Recent Posts

3 May 2022 - by Dr Kirsty Horsey
The UK's Human Fertilisation and Embryology Authority (HFEA) has been tasked by the Government to advise on what changes should be made to the Human Fertilisation and Embryology Act. The Progress Educational Trust (PET) event 'Authority Over Assisted Reproduction: What Powers Should the HFEA Have?' heard from an expert panel on the issues. PET's director, Sarah Norcross, said in her introduction that this is a 'once-in-a-generation opportunity to revise the legislation'. This means that care should be taken to get this right, and to future-proof regulation as much as possible.

The chair of the HFEA told the PET annual conference in December that it would make more sense for all aspects of regulation of fertility treatment to be in one place (see BioNews 1125). In her view, the HFEA's power is poorly calibrated – especially regarding sanctions it can impose. Flexibility and a 'graduated ladder of enforcement' are preferred. This more recent PET event asked how far others agree with this.

The first speaker was Rachel Cutting, HFEA director of compliance and information. She pointed out that the HFEA does not make law but must work within it. She explained that regulation was passed initially to cement public confidence in reproductive medicine. She highlighted that much has changed in the 30 years since – fertility treatment is now more mainstream and there are far fewer taboos. However, the sector itself has changed in the last 30 years too. More treatment is now provided in the private sector and often by large clinical groups. New and innovative forms of treatment continue to be developed – including those known as 'add-ons', which can be contentious. The creation of life in a laboratory remains unique and the fundamental need for a specialist regulator hasn't changed, said Cutting. There is still a need to inspect, license and provide information to the public, but the way this happens could be improved.

It is not a question of the HFEA having greater or different powers, she said – what matters is relevant power. She added that any new law must be less prescriptive and restrictive, and more agile, than the present law. She outlined her wish for future-proof legislation that put patient protection at the fore. The HFEA plans a ladder of regulatory tools to enable proportionate sanctions, the ability to look at experimental treatments and encourage innovation, simplification of consent and confidentiality requirements, and greater patient focus by assessing the quality of care provided. She outlined that the HFEA will consult in the summer and report to the Government by the end of the year – and it will then be for the Government to decide on next steps. But she sounded two notes of caution. First, though legislative change is the aim, the process could take years rather than months. Second – and more importantly – such change carries risk: Parliament could end up making things more restrictive.

The next speaker was Dr Mohamed Taranissi, founder and medical director of the Assisted Reproduction and Gynaecology Centre in London. He asked whether the HFEA having greater powers, including the ability to impose economic sanctions such as fines, was necessary. In his view, if the HFEA wants to extend its remit to consider the clinical performance of centres then we must look at reviewing its constitution. As stipulated by legislation, the majority of the authority proper (as distinct from the HFEA's executive) are lay members. Furthermore, the chair and deputy may not be medical practitioners and may not have worked in the sector. He said that if the HFEA wants to extend its remit to look at emerging technologies and treatments, then it must have members with the right expertise and the lay majority should be reconsidered, especially if they will have powers to impose sanctions.

Dr Taranissi also pointed out that the proposal for more power and financial sanctions is not new, but was previously made by the HFEA in 2004-5 when the Government announced the last major review of the legislation. The Science and Technology Committee at the time agreed that the regulator needed a wider range of sanctions but was concerned that the focus was on penalties and not on improving standards and systems. The Government did not accept financial powers for the HFEA then, as it was satisfied that the Human Fertilisation and Embryology Act's criminal provisions and measures attached to licensing were enough.

The third speaker was Marta Jansà-Pérez, director of embryology at British Pregnancy Advisory Service and leader of its fertility services. She was speaking from the perspective of a recently opened, inspected and licensed centre and agreed that while the legislation needs review, it remains important as it ensures clinics provide high standards of care and gives people working in the sector reassurance. She said that a review of the legislation should also mean a review of the HFEA's powers, and all should be focused on optimising patient care.

Considering specific aspects of the legislation that should be reviewed, she asked whether we should retain the current welfare of the child (WoC) assessment, saying it is beyond the remit of those treating women. Later she clarified that a strong multidisciplinary approach might be welcomed, rather than pro-forma questions, especially when a child is not yet there. Also, she argued, the law should support the growing diversity of the patient population and family forms being created – including revisiting the meaning of 'mother', 'father' and even 'partner' (for example, when there is a polyamorous relationship), as well as ensuring different genders are properly treated. Additionally, the rules on confidentiality and data sharing are currently strict, even between other healthcare providers. More openness might lead to better patient care and even facilitate WoC, she argued.

Dr Debra Bloor, director of governance at CARE Fertility and previously chief inspector at the HFEA, spoke next. She agreed with others that oversight and governance should be and often is a force for good and pointed to the reduction in multiple births (see BioNews 1132) as an example of this. She argued that the benefits of regulation are achieved most effectively when delivered by experts, remembering a time when it was proposed that the HFEA's powers could be transferred to the Care Quality Commission (CQC), but it was recognised belatedly that the CQC simply didn't have the right expertise. In her view the HFEA should continue to do what it does best, but she was less sure of its capacity in relation to innovations or clinical practice. In relation to new technology, as an example, we already have the Medicines and Healthcare Products Regulatory Agency. To transfer those kinds of responsibilities to the HFEA would be time-consuming, expensive and not straightforward, and the same applies to the Competition and Markets Authority (CMA), Advertising Standards Authority (ASA), etc – who are already in place and increasingly effective at what they do.

