Andreas SCHMUTZLER (Germany)
PD Dr. med. habil. Andreas G. Schmutzler is a gynaecologist and lawyer, specialist in reproductive medicine, and lecturer, at the Women’s Hospital of the Christian-Albrechts-University Kiel, Germany and at the private IVF centre gyn-medicum in Goettingen, Germany. He studied law in Bonn, Germany and Geneva, Switzerland, worked as an interpreter for German, English and French, studied human medicine in Bonn, worked two years for electives and research in Norfolk, VA and New York, NY, USA. He got the first baby with assisted fertilization in Germany and established one of the first labs for polar body screening in Germany. He published more than 300 articles and talks, is founding member of the German Society of Reproductive Biology of the Human, member of the Commissions for Strategy and Billing of the Federal Association of the German IVF Centres, member of the ESHRE PGD Consortium and the ESHRE Task Force on PGS. He participated in several projects of the European Commission on the interface of reproductive medicine and genetics and of the ESHRE on Preimplantation Genetic Screening. He also runs, together with his wife Dr. Monica Tobler, the International School of Medicine with practical courses in reproductive medicine for gynaecologists.
Debate (For): Benefits Outweigh Glitches So Should Be for Everyone
In PGS the patients suffer from sterility but do not have specific genetic problems. They just want to improve their chance for a successful sterility treatment. So in PGS we look for general genetic risks in gametes or embryos. The method is in use globally. But its main columns are contested: theory, practice, methods, results and conclusions, in terms of clinics, embryology and genetics.
There are different distinctive aims, which correspond to different distinctive indications. These compete which each other. So the physician, and neither the embryologist nor the geneticist, have to explore the patients’ will and intentions, in order to decide together with them, what is the ranking of their aims. Depending on this he has to make up his mind, if these aims are reachable with a reasonable amount of investment in terms of time, “nerves” and money. And then he has to decide, if there is an indication for PGS in this case. And then he has to communicate this decision to the patients.
This decision depends on a subsumption of the case to the rules of evidence based medicine. These are ranked in three levels, and, different from the attitude of many, all three can justify a decision. This includes, besides the highest level, i.e. RCTs, i.e. randomized clinical trials, also the “lowest level”, experience, gut feeling and mathematics, especially stochastics. Examples for this will be given.
The different methods will be analyzed for their results and conclusions will be drawn respectively, in terms of clinics, embryology and genetics. Most importantly the decision for or against PGS must be kept flexible to the needs and circumstances of the patients, also during the course of the treatment. A strict decision making like in the “intention to treat” strategy of RCTs is unethical. Especially the decision has to be reconsidered directly before the biopsy, especially under stochastic considerations. PGS as a therapeutic and as a diagnostic tool will be differentiated. In sum: Yes, PGS nowadays is to be considered for everyone. But the decision of when and why has to follow rules derived from evidence based medicine.