In vitro fertilization widely used
By PAMELA SCHAEFFER
Dawn Meadows had been married just a year when she and her husband decided to undergo in vitro fertilization at a St. Louis clinic as a last-resort effort to have their own child. Meadows had recently turned 40.
The couple faced some resistance from family members on religious grounds, so before making the final decision they consulted two priests, one during a retreat. Meadows and her husband are practicing Catholics and totally pro-life, she said.
Both priests told us the same thing, Meadows said, that we should look within our hearts and ask ourselves why we were doing it. They gave qualified approval, she said, as long as the couple didnt intend to dispose of embryos. But we would never do that, Meadows said. We agreed that all the embryos that werent implanted had to be frozen and saved.
In vitro fertilization, by far the most common of reproductive procedures that fall under the broad heading of biotechnology, has gained wide acceptance in the 21 years since Louise Brown, the worlds first test tube baby, was born in England. Although the process is condemned by the Catholic church and criticized by lawyers and ethicists in its current practice, success in sheer numbers of live births produced through assisted reproductive technology is astonishing. Despite early outcries from religious leaders warning of playing God, as of last year some 300,000 children worldwide owe their existence to in vitro fertilization, according to an article in the July 31, 1998, issue of Science. Even Muslim countries have adopted the technology; Irans first test-tube baby was born in 1990.
According to a recent poll, the process is approved by 75 percent of the U.S. population (which includes some 70,000 people who got their start that way).
The implications of in vitro fertilization, however, are much broader than are generally known. In the words of Lee M. Silver, biology professor at Princeton University and author, the development of that new reproductive process marks the dawn of a new age -- the point in history when human beings gained the power to seize control of their own evolutionary destiny.
In a very literal sense, Silver wrote in Remaking Eden, in vitro fertilization allows us to hold the future of our species in our own hands. In vitro fertilization, literally fertilization in the glass, is accomplished by combining egg and sperm in a petri dish. The process, by bringing the gametes -- the egg and sperm -- into view, along with the embryo their union creates, and by making its genetic material accessible, has opened the door to a variety of other reproductive possibilities: third-party donations of sperm or eggs, surrogate mothers, embryo division, sex selection of children, genetic testing, genetic engineering, cloning and a range of new moral, theological and legal issues. Science is forging ahead, leaving experts in other fields gasping to catch up.
A few of the issues become apparent in startling headlines.
Fifty-five-year-old womans delivery of four infants has the nation asking whos fit to be a mother.
Grandmother carries her own grandchildren; 63-year-old woman gives birth.
Baby is born two years after mothers death.
In theory, it may be possible someday for a woman, using frozen embryos, to give birth to children who are genetically her great aunt and great uncle.
Collecting sperm from men who are comatose or even dead so that their progeny can be brought to life has become almost routine -- a practice at least one ethicist likens to rape. According to an article by Lori Andrews in the March 31 issue of The New York Times Magazine, wives, girlfriends and parents have submitted requests for sperm. In one case, a widow gave birth to a child using her dead husbands sperm and then successfully sued the Social Security Administration for death benefits for the child, according to Andrews, a professor at Illinois Institute of Technologys Chicago-Kent College of Law and a critic of reproductive technology. Andrewss book The Clone Age is replete with bizarre stories about peoples experiences with reproductive technologies.
New developments in biotechnology occur almost daily. In fact, said James J. Walter, a Catholic theologian specializing in implications of biotechnology, its impossible to keep up with whats happening in this field unless you devote full-time to it. Walter just moved from Loyola University in Chicago to Loyola Marymount University in Los Angeles, where he holds the Austin and Ann OMalley chair in bioethics, in order to do just that.
Among recent developments in what Lisa Belkin, writing in The New York Times Magazine July 25, called this dizzying decade, a fertility clinic in Fairfax, Va., announced last September that it had become the first authorized to help couples pre-select their childs gender with a machine that sorts sperm by their female (X) and male (Y) chromosomes. The process, called Microsort, has been used in animal breeding for years. In human use, it was originally intended to help parents avoid genetic diseases (some 350 diseases are linked to the X chromosome). But the clinic, the Genetics and I.V.F. Institute, now allows families to pre-select gender for balancing families. To avoid gender discrimination, the clinics current policy requires couples to have at least one child and to pre-select the non-dominant gender in the family. Even at $2,500 per attempt (and the technique usually requires three tries), it is cheaper and, to some, morally preferable to discarding or freezing embryos that are not of the selected sex. The clinic says its method is currently 93 percent reliable for choosing girls, 73 percent for boys.