On the question of sanctions, she said that she believed in 2005 and still now that the sector is hugely compliant. She argued that HFEA has a brilliant track record of achieving its aims through engagement and collaboration, and worried this could be lost if that HFEA had a more punitive function, which may make the relationship between regulator and regulated more combative. However, she would like the legislation to give the HFEA more power to be flexible in interpreting the law – able to take account of changes in society, family structures, issues to do with screening and confidentiality, and in relation to consent (especially regarding parenthood), arguing that the complex catalogue of existing consents can lead to mistakes.

The final speaker was Katy Lindemann, former fertility patient and now advocate and commentator on infertility and childlessness. She began by outlining the change of emphasis of the legislation over time: whereas its initial focus was protecting the public against misuse of reproductive technology, that has somewhat shifted to considering how patients can best be protected against exploitation by commercial interests.

She argued that we should consider whether the HFEA's current powers are being used effectively. As an example she discussed what informed consent means in the context of the legislation and the impact of Supreme Court case Montgomery [2015], which clearly outlined the modern legal test for informed consent, and asked how this has been translated into the HFEA's Code of Practice (CoP). An HFEA presentation last year after a CMA review was undertaken showed that only three percent of clinic websites comply with the CoP. From a patient perspective, Lindemann argued, saying that the CMA and ASA already cover this is fine, but they only investigate non-compliance if a complaint is made. 'Compliant clinics' are not always complying, as illustrated by the HFEA's recent patient survey results (see BioNews 1141), where fewer than 50 percent of respondents felt they received enough information about costs of add-on(s), evidence for their effectiveness, or potential associated risks. In addition, despite what the law and the CoP say, the patient survey showed some of the lowest ratings for support provided by clinics (including counselling).

The Q&A with the audience at the end of the event brought some of these issues to the fore again, including the composition/constitution of the HFEA, how satellite centres can be monitored and inspected (and results made available to patients), what to do with the WoC assessment, and support for donor-conceived people (especially regarding access to information). Much of the discussion came back to the difference between what is mandated in the law, and what is only guidance.

All of the speaker the presentations, and the Q&A, showed just how important it will be for all stakeholders to engage with any HFEA consultations (and more broadly) on these issues. The voices of the sector, patients and wider society need to be heard, in order that any future law is appropriate and best suited to protect patients, families, scientific advancement and innovation.

11 April 2022 - by Zaina Mahmoud
Endometriosis is seen as a 'modern mystery' in gynaecology, with its causes not yet fully understood. Prevalent in up to ten percent of people of reproductive age, it is one of the most common gynaecological pathologies. Studies suggest up to 50 percent of infertile people have endometriosis, and 30-50 percent of those with endometriosis are infertile. Despite this association between endometriosis and infertility, a causal relationship has yet to be established. While March was endometriosis awareness month, medical professionals should always be engaged in increasing awareness and education on the various options available for fertility preservation and planning, rather than concentrating efforts to a single month each year.

Those diagnosed with endometriosis are exceptionally worried about the impact on their fertility, as well as the impact of endometriosis treatment on their fertility. Oocyte cryopreservation (more often known as egg freezing) is the procedure of choice for individuals with endometriosis, promoting reproductive autonomy by increasing fertility options, including when to pursue pregnancy. Recognising the impact of age on egg quality, younger people wanting to preserve their potential future fertility may wish to seek egg freezing. Additionally, egg freezing is a good option for them because it does not impact future ovarian reserves. Therefore, fertility preservation should be integrated as an essential component in ovarian endometriosis management.

While the National Institute for Health and Care Excellence (NICE) guidelines outline surgical management for endometriosis should include pre-operative ovarian reserve testing, they do not recommend egg freezing for endometriosis. Importantly, these guidelines have not been updated since they were first published in 2017. Egg freezing has come a long way over the last decade: technological advances have resulted in excellent survival rates and clinical outcomes are similar to those with fresh eggs. Recognising the need to ensure guidelines are kept updated, Endometriosis UK has launched a campaign to rectify these gaps, and evaluate current best practice and evidence. This is especially timely, given that the European Society of Human Reproduction (ESHRE) released comprehensive guidelines, including over 100 recommendations on diagnosis, treatments for pain and infertility, and other aspects of management.

Increasingly, it has become clear that there is a need for timely diagnosis and management of endometriosis. Recently published research reveals these as key to increasing the likelihood of success during IVF treatment. Dr Katrina Moss and her team found that an endometriosis diagnosis prior to starting IVF resulted in fewer cycles and a shorter time frame needed to report a birth. Conversely, undiagnosed endometriosis prior to starting IVF was more likely to result in the use of intrauterine insemination (IUI), with more IVF cycles and more time needed to report a live birth. These findings conflict with the most recent ESHRE guidance, which recommends IUI, unless there is male factor infertility, as well as with the 2017 NICE guidelines which argue against the use of IUI in mild endometriosis.

