Download Dr. V. Jamuna

Ethics in Infertility treatment
A study of practices in Allopathy
and Siddha medicine
Dr.V.Jamuna
Dr.Aruna Sivagami
Contents
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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
Introduction
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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
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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
Infertility
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Infertility is the inability to conceive after
attempting to do so for 1 year.
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It occurs in about 10%-15% of couples
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It is a result of physiological problems in either
partner
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Increasing prevalence a cause for concern
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Attributed largely to changes in
lifestyle,environment and pollution.
How big is it a problem?
10
20
20
50
Male
Combined
Female
Unknown
Source: American college of Obstetricians and Gynecologists
Common Causes for Infertility
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MALE
Azoozspermia
Oligospermia
Vas block
Varicoceles
Hormonal Deficiency
Genetic disorders
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FEMALE
Anovulation
Fallopian tube block
Endometriosis
Hormonal Imbalance
Anatomical
abnormalities
Genetic disorders
Treatment / Procedures - Allopathic
Practitioners
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Male Infertility
– Hormonal therapy to increase Sperm counts
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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 Options
Exogenous
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IUI
ICSI
Sperm extraction
GIFT
ZIFT
Unethical Practices of Allopathic Medicine Criticism
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Adverse effects of supra-normal doses of hormones
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False hopes to the patients
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Low Percentage of Success of Tuboplasty & In vitro
fertilization
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High-cost treatments- out of reach for some couples
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Legal status of embryos fertilized and not transferred
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IVF’s have a higher percentage of Multiple
pregnancies leading to Medical and Social problems
for the Family
Unethical Practices of Allopathic Medicine Criticism
(cont…..)
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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.
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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 issues
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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 …..contd
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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
Mother & Child….!
Treatment / Steps followed in Siddha
System of medicine
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Includes new combinations of herbal drugs not available in other
systems
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Aimed at providing a Healthy life and not just the cure of
symptoms.
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System based on “ Tridosha” – humoral theory akin to modern
Endocrinology
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System inculcates good cultural principles & moral conduct
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System based on natural herbs and Ingredients rendering new
impetus for stimulation of active life
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Siddha Rx paves the way for restoration of the potency of
obstructed fallopian tubes without any surgery.
Treatment / Steps followed in Siddha
System of medicine
contd..
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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
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Use of cotton Garments [particularly inner wears]
Regular exercise in the form of walking or jogging…
Treatment modalities –Endogenous
(Ref. Indian Medicinal Plants, Arya Vaidya Sala )
Aloe indica
Withania somnifera
Terminalia chebula
Phyllanthus niruri
Treatment modalities –Endogenous
(Ref. Indian Medicinal Plants, Arya Vaidya Sala )
Phyllanthus emblica
Piper longum
Phylanthus reticulatus
Terminalia bellirica
Treatment modalities –Endogenous
(Ref. Indian Medicinal Plants, Arya Vaidya Sala )
Polyalthia longifolia
Smilax china
All the above mentioned points
are rationally proven and not
mere “BLIND BELIEFS”
Unethical Practices of Traditional
Medicine & Criticisms
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Issues of compatibility between varieties of
Traditional medicine & the scientific method
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Lack of proper testing or Evidence based
Medicine (EBM)
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No Randomized Control trials
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Safety aspects
Ethical issues- Endogenous
medicine
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Long duration of treatment- dilemma for
already old patient
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Unscrupulous practices by Medical
Practioners
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False hopes and magic cures being offered
Case histories –Successful candidates
CASE STUDY 1
( With Consent from patients)
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Mr.Bhasker & Dr.Kumudha M.D
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Date of Consultation : Feb 2005
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Cause of Infertility:
– Pelvic scan revealed –Polycystic ovarian disease
– HSG – Block in both fallopian tubes at distal ends
– Normal Semen analysis
HSG -blocked
Clinical discussion
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Investigations performed
– Semen analysis
– Pelvic Scan
– HSG
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Counseling on
– Current medical status
– Rx that they have received
– Risk involved with the treatment
– Success rate of the treatment
Result
HSG – Patent Fallopian Tubes
USG - Pregnancy
Outcome
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Effects of treatment (Medicines,
Food, habits) were explained to
the patient
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Treatment taken for 13 months
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Couple conceived in March
2006
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Dr.Kumudha being an
Allopathic Doctor did not do
any unnecessary investigations
knowing the low success
percentages.
