Ethics in Infertility treatmentEthics in Infertility treatmentA study of practices in Allopathy A study of practices in Allopathy

and Siddha medicineand Siddha medicine

Dr.V.Jamuna

Dr.Aruna Sivagami

ContentsContents Introduction Treatment / Procedures - Allopathic Practitioners Unethical Practices of Allopathic Medicine -

Criticism Treatment / Steps followed in Siddha System of

medicine Unethical Practices of Traditional Medicine –

Criticism Case History of successful patients treated through

Siddha system of Medicine Conclusion

IntroductionIntroduction

Medical ethics is the discipline of evaluating the merits, risks and social concerns of activities in the field of medicine.

Six of the principles which in common doctors should consider while decision making.– Beneficence– Non- Malificence– Autonomy – Justice– Dignity– Truthfulness and honesty

This presentation focuses upon ethical and unethical medical practices in treating infertility amongst man and woman in India

InfertilityInfertility

Infertility is the inability to conceive after

attempting to do so for 1 year.

It occurs in about 10%-15% of couples

It is a result of physiological problems in either

partner

Increasing prevalence a cause for concern

Attributed largely to changes in

lifestyle,environment and pollution.

How big is it a problem?How big is it a problem?

20

20

50

10

Male FemaleCombined Unknown

Source: American college of Obstetricians and Gynecologists

Common Causes for InfertilityCommon Causes for Infertility

MALE Azoozspermia Oligospermia Vas block Varicoceles Hormonal Deficiency Genetic disorders

FEMALE Anovulation Fallopian tube block Endometriosis Hormonal Imbalance Anatomical

abnormalities Genetic disorders

Treatment / Procedures - Allopathic Treatment / Procedures - Allopathic PractitionersPractitioners

Male Infertility– Hormonal therapy to increase Sperm counts

Female Infertility (Ref. Novak’s Textbook of Gynecology )

– Medication to stimulate the ovaries to “ripen” and release eggs (e.g.: Clomiphene citrate)

– Surgery to restore patency of obstructed fallopian tubes ( Tuboplasty )

– Artificial insemination which involves the woman being inseminated with Husband / donor sperm.

– Invitro fertilization (IVF) in which eggs are removed from the woman, fertilized and then placed in the woman’s uterus bypassing the fallopian tubes.

Treatment OptionsTreatment Options

Exogenous IUI ICSI Sperm extraction GIFT ZIFT

Unethical Practices of Allopathic Medicine - Unethical Practices of Allopathic Medicine - CriticismCriticism

Adverse effects of supra-normal doses of hormones

False hopes to the patients

Low Percentage of Success of Tuboplasty & In vitro

fertilization

High-cost treatments- out of reach for some couples

Legal status of embryos fertilized and not transferred

IVF’s have a higher percentage of Multiple

pregnancies leading to Medical and Social problems

for the Family

Unethical Practices of Allopathic Medicine - Unethical Practices of Allopathic Medicine - Criticism Criticism (cont…..)(cont…..)

Psychological impact – Anxious to conceive – creates and worsened Marital

discord– Clinical depression rates among Women undergoing

Infertility treatment similar to those with Cancer or Heart disease.

Medications like Steroids & Anti-fungals known to cause Infertility

Surgical complications of Diagnostic procedures (Diagnostic laproscopy)

Birth defects are increased with the use of IVF in general and ICSI specifically.

Ethical issuesEthical issues Issues regarding Donor

Insemination– Emotional turmoil of Father– Emotional turmoil of Child– Lack of paternal bonding by

children – Legal issues regarding

property rights, etc– Possibility of genetic disorders

being transmitted through Donor insemination

– Use of unauthorized Donor Insemination

Ethical issues …..contdEthical issues …..contd

Issues regarding Surrogacy– Joy of Motherhood – taken

away– Risk of Fetal Well being due to

surrogacy– Bio-ethical dilemmas in

commercial surrogacy

Emotional bonding between Emotional bonding between Mother & Child….!Mother & Child….!

Treatment / Steps followed in Siddha Treatment / Steps followed in Siddha

System of medicineSystem of medicine Includes new combinations of herbal drugs not available in other

systems

Aimed at providing a Healthy life and not just the cure of

symptoms.

System based on “ Tridosha” – humoral theory akin to modern

Endocrinology

System inculcates good cultural principles & moral conduct

System based on natural herbs and Ingredients rendering new

impetus for stimulation of active life

Siddha Rx paves the way for restoration of the potency of

obstructed fallopian tubes without any surgery.