Endometriosis is not listed as a research priority by the UK National Institute for Health Research or any other major funder. This may contribute to the fact that, to date, there are no published data on the clinical outcomes of fertility preservation in individuals with endometriosis. Despite this, fertility specialists must change the way we manage endometriosis patients, especially since there are well-documented significant delays in receiving a diagnosis of endometriosis. In addition to diagnosis delays, there are 63 endometriosis centres across the UK, with huge variance in patient capacity. Where people with a suspected or documented diagnosis of endometriosis present, their concerns must be taken into management decisions, with reproductive counselling an integral part of management and care. If fertility preservation is a key concern, then egg freezing should not be delayed, ideally undertaken, prior to surgery to maximise the number of eggs obtained, and later IVF success rates. It is known that endometriosis patients who underwent cystectomies prior to egg freezing had lower success rates.

However, the decision to offer fertility preservation options falls onto Clinical Commissioning Groups (CCGs). There are 63 endometriosis centres across the UK, with huge variance in patient capacity. In essence, similar to the infamous IVF postcode lottery (see BioNews 1120) individuals with endometriosis face significant differences in access to fertility treatment. The All-Party Parliamentary Groups on endometriosis noted that fertility preservation support is severely lacking in many areas, with some CCGs drawing boundaries between ovarian removal due to endometriosis and cancer, funding treatment for the latter but not the former. As a result, most people wanting to undertake fertility preservation must do so privately.

In line with a reproductive justice lens, egg freezing must be practically accessible, rather than merely theoretically. Currently, the adopted approach results in stratified and stratifying reproductive healthcare. This is remedied through recognition of egg freezing for endometriosis as a valid treatment plan, thereby enhancing reproductive autonomy. Medical professionals have a duty to inform themselves on the possibilities of fertility preservation as a therapeutic approach, through enhanced and up-to-date training in the diagnosis, investigation and management of endometriosis that takes into account patients' concerns. Those diagnosed with endometriosis already have to deal with chronic pain and other debilitating symptoms, as well as a medical system that has long neglected their concerns. Hopefully, Endometriosis UK's campaign will ensure that everyone is able to access necessary healthcare, without needing to travel and pay.

11 April 2022 - by Zaina Mahmoud
Endometriosis is seen as a 'modern mystery' in gynaecology, with its causes not yet fully understood. Prevalent in up to ten percent of people of reproductive age, it is one of the most common gynaecological pathologies. Studies suggest up to 50 percent of infertile people have endometriosis, and 30-50 percent of those with endometriosis are infertile. Despite this association between endometriosis and infertility, a causal relationship has yet to be established. While March was endometriosis awareness month, medical professionals should always be engaged in increasing awareness and education on the various options available for fertility preservation and planning, rather than concentrating efforts to a single month each year.

Those diagnosed with endometriosis are exceptionally worried about the impact on their fertility, as well as the impact of endometriosis treatment on their fertility. Oocyte cryopreservation (more often known as egg freezing) is the procedure of choice for individuals with endometriosis, promoting reproductive autonomy by increasing fertility options, including when to pursue pregnancy. Recognising the impact of age on egg quality, younger people wanting to preserve their potential future fertility may wish to seek egg freezing. Additionally, egg freezing is a good option for them because it does not impact future ovarian reserves. Therefore, fertility preservation should be integrated as an essential component in ovarian endometriosis management.

While the National Institute for Health and Care Excellence (NICE) guidelines outline surgical management for endometriosis should include pre-operative ovarian reserve testing, they do not recommend egg freezing for endometriosis. Importantly, these guidelines have not been updated since they were first published in 2017. Egg freezing has come a long way over the last decade: technological advances have resulted in excellent survival rates and clinical outcomes are similar to those with fresh eggs. Recognising the need to ensure guidelines are kept updated, Endometriosis UK has launched a campaign to rectify these gaps, and evaluate current best practice and evidence. This is especially timely, given that the European Society of Human Reproduction (ESHRE) released comprehensive guidelines, including over 100 recommendations on diagnosis, treatments for pain and infertility, and other aspects of management.

Increasingly, it has become clear that there is a need for timely diagnosis and management of endometriosis. Recently published research reveals these as key to increasing the likelihood of success during IVF treatment. Dr Katrina Moss and her team found that an endometriosis diagnosis prior to starting IVF resulted in fewer cycles and a shorter time frame needed to report a birth. Conversely, undiagnosed endometriosis prior to starting IVF was more likely to result in the use of intrauterine insemination (IUI), with more IVF cycles and more time needed to report a live birth. These findings conflict with the most recent ESHRE guidance, which recommends IUI, unless there is male factor infertility, as well as with the 2017 NICE guidelines which argue against the use of IUI in mild endometriosis.

Endometriosis is not listed as a research priority by the UK National Institute for Health Research or any other major funder. This may contribute to the fact that, to date, there are no published data on the clinical outcomes of fertility preservation in individuals with endometriosis. Despite this, fertility specialists must change the way we manage endometriosis patients, especially since there are well-documented significant delays in receiving a diagnosis of endometriosis. In addition to diagnosis delays, there are 63 endometriosis centres across the UK, with huge variance in patient capacity. Where people with a suspected or documented diagnosis of endometriosis present, their concerns must be taken into management decisions, with reproductive counselling an integral part of management and care. If fertility preservation is a key concern, then egg freezing should not be delayed, ideally undertaken, prior to surgery to maximise the number of eggs obtained, and later IVF success rates. It is known that endometriosis patients who underwent cystectomies prior to egg freezing had lower success rates.