Case Study 2
( With Consent from patients)
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Mr.Franklin Samuel 31 yrs
 Mrs. Catherine Samuel 27 yrs
 Date of Consultation: December 2000
 Cause for Infertility:
– Azoospermia
– No significant problem in female
Clinical discussion
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Investigations performed
– Semen analysis
– Pelvic Scan
– HSG
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Counseling on
– Current medical status
– Rx that they have received
– Risk involved with the
treatment
– Success rate of the
treatment
Result
Outcome
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Effects of treatment
(Medicines, Food, habits)
were explained to the
patient
Treatment taken for 15
months
Mrs.Catherine Conceived
on Feb 2002
Ethical issues
Unnecessary investigations
performed
Invg in Mr.Franklin
Invg. on Mrs.Catherine
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Testicular Biopsy
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Hormonal therapy
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Hormonal therapy
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Diagnostic Laproscopy
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Steroid administration
Case histories –Successful candidates
CASE STUDY 3
( With Consent from patients)
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Mr. Singaravelan
 Mrs. Kalaivani
 Date of Consultation: 19th April 1999
 Cause for Infertility:
– Bilateral Fallopian tube block
– No Significant problems in Male
Clinical discussion
Discharge Summary –CMC
Vellore
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Investigations performed
– Semen analysis
– Pelvic Scan
– HSG
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Counseling on
– Current medical status
– Rx that they have received
– Risk involved with the
treatment
– Success rate of the
treatment
Result
HSG report –Blocked tubes
Pregnancy Test- Positive
Outcome
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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 candidates
CASE STUDY 4
( With Consent from patients)
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Mr. Muthukumar
 Mrs. Chitra Devi
 Date of Consultation: 9th May 2001
 Cause for Infertility:
– Bilateral Fallopian tube block in Female
– Azoospermia in Male counterpart
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Combined cause for Infertility
Clinical discussion
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Investigations performed
– Semen analysis
– Pelvic Scan
– HSG
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Counseling on
– Current medical status
– Rx that they have received
– Risk involved with the
treatment
– Success rate of the
treatment
Investigations
HSG report –Blocked tubes
Semen Analysis- Azoospermia
Result of treatment
HSG report –Patent tubes
Semen Analysis -Normal
Outcome
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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 case
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Couple advised
– Surgery for removing Fallopian tube blocks
– Donor Insemination
– Expensive In-vitro fertilization techniques
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But the same couple received Siddha treatment
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They had a Spontaneous conception
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Now they are healthy & happy
Bio ethical dilemmas - 1
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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 -2
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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 3
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A 35 & 32 yr old couple with female factor infertility
(blocked fallopian tubes)
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Assured of 100% success with IVF
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Sold his house to mobilize money for the IVF
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Was not Successful in conception by IVF
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Heart broken & homeless !
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NO HOME and NO HEIR!
Bio ethical dilemmas- 4
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44 yr old male & 42 yr old female sought
consultation for male factor infertility
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Received treatment for 2 years with herbal
medicines
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Male factor infertility resolved
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But, wife had a menopause after 2 years
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Husband wants to remarry …?
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Should the Man pause now…?
Bio ethical dilemmas- 5
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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…….
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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
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There are Pros & Cons in both systems of Medicine
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Both of them have situations that are pose Ethical
dilemmas
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An ideal balance taking the pros of each of the
systems should be followed
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Patient care of utmost importance ..!
NOT THE SYSTEM OF MEDICINE
“First ,Do no harm”
Hippocrates