Tackling real-world issues in human ARTs-the missing link between stakeholders

Few would argue about the troubling tenor of a past and current dialogue between stakeholders across the ART/MAR (medically assisted reproduction) landscape. Be they REI clinicians, the infertile (and fertile) patients they serve, basic scientists, industry, or society, the failure to communicate and integrate truth into the reproductive medicine enterprise is taking its toll-perhaps no more in evidence than in the first half of 2024.

With this backdrop, and evidenced by this month’s contents, we challenge our readership to engage and seek insight into a selection of topics tempting fate from all sectors willing to venture an ill-informed opinion or uneducated guess as to who, where, and why each stakeholder of ARTs has yet to tie the knot society needs at this critical juncture. That the societal pathophysiology of “embryoitis” is upon the ART and MAR drawing board should not be a surprise given past obsessions to define what we mean by the term embryo especially in countries like the USA [1]. But, like the climate change conundrum, the multifaceted problem at hand is indeed a global one as discussed below.

Discrepancies between countries in funding, coverage, access, and scientific contributions, with the potential to alter the course of ART’s future, constitute obstacles that are widespread, despite efforts of some professional organizations to bridge geographical divides [2–4]. Moreover, variance in governmental involvement, whether taking the form of regulation in reproductive care or establishing access and coverage to those in need further compounds taking actions towards resolving disparities across and within countries [5], now emergent in subspecialty areas like fertility preservation (Reflections on appropriately liberalizing ART for groups requiring special attention in China, 10.1007/s10815-024-03184; addressing disparities and enhancing accessibility in fertility preservation for male cancer patients in China, 10.1007/s10815-024-03187).

Here, we suggest and offer a roadmap to elevate medically assisted reproduction or ARTs built upon four obvious pillars that together, if implemented, might begin to resolve the turmoil of the times for all stakeholders: history, ethics, science, education.

Starting with recent history following the US Supreme Court decision to overturn Roe v. Wade, Sharifi and colleagues prompt the conversation from the microcosm of a single US state and how public perceptions have evolved since that landmark decision was made 2 years ago (Attitudes, concerns, and perceptions of patients undergoing fertility treatments in an abortion restrictive state in the aftermath of the Roe v. Wade reversal 10.1007/s10815-024-03145). Bayefsy next contextualizes and contemporizes the immediate sense of despair elicited by the more recent events (again in the USA uniquely it seems) threatening as a result access to care but for what would have been unimaginable reasons even 2 years ago (Protecting access to infertility treatment in a post-Dobbs United States 10.1007/s10815-024-03158).

That science and education should be intertwined especially in the context within which reproductive medicine and its ancestor reproductive biology (not to offend the developmental biologists who may come across this piece) measure all that is good as byproducts of the germline (gametes) and the embryos brought to fruition by natural or unnatural means. Kate MacCord in her recent book brings to life not only an engaging portrayal of how the sex cells came to be understood from a historical perspective but prompts even the “traditionalists” amongst us to reconsider some of the most fundamental challenges nature has had to confront to guarantee a species survival [6]. Likening gametogenesis to the long-term educational pursuit of a goal (sic embryo) may not be too far a stretch of the imagination. Sex determination, meiotic machinations, maturation, and voila—the stage is set, having traversed the gauntlet of gametogenic selection to meet an appropriate suitor on the road to making a zygote.

Gametes continue to gain the public limelight given highly publicized reports of the making of sperm and eggs from stem cells (more in an upcoming issue). In parallel, the coverage of germline genome editing has also attracted much attention and in this issue we bring our readership the first of Point v. Counterpoint feature on this hotly debated topic, again drawing attention to the tenuous interface of our four pillars underscoring all things ARTs (Stringent criteria needed for germline genome editing of human IVF embryos 10.1007/s10815-024-03125; Germline genome editing of human IVF embryos should not be subject to overly stringent restrictions 10.1007/s10815-024-03174).

Closing out our coverage of examples of where the missing link between stakeholders begs for refinement and a plausible action plan is the timely topic of the latest member of the PGT “family” of tests, preimplantation genetic testing-polygenic (PGT-P). What has become emblematic in the conversations around PGT-P is the dual purpose nature of such screening to on the one hand screen embryos bearing greater risks for manifesting serious disease states later in life or selecting embryos for “traits” that some have construed as more of an engineering imperative rather than one of altruistic value to the individual, the family, or society. Constrained to date by the use of surveys to weigh public perceptions and inclinations, once again the disparate nature of the results from such studies leaves open basic questions about human genetics as we know it today and the disposition of embryos that would otherwise have undergone a natural fate with or without ART interventions [7, 8].

Finally, we wish to acknowledge the contributions of members of our editorial board for their service over the past years—Thank you Carol Lynn Curchoe, Valentina Lodde, and Mary Mahony. And in the ongoing spirit of enriching our editorial board with the kind of dedication and expertise that underscores our commitment to the fields of ARTs and Reproductive Genetics, we are pleased to recognize the addition of the following talented group of individuals who will carry JARG into the future. Share with us in welcoming Alexis Heng Boon Chin, David Keefe, Sigal Klipstein, Barbara Lawrenz, Alberto Luciano, Molly Moravek, Daniela Nogueira, Paola Piomboni, and Rima Slim.

For a glimpse of upcoming issues, be prepared for a deep dive into our second special coverage on oocyte in vitro maturation and the wonderful world of retroposons as modulators of gametogenesis and early development. Stay tuned.