However, the decision to offer fertility preservation options falls onto Clinical Commissioning Groups (CCGs). There are 63 endometriosis centres across the UK, with huge variance in patient capacity. In essence, similar to the infamous IVF postcode lottery (see BioNews 1120) individuals with endometriosis face significant differences in access to fertility treatment. The All-Party Parliamentary Groups on endometriosis noted that fertility preservation support is severely lacking in many areas, with some CCGs drawing boundaries between ovarian removal due to endometriosis and cancer, funding treatment for the latter but not the former. As a result, most people wanting to undertake fertility preservation must do so privately.

In line with a reproductive justice lens, egg freezing must be practically accessible, rather than merely theoretically. Currently, the adopted approach results in stratified and stratifying reproductive healthcare. This is remedied through recognition of egg freezing for endometriosis as a valid treatment plan, thereby enhancing reproductive autonomy. Medical professionals have a duty to inform themselves on the possibilities of fertility preservation as a therapeutic approach, through enhanced and up-to-date training in the diagnosis, investigation and management of endometriosis that takes into account patients' concerns. Those diagnosed with endometriosis already have to deal with chronic pain and other debilitating symptoms, as well as a medical system that has long neglected their concerns. Hopefully, Endometriosis UK's campaign will ensure that everyone is able to access necessary healthcare, without needing to travel and pay.

31 August 2021 - by Dr Alka Prakash and Mrs Uma Gordon
A recent Human Fertilisation and Embryology Authority (HFEA) report has indicated that people from black, Asian and ethnic minority backgrounds undergoing fertility treatment are less likely to have a baby, with black patients having the lowest chances of successful treatment (see BioNews 1089). This is indeed concerning and needs urgent action to address the inequality.

Various reasons have been cited for the differences. Among the medical factors, black women are known to have an increased incidence of uterine fibroids and tubal factors that impact fertility negatively, as shown by results of a survey published in the Journal of Women's Health in 2013. Women who have had multiple surgeries to treat gynaecological symptoms prior to presentation with subfertility can have adversely impacted fertility outcomes, even though the surgeries helped with symptoms. Similarly, Asian populations are known to have a higher incidence of polycystic ovarian syndrome that impairs ovulation thereby leading to subfertility.

Medical reasons in isolation, however, do not explain the poorer outcomes of fertility treatment among ethnic minority populations. As we look at the data provided by the HFEA, it is clear that fertility treatment is accessed at a later age by this subgroup of women. Female age, as we know, is the single most important prognostic factor for live birth outcome. Hence medical comorbidities along with delayed access to fertility treatment can to some extent explain the findings of this report.

Black women also appear to have more complications such as multiple pregnancies associated with fertility treatments. This might be due to increased age at treatment leading to poorer quality embryos, and a tendency towards double embryo transfers to optimise success rates.

Addressing these inequalities will require a focus on medical issues as well as social inequalities. These common conditions have medical treatments which are effective when offered as fertility preserving procedures such as myomectomy for fibroid uterus. Women should be informed about the adverse impact of delayed child bearing with such pathologies. Similarly in metabolic conditions like polycystic ovarian syndrome, early advice on weight loss and lifestyle measures allow for spontaneous conception and increased success with treatment options.

Concerning the social aspects, infertility as a disease has been stigmatised almost universally. This social stigma appears to be more pronounced in these ethnic subgroups creating a resistance to access help at the right time, as shown in a 2015 paper published in Psychology of Women.

Increasing awareness through knowledge is key to addressing these issues. Opportunistic discussion about future fertility at primary care level would be a good start to give this subgroup relevant and timely information. In addition, it is important to involve the community through religious and social leaders. They will have a greater understanding of the cultural and religious beliefs, to help influence and overcome barriers. It will also help destigmatise the process of fertility treatment, so that more people from ethnic minorities come forward for gamete donation.

It is evident from the HFEA report that there is a serious lack of availability of donated eggs in the UK from black, Asian and ethnic minority subpopulation, necessitating the use of eggs from white donors by those patients who require donor gametes.

There are other social issues that can impact fertility outcome. Socially deprived areas often have poor diet/living conditions, increased environmental pollution and stress, leading to overall poorer health outcomes. Furthermore, the access to state funded fertility treatment varies regionally and some of the ethnic minorities may have been much more impacted by this. This postcode inequality needs to be redressed to enable equity in health services provision.

The HFEA report is very much welcomed and helps highlight some very important facts. It would, however, be good to scrutinise specifics within each of the different ethnic groups, as the needs and requirements vary widely. There is an urgent need for further research in this area to distil the various causes and take action to challenge the problem.

