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Infertility affects about 1 in 8 couples and gives rise to considerable distress. Many techniques are available that can assist a couple to have a baby. How do we decide which are ethically acceptable?
A couple usually seeks advice about infertility once the woman has failed to become pregnant after 1-2 years of unprotected intercourse. In about one third of couples the problem originates in the man, in another third in the woman and in the final third no cause is identified.
Adoption is a positive option, but in reality, few babies are available, so an increasing number of people are turning to medical treatments that can assist them to have a baby.
The first IVF or test-tube birth occurred in England in 1978 and the baby, Louise Brown, is now a healthy young woman. Since then thousands of such babies have been born.
Reproductive biology
A woman normally releases an egg from one of her two ovaries about 14 days after her last period started. It floats into the Fallopian tube, where, if intercourse has occurred, it may be fertilised by one of the millions of sperm. Over the next few days the fertilised egg gradually grows into a ball of cells. It is now called a 'pre-implantation embryo'.
At this stage it appears that any cell has the ability to develop into any part of the embryo. The embryo may even split to form genetically identical twins.
All this time the embryo is floating down the Fallopian tube and into the mother's womb. By about ten days after fertilisation the embryo starts to embed into the lining of the womb. When this is complete, a hormone, Human Chorionic Gonadotrophin (HCG), is released from the embryo. This inhibits the next menstrual period and the mother becomes aware of the pregnancy. HCG is the hormone detected by most pregnancy test kits.
Within the ball of cells, the developing embryo becomes visible as a dark streak. From now on, different cells are committed to form different organs and twinning can no longer occur.
Artificial techniques
Artificial insemination
Artificial insemination by husband (AIH) can be used when the man's sperm count is low. It involves concentrating several semen samples and introducing this into the neck of the woman's womb when she ovulates. Unlike the other techniques it has been available for more than 50 years, but has a low success rate.
Artificial insemination using donated sperm (DI) is used where the man either cannot produce any sperm, or is carrying a genetic disease which he does not wish to pass on to any children.
It is also used by some women who are not in a heterosexual relationship, but still want a baby.
GIFT
In Gamete Intra-Fallopian Transfer (GIFT) the egg and the sperm are collected and placed in a fine tube with the sperm and egg separated by an air bubble.
The tube is inserted into the woman's Fallopian tube, and the contents released, allowing the egg to be fertilised naturally.
ZIFT
Here the egg and sperm are brought together before being inserted into the Fallopian tube. This means that fertilisation itself occurs outside the body. The newly fertilised egg, or zygote, is then injected - Zygote Intra-Fallopian Transfer (ZIFT).
IVF
In vitro is Latin for 'in glass'. It is used to indicate that the process has occurred in a laboratory dish rather than inside a person or animal.
In in vitro fertilisation (IVF) eggs and sperm are collected and brought together in a petri dish. The fertilised egg, called a zygote, is incubated for a few days, by which time it is a blastocyst of eight or so identical cells. Healthy blastocysts can be inserted into the mother's womb.
The more blastocysts inserted, the more chance of a pregnancy being achieved. But if four or more are inserted there is the risk of quads or quintuplets. Consequently, in the UK, the number of blastocysts that may be returned is regulated and currently must not exceed three.
It is essential to monitor the woman's menstrual cycle and hormone levels if the process is going to have the maximum chance of working. In the best centres, about 25 per cent of IVF treatment cycles result in the woman having a baby.
ICSI
In Intra-Cytoplasmic Sperm Injection (ICSI) a single sperm is injected into the egg, which is then transferred into the woman's womb. This gives men who produce very few sperm the chance of fathering children.
PID
Some couples know that specific chromosomal or genetic disorders run in their families. In a few genetic diseases it is technically possible to take one or two cells from the blastocyst and look for the particular mutant gene. Such Pre-Implantation Diagnosis (PID) allows doctors to pick embryos that are not affected by the disease. Only these are inserted and the rest are discarded.
The technique is very new and still under development. It is only available in very specialised centres.
Egg donation
For egg donation to have a maximum chance of working the menstrual cycles of both donor and recipient must be harmonised.
Egg donation, and collection of eggs for IVF, involves giving the donating woman powerful drugs to induce multiple ovulation. Occasion-ally this causes serious side-effects.
The eggs are collected using a needle or fine tube (laparoscope) and fertilised in an IVF proceedure.
Surrogate mothers
If a woman has no uterus or is for some other reason unable to maintain a pregnancy it is technically possible to use IVF and return the fertilised egg to any prepared uterus. The surrogate mother carries the baby to term and 'hands' him or her to the 'commissioning' woman at birth.
The law
All techniques involving the fertilisation of eggs outside the body are regulated by the Human Fertilisation and Embryology Act 1990. Centres undertaking this type of treatment have to be licensed and inspected and keep careful records of their activity and success rates.
Any fertility centre that fails to reach the required standards, either technically or ethically, can have its licence taken away.
Ethical issues
. In all artificial techniques fertilisation occurs without the act of sexual intercourse. Whereas the use of contraception enables a couple to have intercourse but no baby, here we have the reverse.
. Some people are concerned that the sperm have to be obtained by masturbation and others that artificial techniques interfere with the couple's marriage.
