmental influences on the reproductive organs. Further research projects arise from the complex of ethical and legal questions, e.g. B. the social impact of pre-implantation diagnostics including the possibility of selection according to gender or other criteria.
Since embryonic stem cells are primarily obtained from in vitro fertilization, international reproductive medicine cannot be strictly separated from stem cell research. Special legal regulations apply to stem cell research in Germany .
“The 40 year olds today  are the first generation of“ wishful children ”, having children is no longer a god-willed fate. However, today's state of reproductive medicine allows much more. It allows each individual phase of reproduction to be technically influenced and thus optimized in a targeted manner. No other medical technology has direct social consequences on such a broad level: life and career planning, family models, gender roles, up to and including a derived “right to procreation” - all of this has to be discussed in a completely new way when a child has up to two genetic, one biological and social mother, as well as genetic and social father. In which constellation do I have children, in which phase of life (before, during or after my career), how do I influence and control who is born there? What are the constraints associated with this form of freedom to shape life and how can it be tolerated at all? Who can afford it? An increasing economization of reproductive technology offers, a real "reproductive tourism" has started. The target group of reproductive medical interventions are no longer the "sick" but rather the "healthy", to whom the idea of the controllability and design of reproduction is brought up. "
In addition, cost pressure in the healthcare system plays a role: When, for example , pre- implantation diagnostics (PGD) or prenatal diagnoses are concerned with the question of whether subsequent costs of an abortion can be avoided by avoiding medical treatments that may become necessary or possibly necessary intellectual treatments Promotion of the offspring.
Ethical conflict - artificial insemination
In the case of artificial insemination, there are some ethical conflicts that are heavily debated by bioethicists and tried to be resolved by the ethics council . Affected people suffer from physical and psychological stress during artificial insemination. There is a likelihood that there may be an increased rate of multiple pregnancies. For example, a case from California in 2009 is known where a woman was artificially inseminated and then gave birth to eightlings. In addition, malformations and damage can also occur in children who were conceived with the help of assistive reproductive medicine. Finally, in the case of fertilization measures carried out extracorporeally, it can never be completely ruled out that an interchanging event occurs, in which human germ cells or embryos are interchanged. The legal problems caused by this are manifold and in some cases severely burden the couples concerned.
Another question deals with the couples who are eligible for artificial insemination. Should it be single, married and / or homosexual? Should there be an age limit? As an example of the ethical conflict, there is a case from Spain from 2006: a woman gave birth to twins through artificial insemination at the age of 67, but died of cancer at the age of 69. The children are now growing up as orphans.
Surrogacy also shows numerous ethical conflicts. On the one hand, there is the position of the mother who cannot bear her own child. Second is the position of the surrogate mother , who can develop an emotional bond with the child during pregnancy. She then has to decide whether she can give the child away or not.
What does it mean when health insurances cover the cost of artificial insemination? Another question that is discussed ethically. Does coverage mean that infertility is considered a disease? Or should this measure be seen as a standard therapy or is it comparable to cosmetic surgery?
Ethical conflict - stem cell research
In the area of stem cell research, there are also numerous points of discussion for bioethics. Research with stem cells is of great importance to science: it has the potential to cure diseases such as Parkinson's , Alzheimer's , severe burns and cancer. The stem cells for treatment are used from embryos that are being saved for artificial insemination or from aborted embryos and fetuses.
Two different perspectives result in an ethical dilemma: on the one hand, the duty to prevent or reduce suffering, and on the other hand, the duty to respect human life, which some also include embryos. Questions such as: should embryos be destroyed at an early stage of development in order to obtain embryonic stem cells? Or should new medical treatment strategies be developed using stem cells to alleviate the suffering of many people? To answer these questions, the embryo is assigned a so-called moral status.
The moral status of a human embryo
The main question of the great debate about the moral status of the human embryo is who or what can be considered a human, and when does one come into contact with a human. This question is followed by the treatment of an embryo, should it resemble a child or an adult, is it then also the bearer of fundamental rights or not. This means whether or not an embryo is subject to the protection of life or the general ban on killing and the ban on instrumentalization. A distinction must be made here between two views. One side sees the embryo as a human being from fertilization. These are under the protection of life equally in all phases of life. This means as soon as fertilization takes place, life begins and thus life must also be protected. It is no longer permitted to weigh up whether an embryo may be used for stem cell research. The opposite side sees only a human life in the embryo for the first 12 to 14 days, which is assigned increasing protection with increasing development. Thus the beginning of life and the protection of life fall apart. The life of the embryo is weighed up under certain conditions. Different variants differ here: beginning of the protection with the exclusion of the multiple formation or only with the pain sensitivity or even later.
Ethical Aspects of Reproductive Medicine
In reproductive medicine, and in particular in embryo and stem cell research, it is controversial whether the means to achieve the goals set are acceptable and legally permissible. For this discussion, four arguments were formulated to examine the admissibility.
The argument of species membership assigns everyone a moral status, or the same right to recognition of their dignity, as soon as one is a human being and belongs to the human species. The expression of specific human characteristics is not a prerequisite for this, so that a clone belonging to the human species is also worthy of protection.
The continuity argument shows the difficulty of dividing the development of an embryo into distinctive incisions. It is continuous so that the moral status cannot be determined at any specific point in time. For this reason, this argument pursues the idea of necessarily measuring the moral status of an embryo with that of an adult.
The identity argument states the opinion that a living being remains the same with itself at every point in its development. Thus the human being is not different in his identity from the embryo from which he developed. Thus, they are assigned the same moral status or dignity as more developed fetuses or newborns.
The last argument describes the potentiality argument. Here the embryo is measured according to whether it develops into a human subject. As an argumentation example, unborn people are compared with unconscious people who in fact do not have their consciousness or can act autonomously. Nevertheless, these are considered to be conscious and autonomous subjects. Thus the dignity and the protection of life are awarded to them as well as unconscious people.
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