Information provision across the fertility sector needs to be improved and we should put in place early access criteria for these women for both fertility assessment and treatment. Broader issues such as systemic racism need to be identified and tackled as they may also deter women from accessing care and treatment. We, as multidisciplinary members and practitioners of the sector, need to take individual onus and responsibility to do all it takes to eradicate this inequality. We look upon the national professional bodies such as the British Fertility Society, The Royal College of Obstetricians and Gynaecologists' Race Equality Taskforce and the HFEA to guide this fight against health disparity based on ethnicity. 

31 August 2021 - by Dr Alka Prakash and Mrs Uma Gordon
A recent Human Fertilisation and Embryology Authority (HFEA) report has indicated that people from black, Asian and ethnic minority backgrounds undergoing fertility treatment are less likely to have a baby, with black patients having the lowest chances of successful treatment (see BioNews 1089). This is indeed concerning and needs urgent action to address the inequality.

Various reasons have been cited for the differences. Among the medical factors, black women are known to have an increased incidence of uterine fibroids and tubal factors that impact fertility negatively, as shown by results of a survey published in the Journal of Women's Health in 2013. Women who have had multiple surgeries to treat gynaecological symptoms prior to presentation with subfertility can have adversely impacted fertility outcomes, even though the surgeries helped with symptoms. Similarly, Asian populations are known to have a higher incidence of polycystic ovarian syndrome that impairs ovulation thereby leading to subfertility.

Medical reasons in isolation, however, do not explain the poorer outcomes of fertility treatment among ethnic minority populations. As we look at the data provided by the HFEA, it is clear that fertility treatment is accessed at a later age by this subgroup of women. Female age, as we know, is the single most important prognostic factor for live birth outcome. Hence medical comorbidities along with delayed access to fertility treatment can to some extent explain the findings of this report.

Black women also appear to have more complications such as multiple pregnancies associated with fertility treatments. This might be due to increased age at treatment leading to poorer quality embryos, and a tendency towards double embryo transfers to optimise success rates.

Addressing these inequalities will require a focus on medical issues as well as social inequalities. These common conditions have medical treatments which are effective when offered as fertility preserving procedures such as myomectomy for fibroid uterus. Women should be informed about the adverse impact of delayed child bearing with such pathologies. Similarly in metabolic conditions like polycystic ovarian syndrome, early advice on weight loss and lifestyle measures allow for spontaneous conception and increased success with treatment options.

Concerning the social aspects, infertility as a disease has been stigmatised almost universally. This social stigma appears to be more pronounced in these ethnic subgroups creating a resistance to access help at the right time, as shown in a 2015 paper published in Psychology of Women.

Increasing awareness through knowledge is key to addressing these issues. Opportunistic discussion about future fertility at primary care level would be a good start to give this subgroup relevant and timely information. In addition, it is important to involve the community through religious and social leaders. They will have a greater understanding of the cultural and religious beliefs, to help influence and overcome barriers. It will also help destigmatise the process of fertility treatment, so that more people from ethnic minorities come forward for gamete donation.

It is evident from the HFEA report that there is a serious lack of availability of donated eggs in the UK from black, Asian and ethnic minority subpopulation, necessitating the use of eggs from white donors by those patients who require donor gametes.

There are other social issues that can impact fertility outcome. Socially deprived areas often have poor diet/living conditions, increased environmental pollution and stress, leading to overall poorer health outcomes. Furthermore, the access to state funded fertility treatment varies regionally and some of the ethnic minorities may have been much more impacted by this. This postcode inequality needs to be redressed to enable equity in health services provision.

The HFEA report is very much welcomed and helps highlight some very important facts. It would, however, be good to scrutinise specifics within each of the different ethnic groups, as the needs and requirements vary widely. There is an urgent need for further research in this area to distil the various causes and take action to challenge the problem.

Information provision across the fertility sector needs to be improved and we should put in place early access criteria for these women for both fertility assessment and treatment. Broader issues such as systemic racism need to be identified and tackled as they may also deter women from accessing care and treatment. We, as multidisciplinary members and practitioners of the sector, need to take individual onus and responsibility to do all it takes to eradicate this inequality. We look upon the national professional bodies such as the British Fertility Society, The Royal College of Obstetricians and Gynaecologists' Race Equality Taskforce and the HFEA to guide this fight against health disparity based on ethnicity. 

16 August 2021 - by Dr Rachel Montgomery
A recent study has found that as many as one in 15 men carry mutations in their sperm that could impact the health of their children.

Previous research has reported that children born to older men have a higher risk of being born with some conditions, including autism spectrum disorder (ASD). Researchers from the Rady Children's Institute of Genomic Medicine in San Diego, California and the University of California San Diego School of Medicine used whole genome sequencing to determine whether there are any differences in the number of mutations seen in sperm from older men compared with younger men.

'We found that each ejaculate from a man shows an average of 30 mutations,' said co-first author Dr Xiaoxu Yang. 'Almost all of these were found in serial sampling from a period of six to 12 months, whereas most of the mutations were completely absent from a saliva or blood sample.'

Their results, published in Cell, showed that the number of mutations in the semen samples did not, in fact, differ between younger and older men - although the number of mutations in blood samples (reflecting the somatic genome) did increase with age as expected. Further still, the mutations seen were largely unique to the sperm samples, and were not seen in the saliva or blood of the men tested.