. The use of donated egg or sperm, or a surrogate mother introduces a third (or even fourth or fifth) party. The child is no longer a symbol of the bond between two parents.
. Is a pre-implantation embryo a person who warrants care and protection, or a lump of cells that can be disposed of or used for research? What do we do with spare embryos?
Note that the development of most of these techniques required many pre-implantation embryos to be used in research.
. Donors, surrogates, and above all the child must be protected from financial and emotional exploitation.
. How will the child cope with an unusual form of parentage? Should he or she be informed, or should the treatment be kept secret? When a child becomes an adult should he or she be allowed to trace any donor who was a biological parent?
. Can a surrogate mother give up the child she has carried during the pregnancy without herself being emotionally wounded?
. These techniques are expensive. Should health authorities purchase them and how should they set priorities? If these techniques are only available through the private sector some people will be able to afford to have a baby, but others won't.
. Could the use of pre-implantation testing for genetic diseases lead to a world of 'designer babies' and genetic manipulation, maybe even a new form of eugenics?
Christian principles
The Bible shows that God is concerned about infertility and the heartbreak it brings. Abraham and Sarah had to wait longer than they felt able before their promised son Isaac was born1 and Samuel's mother Hannah's anguished prayer illustrates the stress of infertility[2].
Several biblical heroes had unconventional parents and upbringing: Moses was brought up as an adopted son of a royal princess[3], Samuel was raised largely by the temple priests and John the Baptist was born to aged parents[4]. Jesus declared that our attitude towards him is more important than that towards our blood-ties[5].
Although Christians reach different conclusions in this highly controversial area there are certain biblical principles on which all agree.
Truth and integrity
An honest approach is essential for the counselling of both potential parents and donors. Before they start, couples must be aware of the cost in both emotional and financial terms.
The children born must have truthful information and parents need to be encouraged to be open with them about their origins.
Consideration should also be given to donors and whether or not their confidentiality needs protecting. This is a complex issue as the rights and interests of all parties need to be held in balance.
The value of the individual
Some people believe that at the moment of fertilisation a person has been formed who has full human rights. Some of these people find almost all forms of artificial reproduction unacceptable.
Others believe that as the techniques are now available, despite the research used for their development, they can be used, provided no pre-implantation embryos are discarded.
Yet others believe that pre-implantation embryos do not yet have any personal status and can therefore legitimately be discarded or used for research. This view was accepted by the 1984 Warnock Committee[6] who said that human embryos could be used in experiments up to 14 days after fertilisation.
Supporters of this view point to the fact that fertilised eggs are unwittingly lost naturally and when certain forms of contraception are used, including the widely used 'mini-pill' and contraceptive implants. They also say that the Old and New Testaments show that God is chiefly concerned with how we relate to one another and to him. If the essence of being human is forming relationships, an embryo can only start to become a person, they say, after implantation when a rela-tionship is formed with the mother.
The value of the family
With regard to the value of the family, Christians again have differing views. To many the whole concept of 'making' babies in the laboratory rather than 'begetting' them through the loving union of the potential parents seems alien to the God-given concept of the family. Some find masturbation a wrong use of the sexual mechanisms.
Others accept the use of artificial techniques, provided only the couple's own eggs or sperm are used. Donation of eggs or sperm is sometimes said to be equivalent to adultery. However, many Christians would argue that adultery involves human relationships outside the partnership, rather than simply introducing new genes. Even so most Christians are concerned about the potential confusion and 'genea-logical bewilderment' for the child that is inherent in any form of donation and would therefore generally advise against its use.
Concern for the child
All Christians are concerned about the child and that his or her welfare has highest priority. A clause to that effect is included in the 1990 Act of Parliament. This aspect is easy to forget when faced with a couple who desperately want a baby. Inter-pretation is also difficult as neither parenting ability nor home stability are easy to predict.
If we believe that the creation pattern shows that for an optimal start a baby needs two parents of opposite sexes this should preclude the use of these techniques by same sex couples. Requests for such pregnancies are rare but do occur.
Also surrogate mothers are exceedingly vulnerable as they inevitably make strong bonds with the babies as they develop in their wombs. Very careful consideration of the interest of these individuals is essential and it is important that the infertile couple's desire for a child, which may be overwhelming, is kept in perspective.
Christians see children as gifts from God and none of us has any right to demand such a gift or to trample on the lives of others in order to obtain one. Yet childless people are also vulnerable and in need of help, protection and wisdom to know when to call a halt to their use of high-technology.
Conclusions
These new technologies have opened the door to a host of possibilities, but it should be clear that they also illustrate the saying that 'what is possible is not always what is right'. Some Christians see none of these techniques as permissible. Others believe they can be used responsibly in ways compatible with Christian principles. However, discussion of a case study shows just how difficult it really is to make these decisions.
Caroline Berry has considerable experience counselling couples facing genetic problems. She was formerly the clinical director of the South Thams (East) Genetics centre, based at Guy's Hospital, London.
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References
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Further reading
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This series arose out of discussions within the Medical Study Group of the Christian Medical Fellowship. The series editor is Pete Moore PhD. The views expressed in these papers are not necessarily those of the publisher. CMF Files can be ordered from CMF.
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Copyright ©2002 Christian Medical Fellowship.
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