Last November news reports hailed the arrival of egg freezing, which would purportedly allow women to plan their childbearing around their careers. Little noted in the celebratory reports, The Guardian in London complained, was the motivation for this scientific advance. It was devised not as a convenience to career women who want to extend their childbearing years (though that may ultimately result in the procedures greatest demand) but to allow women undergoing cancer treatments, at risk to their fertility, to preserve their eggs. Nor was it noted in many of the reports that the eggs would have to be fertilized in vitro and then implanted, an expensive and often futile process.
Also last year, researchers announced that it was possible to grow fertilized eggs in a nutritional solution two to three days longer than before, allowing more mature embryos (called blastocysts) to be inserted into the womb. Although it is too early to know whether that advance might put children at greater risk, it may reduce the need for inserting multiple, less mature embryos to increase chances of success. Where it works, it would also reduce incidences of abortion. Women sometimes elect to abort embryos if more than one or two begin developing.
Legally, in vitro fertilization is almost as much of a legal quagmire as cloning, expanding to possibly five the number of people potentially asserting parental rights: the man and woman who contribute gametes (sperm and egg); the woman who bears the child; a couple who raise the child. If the prospect of children with multiple parents is a marketing dream for the greeting card industry, its also sure to make some lawyers rich.
Among recent court cases, a woman sued her ex-husband after their divorce for access to their frozen embryos. She still wanted to have a child. The New York Court of Appeals upheld her ex-husbands right to not become a father, overturning a trial courts decision that she could have the embryos implanted. In another case, a white woman gave birth last December to twins, one black, the other white. A black couple sued the white couple and a fertility specialist in their effort to gain custody of their genetic child.
Lawyers and ethicists complain that couples, at a time when they are often particularly vulnerable because of their strong desire for a child, are not always fully informed of alternative treatments available at other clinics nor of risks, including risks of taking fertility drugs and the low success rate of in vitro fertilization (it averages around 25 percent in the United States). They also are often surprised, experts say, by its physical and emotional demands and its high costs. An article in the July 31, 1994, issue of The New England Journal of Medicine estimated the cost of a successful delivery after in vitro fertilization at between $44,000 and nearly $212,000 based on a number of factors, including the number of attempts required.
Where clinical success rates are unusually high, ethicists note that the favorable numbers are often accompanied by a high rate of multiple births. (The more embryos transferred, the better the chances of success.) The costs of multiple births, in health risks as well as dollars, are far higher than single births.
In vitro is arduous and time-consuming, involving multiple hormonal injections (to prevent ovulation, to stimulate egg production, then to induce ovulation), sedation during egg removal, sonograms, blood tests and days of bed rest after embryos are transferred. Resources can be quickly used up, and less than one in five couples may end up with a baby. Most insurers do not cover the process.
The Vatican foresaw experimentation on human embryos when it condemned in vitro fertilization in Donum Vitae, a 1987 document issued by the Congregation for the Doctrine of the Faith. In vitro fertilization, the document said, allows human beings to set themselves up as givers of life and death, and sets up a dynamic of violence and domination.
The Vatican document, also known as Instruction on Respect for Human Life in its Origin and on the Dignity Procreation, cited two major problems with the procedure:
Currently, Andrews, author of The Clone Age, reports there are more than 100,000 souls on ice in the United States, a number that is increasing by nearly 19,000 a year.
Needless to say, the Vatican strongly opposes selective pregnancy reduction (transferring multiple embryos and then aborting some later if too many begin to develop), as well as producing embryos for research. In Britain, a law was passed limiting storage of frozen embryos to five years. When the first deadline arrived and unclaimed embryos were to be destroyed, the Vatican, decrying this prenatal massacre, proposed that women adopt the embryos and bring them to term. More than 100 Italian women, including two elderly nuns, volunteered. Nevertheless, the embryos were destroyed.