Together, this led the researchers to suggest that the mutations seen in the semen samples had not arisen due to age, but instead had been present since birth and had specifically developed in the sperm cells during embryonic development.

Although the mutations were only seen in a small sub-population of the semen samples – a term called clonal mosaicism – the researchers have speculated that they could give rise to diseases in 1 in 300 conceptions.

Senior author Professor Joseph Gleeson said, 'We think that these mutations contribute a substantial burden on human health, potentially causing 15 percent of ASD cases, congenital heart disease and severe paediatric diseases. But we are hopeful that by identifying men at risk, future cases of disease can be avoided.'

The researchers are now working with fertility clinics to assess whether these mosaic mutations are actually passed to embryos, with the goal of ultimately preventing disease in children.

16 August 2021 - by Dr Rachel Montgomery
A recent study has found that as many as one in 15 men carry mutations in their sperm that could impact the health of their children.

Previous research has reported that children born to older men have a higher risk of being born with some conditions, including autism spectrum disorder (ASD). Researchers from the Rady Children's Institute of Genomic Medicine in San Diego, California and the University of California San Diego School of Medicine used whole genome sequencing to determine whether there are any differences in the number of mutations seen in sperm from older men compared with younger men.

'We found that each ejaculate from a man shows an average of 30 mutations,' said co-first author Dr Xiaoxu Yang. 'Almost all of these were found in serial sampling from a period of six to 12 months, whereas most of the mutations were completely absent from a saliva or blood sample.'

Their results, published in Cell, showed that the number of mutations in the semen samples did not, in fact, differ between younger and older men - although the number of mutations in blood samples (reflecting the somatic genome) did increase with age as expected. Further still, the mutations seen were largely unique to the sperm samples, and were not seen in the saliva or blood of the men tested.

Together, this led the researchers to suggest that the mutations seen in the semen samples had not arisen due to age, but instead had been present since birth and had specifically developed in the sperm cells during embryonic development.

Although the mutations were only seen in a small sub-population of the semen samples – a term called clonal mosaicism – the researchers have speculated that they could give rise to diseases in 1 in 300 conceptions.

Senior author Professor Joseph Gleeson said, 'We think that these mutations contribute a substantial burden on human health, potentially causing 15 percent of ASD cases, congenital heart disease and severe paediatric diseases. But we are hopeful that by identifying men at risk, future cases of disease can be avoided.'

The researchers are now working with fertility clinics to assess whether these mosaic mutations are actually passed to embryos, with the goal of ultimately preventing disease in children.

2 August 2021 - by Sarah Wood-Heath
Since 1991, the number of IVF cycles has increased significantly with success rates also growing. With freezing techniques improving, according to the Human Fertilisation and Embryology Authority (HFEA), frozen embryo transfers continue to increase year-on-year. In fact, the HFEA state that frozen embryo transfers increased by 86 percent from 2014 to 2019 (see BioNews 1097). According to the HFEA, the typical patient undergoing treatment will have a single fresh embryo transferred in their first cycle with additional embryos stored for use in subsequent cycles.

It is clear that the advancement in such techniques has offered many people the opportunity to have a biological family, who otherwise would not, and embarking on such treatment as a couple is an exciting yet anxious and daunting time. However, storing embryos for future use, means couples run the risk of eventually facing the difficult and often unanticipated question of what should happen to embryos they created together, in the event their relationship breaks down. This is an increasingly challenging area and one which raises extremely sensitive and emotive questions.

At present embryos created for fertility treatment can be stored for a maximum of 10 years under the Human Fertilisation and Embryology Act 1990 (although this has been extended to 12 years due to the COVID-19 pandemic and there are calls to increase it further). A central concept within fertility treatment is that of consent, and whether these frozen embryos, following a separation, can then continue to be stored, used for treatment, or destroyed is dependent on the mutual consent of the parties. By law, the embryos can only be used for the purposes that each of the parties have given their consent to.

At the outset of treatment, the parties' consent is recorded by the completion of various forms with the fertility clinic, however, it is possible for either party to change their mind and subsequently withdraw or vary their consent, in writing, at any point up to the implantation of the embryo in the womb in the UK. This withdrawal or variation can give rise to some difficult and distressing situations.

In the event that one party withdraws their consent to the continued storage of the embryo, then the law requires the fertility clinic to take all reasonable steps to notify those due to be treated with that embryo of the withdrawal. A 12-month cooling-off period is triggered from the date the fertility clinic receives the written withdrawal of consent, during which the embryos will continue to be stored – but cannot be used – to enable the parties to consider their position and the way forward.

After 12 months if both parties do not consent to the continued storage, the embryos will be destroyed. This is a distressing situation for parties following separation where one party is making the difficult decision to destroy the embryos whilst the other wishes to continue to keep them for potential use in the future. This raises such deeply personal and emotional concerns for all involved.

This issue has been challenged through the courts and through to the European Court of Human Rights where the court had to balance one party's wish to use the embryos and the other party's objection to the use of them. The court held that the right to respect for family life did not override the fact that the other party had withdrawn their consent to the embryos being used. The court determined that it has no power to intervene on behalf of the party who wants their embryos to be preserved.

