|Year : 2015 | Volume
| Issue : 7 | Page : 57-61
Ethical issues in newer assisted reproductive technologies: A view from Nigeria
JO Fadare1, AA Adeniyi2
1 Department of Pharmacology, College of Medicine, Ekiti State University, Ado-Ekiti, Nigeria
2 Department of Obstetrics and Gynaecology, Federal Teaching Hospital, Ido-Ekiti, Nigeria
|Date of Web Publication||1-Dec-2015|
J O Fadare
Department of Pharmacology, College of Medicine, Ekiti State University, Ado-Ekiti
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Infertility is a prevalent condition in many developing countries with significant physical and psychosocial implications. The aim of this study is to discuss briefly the ethics of newer assisted reproductive technology (ART) with special emphasis on the peculiarities in Nigeria.
Methods: MEDLINE and Google Scholar were searched for English-language articles from January 1990 to July 2014 using the search terms "ethics of ART AND Nigeria," "ethical issues in in vitro fertilization AND Nigeria." Using the above search phrases, a total of 43 articles were retrieved out of which only 5 dealt specifically with the subject matter.
Results: The core ethical issues found in the reviewed literature are listed in [Table 1]. Inequitable access to ART due to its high cost, lack of regulatory body, safety of the procedure, and fate of the embryos were the main themes identified from the papers. Surrogacy, sex selection, and gamete donation were additional relevant ethical issues.
Conclusion: There is an urgent need for stakeholders in developing countries to formulate cultural and context-specific guidelines to help address some of these ethical dilemmas.
Keywords: Assisted reproduction, ethics, infertility, in vitro fertilization, Nigeria
|How to cite this article:|
Fadare J O, Adeniyi A A. Ethical issues in newer assisted reproductive technologies: A view from Nigeria. Niger J Clin Pract 2015;18, Suppl S1:57-61
|How to cite this URL:|
Fadare J O, Adeniyi A A. Ethical issues in newer assisted reproductive technologies: A view from Nigeria. Niger J Clin Pract [serial online] 2015 [cited 2019 Nov 18];18, Suppl S1:57-61. Available from: http://www.njcponline.com/text.asp?2015/18/7/57/170823
| Introduction|| |
Infertility is a prevalent condition in many countries with its impact more prominent in the developing countries of Africa and Asia. The burden of infertility as shown by its prevalence varies across the world; studies from Nigeria, Ghana recorded the prevalence of 30.3% and 11.8%, respectively, while a study involving 27 African countries found a range of between 10% and 20%.,, These values are higher when compared with results from studies carried out in more developed nations of the North; studies conducted in Scotland and the USA found the prevalence of 9.1% and 10%, respectively., Infertility has been classified as primary and secondary with the latter being responsible for the majority of the cases in low- and middle-income countries (LMIC)., Furthermore, since reproduction requires the union of male and female gametes, classification of infertility based on male and female factor has also been in use. In Nigeria, studies have shown that tubal problems secondary to sexually transmitted diseases, postpartum pelvic infections, unsafe abortions, genital mutilation, and childhood marriage and its complications are some of the common causes of female factor infertility., Male factor infertility has also been well investigated in Nigeria with some studies recording 11.4% and 42.2% of infertility being caused by male factor alone., The psychological, social, and economic problems associated with infertility in LMIC are immense ranging from the breakdown of marriages, physical violence, rejection by the society, and poverty.,,, This is because of the pronatalist nature of these societies where parenthood is almost mandatory. Adoption of children is also not very popular in these countries, making this alternative unattractive for people with infertility., Since the success of the first in vitro fertilization (IVF) baby in 1978, a lot of new methods of assisted reproduction has been developed and used routinely. Recent developments in assisted reproductive technology (ART) include intracytoplasmic sperm injection (ICSI), preimplantation genetic diagnosis (PGD), and cryopreservation. In Nigeria, the first "test-tube" baby was delivered in 1989 at the Lagos University Teaching Hospital, and since then, many more IVF clinics have been established. The exact number of these clinics is not known because of constant proliferation, but data from 2013 showed about 30 located mainly in the major cities of Lagos, Abuja, and Port Harcourt. Presently, IVF is mainly private sector driven with over 80% of the market carrying out basic IVF, and some have recently commenced more advanced procedures such as ICSI and PGD. Most of these centers are owned and operated by Nigerians with some technical, collaborative support from institutions from Europe and the United States of America. Despite the proliferation of IVF clinics in Nigeria, there is no regulatory body to oversee and set standard for the practice of assisted reproduction in Nigeria. The use of ART has always elicited ethical concerns worldwide; the main objective of this review is to discuss the ethics of ART with special emphasis on the peculiarities in Nigeria.