Treatment / Steps followed in Siddha Treatment / Steps followed in Siddha System of medicineSystem of medicine contd..contd..

Use of Herbal Medicines Lifestyle changes

– Dietary Changes Eating in Clay vessels, Banana leaves High fiber ,Low Cholesterol diet Avoid preserved Foods

– Personal habits Smoking should be avoided Complete avoidance of alcohol Avoidance of Recreational drug use Complete Avoidance of extra marital affairs or any other abnormal

sexual activities

Use of cotton Garments [particularly inner wears] Regular exercise in the form of walking or jogging…

Treatment modalities –EndogenousTreatment modalities –Endogenous (Ref. Indian Medicinal Plants, Arya Vaidya Sala )(Ref. Indian Medicinal Plants, Arya Vaidya Sala )

Aloe indica

Withania somnifera Phyllanthus niruri

Terminalia chebula

Treatment modalities –EndogenousTreatment modalities –Endogenous (Ref. Indian Medicinal Plants, Arya Vaidya Sala )(Ref. Indian Medicinal Plants, Arya Vaidya Sala )

Phyllanthus emblica

Piper longum Terminalia bellirica

Phylanthus reticulatus

Treatment modalities –EndogenousTreatment modalities –Endogenous(Ref. Indian Medicinal Plants, Arya Vaidya Sala )(Ref. Indian Medicinal Plants, Arya Vaidya Sala )

Polyalthia longifolia Smilax china

All the above mentioned points All the above mentioned points are rationally proven and not are rationally proven and not

mere “BLIND BELIEFS”mere “BLIND BELIEFS”

Unethical Practices of Traditional Unethical Practices of Traditional Medicine & CriticismsMedicine & Criticisms

Issues of compatibility between varieties of

Traditional medicine & the scientific method

Lack of proper testing or Evidence based

Medicine (EBM)

No Randomized Control trials

Safety aspects

Ethical issues- Endogenous Ethical issues- Endogenous medicinemedicine

Long duration of treatment- dilemma for

already old patient

Unscrupulous practices by Medical

Practioners

False hopes and magic cures being offered

Case histories –Successful candidatesCase histories –Successful candidatesCASE STUDY 1CASE STUDY 1

( With Consent from patients)( With Consent from patients)

Mr.Bhasker & Dr.Kumudha M.D

Date of Consultation : Feb 2005

Cause of Infertility:

– Pelvic scan revealed –Polycystic ovarian disease

– HSG – Block in both fallopian tubes at distal ends

– Normal Semen analysis

HSG -blockedHSG -blocked

Clinical discussionClinical discussionInvestigations performed

– Semen analysis– Pelvic Scan– HSG

Counseling on– Current medical status– Rx that they have received– Risk involved with the treatment – Success rate of the treatment

ResultResultHSG – Patent Fallopian Tubes USG - Pregnancy

OutcomeOutcome

Effects of treatment (Medicines,

Food, habits) were explained to

the patient

Treatment taken for 13 months

Couple conceived in March

2006

Dr.Kumudha being an

Allopathic Doctor did not do

any unnecessary investigations

knowing the low success

percentages.

Case Study 2Case Study 2 ( With Consent from patients)( With Consent from patients)

Mr.Franklin Samuel 31 yrsMrs. Catherine Samuel 27 yrsDate of Consultation: December 2000Cause for Infertility:

– Azoospermia– No significant problem in female

Clinical discussionClinical discussion

Investigations performed– Semen analysis– Pelvic Scan– HSG

Counseling on– Current medical status– Rx that they have received– Risk involved with the

treatment – Success rate of the

treatment

ResultResult

OutcomeOutcome

Effects of treatment (Medicines, Food, habits) were explained to the patient

Treatment taken for 15 months

Mrs.Catherine Conceived on Feb 2002

Ethical issuesEthical issuesUnnecessary investigations Unnecessary investigations

performedperformedInvg in Mr.Franklin

Testicular Biopsy

Hormonal therapy

Steroid administration

Invg. on Mrs.Catherine

Hormonal therapy

Diagnostic Laproscopy

Case histories –Successful candidatesCase histories –Successful candidatesCASE STUDY 3CASE STUDY 3

( With Consent from patients)( With Consent from patients)

Mr. SingaravelanMrs. KalaivaniDate of Consultation: 19th April 1999Cause for Infertility:

– Bilateral Fallopian tube block– No Significant problems in Male

Clinical discussionClinical discussion

Investigations performed– Semen analysis– Pelvic Scan– HSG

Counseling on– Current medical status– Rx that they have received– Risk involved with the

treatment – Success rate of the

treatment

Discharge Summary –CMC Vellore

ResultResultHSG report –Blocked tubes Pregnancy Test- Positive

OutcomeOutcome

Effects of treatment (Medicines, Food, habits) were explained to the patient

Treatment taken for 20 months

Mrs. Kalaivani conceived on Jan 2001

Case histories –Successful candidatesCase histories –Successful candidatesCASE STUDY 4CASE STUDY 4

( With Consent from patients)( With Consent from patients)

Mr. MuthukumarMrs. Chitra DeviDate of Consultation: 9th May 2001Cause for Infertility:

– Bilateral Fallopian tube block in Female– Azoospermia in Male counterpart

Combined cause for Infertility

Clinical discussionClinical discussion

Investigations performed– Semen analysis– Pelvic Scan– HSG

Counseling on– Current medical status– Rx that they have received– Risk involved with the

treatment – Success rate of the

treatment

InvestigationsInvestigationsHSG report –Blocked tubes Semen Analysis- Azoospermia

Result of treatmentResult of treatmentHSG report –Patent tubes Semen Analysis -Normal

OutcomeOutcome

Effects of treatment (Medicines, Food, habits) were explained to the patient

Treatment taken for 4 years

Mrs. Chitradevi conceived on 10th Feb 2005

Ethical issues in this caseEthical issues in this case

Couple advised

– Surgery for removing Fallopian tube blocks

– Donor Insemination

– Expensive In-vitro fertilization techniques

But the same couple received Siddha treatment

They had a Spontaneous conception

Now they are healthy & happy

Bio ethical dilemmas - 1Bio ethical dilemmas - 1 A 36 yr old lady & her husband consulted for Infertility

in a Major South Indian hospital Investigations revealed Sperm count abnormality in the

Husband (Azoozspermia) Underwent Artificial Insemination with Husbands

Sperms Conceived & Delivered a Healthy boy baby DNA testing after 1 yr revealed no Paternal links Investigations revealed Patient Underwent DONOR

Insemination without consent at Hospital Legal opinion sought and has filed for divorce. Future of the child ? ? ?...

Bio ethical dilemmas -2Bio ethical dilemmas -2 A 32 & 30 yr old couple sought consultation for

male factor infertility They already had a child through Artificial

Insemination by Donor (AID) Father expressed a desire for a own child Underwent Endogenous treatment for Male factor

Infertility (Oligospermia) Successful spontaneous conception Delivered a healthy baby Father now shuns the earlier child from AID

Bio ethical dilemmas 3Bio ethical dilemmas 3

A 35 & 32 yr old couple with female factor infertility

(blocked fallopian tubes)

Assured of 100% success with IVF

Sold his house to mobilize money for the IVF

Was not Successful in conception by IVF

Heart broken & homeless !

NO HOME and NO HEIR!

Bio ethical dilemmas- 4Bio ethical dilemmas- 4

44 yr old male & 42 yr old female sought

consultation for male factor infertility

Received treatment for 2 years with herbal

medicines

Male factor infertility resolved

But, wife had a menopause after 2 years

Husband wants to remarry …?

Should the Man pause now…?

Bio ethical dilemmas- 5Bio ethical dilemmas- 5 A 33 & 28 yr old couple with male factor infertility

consulted a Endogenous Practitioner. Was started on a regimen of Drugs without basic

Medical Investigations (RFT) During treatment Patient developed facial puffiness &

Pedal edema Was Diagnosed as a Case of heavy metal induced Renal

failure Patient now on regular dialysis. No dreams of becoming a Father Just wants to live…………!!!

Solutions…….Solutions……. The Indian Government is in the process of regulating

ethical practice in Assisted reproductive technique by implementing a law.

Knowledge levels of patient regarding Medical treatment must improve.

Public awareness on resources available for treatment should increase.

Doctor-Patient relationship to improve with both having a fair view of the situation.

Medical practitioners to have high Ethical /Moral values Medical practitioners should NEVER advertise in media

to garner patients , should only offer Health information.

Conclusion Conclusion

There are Pros & Cons in both systems of Medicine

Both of them have situations that are pose Ethical

dilemmas

An ideal balance taking the pros of each of the

systems should be followed

Patient care of utmost importance ..!

NOT THE SYSTEM OF MEDICINE

““First ,Do no harm”First ,Do no harm”HippocratesHippocrates