An increasing and not uncommon aspect to the use of embryos is where a separating couple, who remain on amicable terms, are considering moving forwards with using the embryos post-separation. This can raise difficult issues practically, legally, and also emotionally as each party endeavours to understand their role and respective legal positions.  Often, the parties have been on a long journey and despite the separation, they may still wish to support the other in the use of the embryos, whether on a co-parenting basis or one party moving forwards with sole treatment. Consent to one party moving forwards with the use of the embryos solely is often sought on the condition that the other has no legal status or financial responsibility for any child born, and this is a complicated and grey area of the law.

If the parties are married or in a civil partnership and use the embryos in treatment, then both parties will be considered the legal parents unless one party can evidence that they did not consent to the treatment, and this is a complicated legal question. This applies equally whether the second parent is biologically related to the child or whether donor sperm is used. If the parties were not married or civil partners and treatment was with donated sperm or embryos, then in the event of relationship breakdown consideration should be given to any variation or withdrawal of consent to legal parenthood. The law is especially complicated if the embryos were created with the sperm of the former partner and he seeks to donate the embryo to the other party for sole use.

The issues which surround the use of an embryo created in treatment together are wide and far-reaching for the individuals concerned. The strict application of the law can lead to difficult and emotionally challenging situations. The storage and use of the embryos continues to be a matter of mutual consent and in the event of a relationship breakdown, careful consideration needs to be given to the best way forward for both parties involved.

2 August 2021 - by Sarah Wood-Heath
Since 1991, the number of IVF cycles has increased significantly with success rates also growing. With freezing techniques improving, according to the Human Fertilisation and Embryology Authority (HFEA), frozen embryo transfers continue to increase year-on-year. In fact, the HFEA state that frozen embryo transfers increased by 86 percent from 2014 to 2019 (see BioNews 1097). According to the HFEA, the typical patient undergoing treatment will have a single fresh embryo transferred in their first cycle with additional embryos stored for use in subsequent cycles.

It is clear that the advancement in such techniques has offered many people the opportunity to have a biological family, who otherwise would not, and embarking on such treatment as a couple is an exciting yet anxious and daunting time. However, storing embryos for future use, means couples run the risk of eventually facing the difficult and often unanticipated question of what should happen to embryos they created together, in the event their relationship breaks down. This is an increasingly challenging area and one which raises extremely sensitive and emotive questions.

At present embryos created for fertility treatment can be stored for a maximum of 10 years under the Human Fertilisation and Embryology Act 1990 (although this has been extended to 12 years due to the COVID-19 pandemic and there are calls to increase it further). A central concept within fertility treatment is that of consent, and whether these frozen embryos, following a separation, can then continue to be stored, used for treatment, or destroyed is dependent on the mutual consent of the parties. By law, the embryos can only be used for the purposes that each of the parties have given their consent to.

At the outset of treatment, the parties' consent is recorded by the completion of various forms with the fertility clinic, however, it is possible for either party to change their mind and subsequently withdraw or vary their consent, in writing, at any point up to the implantation of the embryo in the womb in the UK. This withdrawal or variation can give rise to some difficult and distressing situations.

In the event that one party withdraws their consent to the continued storage of the embryo, then the law requires the fertility clinic to take all reasonable steps to notify those due to be treated with that embryo of the withdrawal. A 12-month cooling-off period is triggered from the date the fertility clinic receives the written withdrawal of consent, during which the embryos will continue to be stored – but cannot be used – to enable the parties to consider their position and the way forward.

After 12 months if both parties do not consent to the continued storage, the embryos will be destroyed. This is a distressing situation for parties following separation where one party is making the difficult decision to destroy the embryos whilst the other wishes to continue to keep them for potential use in the future. This raises such deeply personal and emotional concerns for all involved.

This issue has been challenged through the courts and through to the European Court of Human Rights where the court had to balance one party's wish to use the embryos and the other party's objection to the use of them. The court held that the right to respect for family life did not override the fact that the other party had withdrawn their consent to the embryos being used. The court determined that it has no power to intervene on behalf of the party who wants their embryos to be preserved.

An increasing and not uncommon aspect to the use of embryos is where a separating couple, who remain on amicable terms, are considering moving forwards with using the embryos post-separation. This can raise difficult issues practically, legally, and also emotionally as each party endeavours to understand their role and respective legal positions.  Often, the parties have been on a long journey and despite the separation, they may still wish to support the other in the use of the embryos, whether on a co-parenting basis or one party moving forwards with sole treatment. Consent to one party moving forwards with the use of the embryos solely is often sought on the condition that the other has no legal status or financial responsibility for any child born, and this is a complicated and grey area of the law.

If the parties are married or in a civil partnership and use the embryos in treatment, then both parties will be considered the legal parents unless one party can evidence that they did not consent to the treatment, and this is a complicated legal question. This applies equally whether the second parent is biologically related to the child or whether donor sperm is used. If the parties were not married or civil partners and treatment was with donated sperm or embryos, then in the event of relationship breakdown consideration should be given to any variation or withdrawal of consent to legal parenthood. The law is especially complicated if the embryos were created with the sperm of the former partner and he seeks to donate the embryo to the other party for sole use.