| Methods|| |
A literature review was conducted using databases such as MEDLINE, PubMed, and Google Scholar. The databases were searched for English-language articles published between January 1990 and July 2014 relating to the ethics of ART. Search terms included "ethics* of ART AND Nigeria," "ethical issues in IVF AND Nigeria." Using the above search phrases, a total of 43 articles were retrieved out of which only 5 dealt specifically with the subject matter.
| Results|| |
The core ethical issues found in the reviewed literature are listed in [Table 1].,,,, The unnatural means of conception, inequitable access to ART due to its high cost, lack of regulatory body, safety of the procedure, and fate of the embryos were the main themes identified from the papers. Other ethical problems are surrogacy, sex selection, and gamete donation.
|Table 1: Summary of relevant papers on ethics of assisted reproductive technologies in Nigeria|
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| Discussion|| |
The noncoital means of conception
The concept of reproduction without coitus has generated a lot of controversy in religious circles. The stance of the Catholic Church is based on the status of the embryo as a person right from conception while the Protestant movement has a gradualist view of personhood., The Sunni and Shia Islamic sects are in support of assisted reproduction in general with differences of opinion on issues such as third-party gamete donation and surrogacy.
Inequitable access to assisted reproductive technology
Equitable access to IVF remains a fundamental issue in Nigeria where only a small fraction of the populace haves access to health insurance, which does not cover expensive procedures such as IVF. The cost of a cycle of IVF treatment in Nigeria at the moment varies between 3000 and 10,000 US Dollars; this in a country, where the national monthly minimum wage is approximately 110 US Dollars. According to studies from other emerging nations such as Brazil and South Africa, ART is also mainly private sector driven, expensive and may be unaffordable for those in need., This is in contrast to the practice in many European countries where a specific number of cycles of IVF treatment are reimbursed by their governments.
Complications of procedure and quality assurance
The safety of the various procedures during IVF has always been a topic for discussion. The adverse effects of ovarian stimulation are well-documented. The introduction of newer drugs and modification of the procedure to mitigate these effects had led to some improvement in this aspect. Multiple pregnancy and its attendant complications during pregnancy or childbirth is one major issue with IVF. This is due to the transfer of multiple embryos to the uterus to ensure that at least one or two survive and develop until birth. With increasing sophistication and fine-tuning of the procedure, fertility specialists around the world are now able to transfer 1–2 embryos with very good outcomes., Studies from Nigeria have shown the average number of transferred embryos is between 2 and 5, and this is t mainly due to economic reasons and the fear of failure.,, On the contrary, between 1 and 2 embryos were transferred in a report from the South African Register of ART. The fewer number of transferred embryos reported here is likely due to the longer experience with ART and better technical expertise.
Quality assurance of the procedure remains an important factor that must be addressed in emerging economies of the world. Because of lack of national regulatory agencies in most developing countries, most IVF clinics make their own rules and follow different standards. This does not augur well for the practice of assisted reproduction in these climes.
The need for regulation
The need for strict regulation of the practice of ART has led to the setting up of bodies such as the Human Fertilization and Embryology Authority (HFEA), which oversees and makes policy regarding ART in the UK. Presently, there is no law governing the practice of ART in Nigeria despite the relatively long duration of practice. Most ART centers in Nigeria and other developing countries operate based on HFEA guidelines; this practice, however, is not optimal as there are several contextual differences among the different countries. In Africa, only South Africa has legislated concerning ART to regulate the practice of assisted reproduction. A bill for the establishment of the "Nigerian Assisted Reproduction Authority" is before the Nigerian parliament for consideration and if passed will be a good starting point for regulation of ART practice in Nigeria.