A term pre-embryo, in vogue a few years ago among scientists and fertility clinics, had served to soften opposition, at least among parents, to freezing or destroying embryos or using them for research. The suggestion was that the organism showed no human characteristics until the 14th day. But Richard Doerflinger, associate director for policy development at the U.S. bishops Secretariat for Pro-life Activities, said the term has been quietly dropped by most textbooks in embryology. In the last five years theres been a definite movement toward recognizing that human life is a continuum from fertilization on, he said, supporting what the church has always said.
The Vatican instruction does not oppose prenatal diagnosis or treatment aimed at healing, provided it poses no disproportionate risk to the embryo and is not used in a decision to abort. Infertility specialists in England and elsewhere are using pre-implantation genetic diagnosis to rule out such diseases as cystic fibrosis before transferring embryos to the uterus.
The Vatican also does not object to fertility drugs, though they often lead to risky and costly multiple births. The Vatican has [not] approved an infertility treatment known as GIFT, an acronym for gamete intrafallopian transfer, with one qualification: Semen must be collected during intercourse (usually by using a perforated condom, which still allows the possibility for procreation) rather than through masturbation, which is condemned by the church.
In the GIFT procedure, collected sperm are inserted into the womans fallopian tube, along with two or three eggs extracted from her ovaries, through a small incision near her navel. Because fertilization takes place within the womans body, the church approves. Neither drugs nor GIFT are of any help if the fertility problem is with the male.
As for third-party donations of egg or sperm, and surrogate motherhood, in which a woman carries another couples child to term, the Vatican said such arrangements violate the marriage pact, the dignity of spouses and the right of a child to be brought into the world in and from marriage.
Theologically, in contrast to the more open view of Pope John Paul II, the congregations document took the position that human beings should be stewards of creation rather than participants with God in its progress toward fulfillment.
The Vaticans opposition to in vitro fertilization has not gained wide acceptance in the United States. Jesuit Fr. Richard McCormick, moral theologian retired from the University of Notre Dame, says that many ethicists and moral theologians have no problem with the procedure as long as the gametes come from a husband and wife who intend to rear the child. McCormick argues that the reasoning behind the Vaticans condemnation is flawed. The Vatican is wrong, he believes, to insist that the unitive and procreative dimensions of marriage must be present in every sexual act. (He notes that this is impossible, for example, when a couple is infertile because of age or disease.) McCormick believes the unity resides in the relationship itself rather than in a specific act of intercourse, and is not necessarily violated by interventions to block or assist fertilization.
In fact, McCormick said at a conference on reproductive technologies at Loyola University Law School last fall, the willingness of a couple to undergo unpleasant fertility treatments may be a sign of the couples unity; a concrete manifestation of their love.
At the same conference, Fr. Jose Lavastida, medical ethicist at Notre Dame Seminary, defended the Vatican instruction, arguing that in vitro techniques do, in fact, substitute for sexual intercourse, thus nullifying the reproductive aspect of intercourse. Although a couples intention to have a child become part of their relationship may diminish the offense, it does not eliminate its inherent immorality, he said.
Feminists also have their concerns. Women should resist the idea that infertility is a matter of desperation, said Lisa Sowle Cahill, a Catholic theologian who teaches at Boston College. Desperation is a word you see everywhere, as if infertility were the worst possible calamity that could befall anyone.
Cahill, who has three adopted children, would like to see adoption presented as an attractive alternative for infertile couples. You dont want to suggest that nobody has a right to have a child biologically, that all should adopt. Its a question of where to draw the line.
She is also concerned, she said, about social pressures on women to bear children. What these technologies do is reinforce the idea that women can be fulfilled only as mothers, that their bodies should be manipulated to make them mothers.
Women are being commodified, she said. They serve to meet the needs of other couples when they undergo risky hormonal treatments in order to donate or sell their eggs.
Im not one who sees all these things as absolutely, intrinsically immoral. But I have a lot of reservations about the sexual ethics and the social atmosphere that promotes these technologies, she said. Its not just the medical establishment. Americans generally expect technology to solve problems that are really social problems, like the idea that you cant be fulfilled without a baby.
For Dawn Meadows and her husband, four eggs were fertilized, all were transferred and none resulted in a pregnancy. The procedure cost $11,000. Instead of undergoing the process again, the couple decided to adopt twin girls from China.
I wish I had the money now we spent on in vitro, Meadows said. I cant imagine loving a baby any more than I love these girls.
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National Catholic Reporter, October 15, 1999 [corrected 11/19/1999]