The issues which surround the use of an embryo created in treatment together are wide and far-reaching for the individuals concerned. The strict application of the law can lead to difficult and emotionally challenging situations. The storage and use of the embryos continues to be a matter of mutual consent and in the event of a relationship breakdown, careful consideration needs to be given to the best way forward for both parties involved.

5 July 2021 - by Trine Skuland, Dr Birgit Kvernflaten and Joona Räsänen
It is becoming clear that our gene functions are influenced by a variety of epigenetic factors throughout our lives and even before we are conceived. Environmental context may affect gene expression and which genes are 'activated' or not in children conceived via IVF may be influenced by the dietary and lifestyle habits of an embryo's parents or grandparents, as well as by the culture medium in which eggs and embryos are kept in vitro. These findings have implications for the way we think about fertility, assisted reproduction, and genetic identity.

Epigenetics and bioethics of human embryonic development is a multidisciplinary project that spans disciplinary boundaries in order to better understand how scientists, clinicians, patients, and society should respond to these challenges. The project is funded by the University of Oslo Life Sciences, as part of its convergence environments initiative which has seen interdisciplinary research groups formed to address major health and environmental challenges faced. The project started in 2017, and is now drawing towards its close. Here, three of our project members explain their work within the project.

Trine Skuland is a developmental biologist who works on epigenetic regulation of early embryo development.

When an egg and a sperm unite to form a zygote, numerous events need to be coordinated in order to achieve successful development. Out of the ~30,000 human genes, the right selection has to be switched on/off at the appropriate time point. No wonder these events are error-prone!

Upon fertilisation, extensive reprogramming happens in order to reset the epigenetic marks of the egg and the sperm DNA, and to set up a new pattern that is compatible with further embryo development. Epigenetic marks are chemical groups that are attached either to the DNA itself or to the proteins the DNA wraps around inside the cell nucleus. The pattern of these epigenetic marks will decide whether genes are activated or silenced.

When an embryo reaches the eight-cell stage, one of the most critical events takes place. This is when the first major set of genes is activated. My team is currently studying one specific epigenetic mark that we think is important for the embryonic genome activation and we hope our research will contribute in further characterisation of epigenetic factors involved in this crucial part of embryo development.

Our aim is to find another piece of the big genome activation puzzle in order to get a more complete picture of what is necessary for normal embryo development. This is as more than half of the embryos created during assisted reproduction develop abnormally and have to be discarded. Our ultimate goal is giving infertile people higher quality embryos to increase their chances of becoming parents.

Birgit Kvernflaten is a medical anthropologist who looks at prospective parents' experiences of assisted reproductive technologies. 

My role in the project is to explore prospective parents' experiences and perspectives of practices and treatments used in assisted reproduction. It starts from the idea that their experiences do not take place in a vacuum, but are shaped within a particular socio-cultural and political context. The project further aims to explore and understand prospective parents' experiences and perceptions of the status of the embryo, embryo donation, research, and selection, in light of increased epigenetic knowledge.

This project has highlighted how prospective parents' experiences of infertility treatment are related to and shaped by social and cultural discourses on Norwegian family life.

In Norway, biological or genetic ties are considered central to people's understanding of kinship and identity, shaping couples' negotiations about gamete donation, family, relationships, and responsibilities. Yet people's understanding of genes is also ambiguous. As for the concept of epigenetics; it seems it has not yet entered the public's imagination.

Although the role of environmental factors in shaping who we are is acknowledged in Norwegian society, couples tend to view genetics in a rather deterministic way, in that they believe it shapes both looks, personality, and risk of disease. While difficult to truly grasp, the role of genetics is central to people's ideas about reproduction and parenthood. New epigenetic knowledge raises questions about the interface between nature and nurture, as well as opening up discussion related to the role mothers and their bodies play in determining the health of future offspring.

Joona Räsänen is a bioethicist who works on the philosophical and ethical implications of epigenetics.

Epigenetics raises challenging ethical issues throughout the human life cycle. Epigenetic transmission from one generation to the next may raise questions of moral responsibility of parents and grandparents. Epigenetics plays an important role in a range of chronic diseases, such as diabetes. Our lifestyle habits during pregnancy and even before, may influence whether our future children will live healthy lives or suffer from lifelong illness.

It is commonly known that we should eat healthily for our own sake, but these developments in our understanding of epigenetic could imply that we should eat healthily for the sake of our future children as well. Does this demand too much of future parents?

Epigenetics seems to put prospective parents under pressure since they would be partly responsible for their future child's health even before the child is conceived. Pregnant women are often advised to abstain from alcohol and tobacco, but maybe it is worth reminding them to eat healthily as well – and this advice applies not only to future mothers, but to prospective fathers too, since epigenetic inheritance occurs through the male germline as well.

Conclusion

The interplay between science, anthropology, and philosophy in the context of epigenetics is complex. Skuland notes that a key aim for scientists working to unravel the epigenetic mechanisms involved in early embryo development, is to fulfil the needs of IVF patients to have their 'own' child. Dr Kvernflaten shows how genetics is central to patients' ideas about kinship and identity, yet epigenetics is still something unfamiliar to most prospective parents. Räsänen's example suggests that if parents did take on board some of the moral implications of epigenetics, they might find that the scope of their responsibility for future offspring is dramatically expanded.

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