Fate of extra embryos
The fate of extra embryos in the setting of LMIC is another problem; for how long do the fertility clinics store them and at what conditions; keeping in mind that power supply is a problem in Nigeria. Studies from developed countries have shown that the viability of the frozen embryos reduces with longer storage time., The fate of surplus embryos is another topical issue: Do they get donated to someone else or are they destroyed? The earlier stated views of the Catholic Church regarding the embryo and personhood present a strong argument against their destruction. The acceptability of third-party gamete is controversial, especially in the African setting. Bello et al. in a study conducted in Ibadan, Nigeria, found only 35.2% and 24.7% of women open to accepting donated eggs and sperm, respectively. Furthermore, the issue about parenthood (in the case of a sperm donor) comes to bear; what right does the donor have regarding the child? From the point of view of the child, is there a right to know about the means of his/her conception and biological parent? Co-modification of gametes is not considered a major ethical challenge presently, but stakeholders have been aware of this possibility in the future.
In the African culture, every woman wants to be a "mother," by delivering her baby through the natural means (per vaginam). This feeling has led to nonacceptance of cesarean section by some women as it makes them "less than a mother.", From this perspective, the practice of surrogacy may not be widely acceptable to many in developing countries such as Nigeria. In view of this, ethical dilemmas resulting from the practice of surrogacy such as the rights of the surrogate mother, psychological, and emotional effects on the offspring  may not be very important at the moment.
Assisted reproductive technology in people living with HIV
The high prevalence of HIV infection among people in the reproductive age group in Africa has brought a new dimension to this discussion on ethics of ART. The older arguments against ART in people living with HIV include the nondesirability of bringing HIV-infected babies into the world, the risk of children being orphaned early in life, and associated psychological consequences. With the introduction of highly active antiretroviral treatment (HAART), people living with HIV now have a longer lifespan., Furthermore, the availability of better procedures such as sperm washing during ICSI and the prevention of mother-to-child transmission using HAART have made the risk of transmission of infection insignificant., Results from these studies carried out among people living with HIV who had ART showed very good outcomes., These positive developments have made the case for access to ART for people living with HIV with a caveat that all necessary protocols need to be followed to prevent transmission of the infection to the newborn.
| Conclusion|| |
Looking at these ethical issues from the perspective of a developing country like Nigeria, access to ART remains the most critical problem. The safety, quality assurance, and regulation of ART are additional ethical dilemma that needs to be addressed. Other relevant issues are related to gamete donation and the concept of parenthood in the "African" setting. There is an urgent need for stakeholders (fertility specialists, clients, professional organizations, religious bodies, bioethicists, and government) in developing countries to formulate cultural and context-specific guidelines to help address some of these ethical dilemmas.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Adetoro OO, Ebomoyi EW. The prevalence of infertility in a rural Nigerian community. Afr J Med Med Sci 1991;20:23-7.
Geelhoed DW, Nayembil D, Asare K, Schagen van Leeuwen JH, van Roosmalen J. Infertility in rural Ghana. Int J Gynaecol Obstet 2002;79:137-42.
Ericksen K, Brunette T. Patterns and predictors of infertility among African women: A cross-national survey of twenty-seven nations. Soc Sci Med 1996;42:209-20.
Bhattacharya S, Porter M, Amalraj E, Templeton A, Hamilton M, Lee AJ, et al.
The epidemiology of infertility in the North East of Scotland. Hum Reprod 2009;24:3096-107.
Chandra A, Stephen EH. Impaired fecundity in the United States: 1982-1995. Fam Plann Perspect 1998;30:34-42.
Larsen U. Infertility in central Africa. Trop Med Int Health 2003;8:354-67.
Olatunji AO, Sule-Odu AO. The pattern of infertility cases at a university hospital. West Afr J Med 2003;22:205-7.
Umeora OU, Mbazor JO, Okpere EE. Tubal factor infertility in Benin City, Nigeria – Sociodemographics of patients and aetiopathogenic factors. Trop Doct 2007;37:92-4.
Ikechebelu JI, Adinma JI, Orie EF, Ikegwuonu SO. High prevalence of male infertility in southeastern Nigeria. J Obstet Gynaecol 2003;23:657-9.
Ugwu EO, Onwuka CI, Okezie OA. Pattern and outcome of infertility in Enugu: The need to improve diagnostic facilities and approaches to management. Niger J Med 2012;21:180-4.
Omoaregba JO, James BO, Lawani AO, Morakinyo O, Olotu OS. Psychosocial characteristics of female infertility in a tertiary health institution in Nigeria. Ann Afr Med 2011;10:19-24.
Ameh N, Kene TS, Onuh SO, Okohue JE, Umeora OU, Anozie OB. Burden of domestic violence amongst infertile women attending infertility clinics in Nigeria. Niger J Med 2007;16:375-7.
Yildizhan R, Adali E, Kolusari A, Kurdoglu M, Yildizhan B, Sahin G. Domestic violence against infertile women in a Turkish setting. Int J Gynaecol Obstet 2009;104:110-2.
Tabong PT, Adongo PB. Infertility and childlessness: A qualitative study of the experiences of infertile couples in Northern Ghana. BMC Pregnancy Childbirth 2013;13:72.
Nwobodo EI, Isah YA. Knowledge, attitude and practice of child adoption among infertile female patients in Sokoto north-west Nigeria. Niger Postgrad Med J 2011;18:272-5.
Oladokun A, Arulogun O, Oladokun R, Morhason-Bello IO, Bamgboye EA, Adewole IF, et al.
Acceptability of child adoption as management option for infertility in Nigeria: Evidence from focus group discussions. Afr J Reprod Health 2009;13:79-91.
Greer G. To have or not to have: The critical importance of reproductive rights to the paradox of population policies in the 21st
century. Int J Gynaecol Obstet 2009;106:148-50.
Ajayi RA, Dibosa-Osadolor OJ. Stakeholders' views on ethical issues in the practice of in-vitro
fertilisation and embryo transfer in Nigeria. Afr J Reprod Health 2011;15:73-80.
Ajayi RA, Dibosa-Osadolor OJ. Opinion of obstetricians and gynaecologists on ethical issues in the practice of in-vitro
fertilisation and embryo transfer in Nigeria. Afr J Reprod Health 2013;17:130-6.
Bingel DD. An ethical examination of the challenges of in-vitr
o fertilisation in Nigeria. Int Lett Soc Humanist Sci 2014;3:20-5.
Giwa-Osagie OF. Social and ethical aspects of assisted conception in anglophone sub-Saharan Africa. Current Practices and Controversies in Assisted Reproduction. 2002. p. 50.
Jegede AS, Fayemiwo AS. Cultural and ethical challenges of assisted reproductive technologies in the management of infertility among the Yoruba of southwestern Nigeria. Afr J Reprod Health 2010;14:115-27.
Birkhäuser M. Ethical issues in human reproduction: Protestant perspectives in the light of European protestant and reformed churches. Gynecol Endocrinol 2013;29:955-9.
Lanzone A. Ethical issues in human reproduction: Catholic perspectives. Gynecol Endocrinol 2013;29:953-4.
Inhorn MC. Making Muslim babies: IVF and gamete donation in Sunni versus Shi'a Islam. Cult Med Psychiatry 2006;30:427-50.
Huyser C, Boyd L. ART in South Africa: The price to pay. Facts Views Vis Obgyn 2013;5:91-9.
Makuch MY, Simônia de Padua K, Petta CA, Duarte Osis MJ, Bahamondes L. Inequitable access to assisted reproductive technology for the low-income Brazilian population: A qualitative study. Hum Reprod 2011;26:2054-60.
Berg Brigham K, Cadier B, Chevreul K. The diversity of regulation and public financing of IVF in Europe and its impact on utilization. Hum Reprod 2013;28:666-75.
Brison DR, Roberts SA, Kimber SJ. How should we assess the safety of IVF technologies? Reprod Biomed Online 2013;27:710-21.
Luke B, Brown MB, Morbeck DE, Hudson SB, Coddington CC 3rd
, Stern JE. Factors associated with ovarian hyperstimulation syndrome (OHSS) and its effect on assisted reproductive technology (ART) treatment and outcome. Fertil Steril 2010;94:1399-404.
Van Voorhis BJ, Ryan GL. Ethical obligation for restricting the number of embryos transferred to women: Combating the multiple-birth epidemic from in vitro
fertilization. Semin Reprod Med 2010;28:287-94.
Joint SOGC-CFAS. Guidelines for the number of embryos to transfer following in vitro
fertilization No 182, September 2006. Int J Gynaecol Obstet 2008; 102:203-16.
Okohue JE, Onuh SO, Ikimalo JI, Wada I. Patients' preference for number of embryos transferred during IVF/ICSI: A Nigerian experience. Niger J Clin Pract 2010;13:294-7.
Olukoya OY, Okeke CC, Kemi AI, Ogbeche RO, Adewusi AJ, Ashiru OA. Multiple gestations/pregnancies from IVF process in a fertility center in Nigeria, 2009-2011: Implementing policy towards fewer (double and single) embryo transfer. Nig Q J Hosp Med 2012;22:80-4.
Orhue AA, Aziken ME, Osemwenkha AP, Ibadin KO, Odoma G.In vitro
fertilization at a public hospital in Nigeria. Int J Gynaecol Obstet 2012;118:56-60.
Dyer SJ, Kruger TF. Assisted reproductive technology in South Africa:First results generated from the South African register of assisted reproductive techniques. S Afr Med J 2012;102(3 Pt 1):167-70.
Parliament SA. National Health Act No. 61 of 2003. Pretoria: Government Printers; 2003.
Wennerholm UB, Henningsen AK, Romundstad LB, Bergh C, Pinborg A, Skjaerven R, et al.
Perinatal outcomes of children born after frozen-thawed embryo transfer: A Nordic cohort study from the CoNARTaS group. Hum Reprod 2013;28:2545-53.
Veleva Z, Orava M, Nuojua-Huttunen S, Tapanainen JS, Martikainen H. Factors affecting the outcome of frozen-thawed embryo transfer. Hum Reprod 2013;28:2425-31.
Tangwa GB. Third party assisted conception: An African perspective. Theor Med Bioeth 2008;29:297-306.7
Bello FA, Akinajo OR, Olayemi O. In-vitro
fertilization, gamete donation and surrogacy: Perceptions of women attending an infertility clinic in Ibadan, Nigeria. Afr J Reprod Health 2014;18:127-33.
Aziken M, Omo-Aghoja L, Okonofua F. Perceptions and attitudes of pregnant women towards caesarean section in urban Nigeria. Acta Obstet Gynecol Scand 2007;86:42-7.
Enabudoso EJ, Ezeanochie MC, Olagbuji BN. Perception and attitude of women with previous caesarean section towards repeat caesarean delivery. J Matern Fetal Neonatal Med 2011;24:1212-4.
Armour KL. An overview of surrogacy around the world: Trends, questions and ethical issues. Nurs Womens Health 2012;16:231-6.
Englert Y, Van Vooren JP, Place I, Liesnard C, Laruelle C, Delbaere A. ART in HIV-infected couples: Has the time come for a change of attitude? Hum Reprod 2001;16:1309-15.
Miiro G, Todd J, Mpendo J, Watera C, Munderi P, Nakubulwa S, et al.
Reduced morbidity and mortality in the first year after initiating highly active anti-retroviral therapy (HAART) among Ugandan adults. Trop Med Int Health 2009;14:556-63.
Palella FJ Jr, Deloria-Knoll M, Chmiel JS, Moorman AC, Wood KC, Greenberg AE, et al.
Survival benefit of initiating antiretroviral therapy in HIV-infected persons in different CD4+cell strata. Ann Intern Med 2003;138:620-6.
Nicopoullos JD, Almeida P, Vourliotis M, Gilling-Smith C. A decade of the United Kingdom sperm-washing program: Untangling the transatlantic divide. Fertil Steril 2010;94:2458-61.
du Plessis E, Shaw SY, Gichuhi M, Gelmon L, Estambale BB, Lester R, et al.
Prevention of mother-to-child transmission of HIV in Kenya: Challenges to implementation. BMC Health Serv Res 2014;14 Suppl 1:S10.
Sauer MV, Chang PL. Establishing a clinical program for human immunodeficiency virus 1-seropositive men to father seronegative children by means of in vitro
fertilization with intracytoplasmic sperm injection. Am J Obstet Gynecol 2002;186:627-33.
Savasi V, Ferrazzi E, Lanzani C, Oneta M, Parrilla B, Persico T. Safety of sperm washing and ART outcome in 741 HIV-1-serodiscordant couples. Hum Reprod 2007;22:772-7.