reportabout FIVET
Description, social demand in Spain, evaluationethics and legislation and jurisprudence
Gonzalo Herranz.
Pamplona, 25-IV-91.
Description of the technique
IVF (in vitro fertilisation with embryo transfer) is a technique that, borrowed and adapted from veterinary medicine, doctors began to apply during the 1970s to achieve childbearing in infertile couples. The technique was initially used in women whose infertility was due to bilateral fallopian tube obstruction. It has since been applied to cases of female infertility caused by other diseases or of unknown origin, and to certain types of male infertility.
In 1978, Dr. Steptoe and Dr. Edwards, a gynaecologist and a biologist, were the first to succeed in giving offspring to an infertile couple by means of fivet. The technique they developed at internshipconsisted of taking an egg from the woman's ovary, fertilising it in a Petri dish with her husband's sperm, and implanting the resulting embryonic human being in the woman's uterus.
This procedure(taking eggs from the ovary, fertilising them in vitro and transferring the resulting embryos to the mother's uterus) has basically been maintained to this day. However, some modifications have been introduced, including a fundamental one: since each spontaneous ovarian cycle of a woman normally produces only one egg cell, which is insufficient to ensure an acceptable yield for procedure, hormonal hyperstimulation of the woman's ovary is used to cause the simultaneous maturation of several ovarian follicles. This ensures the collection of sufficient, and even surplus, oocytes for IVF. Ovarian hyperstimulation introduces circumstances with significant ethical implications:
The eggs, which are collected at issueplural (usually six to ten), are immediately fertilised, as they are short-lived cells. As they cannot be kept alive for a long time and do not resist well the process of keeping them in a frozen state to thaw them later, they have to be fertilised early, which results in a high number of embryos issue. Since, once fertilised, not all the resulting embryos can be transferred to the mother, due to the danger of producing a multiple pregnancy that would be difficult to carry to term, an attempt is made to preserve the embryos in a frozen state in order to transfer them in successive cycles (embryos resist freezing better than unfertilised oocytes). In each cycle, a few embryos are transferred to the woman, usually three, to avoid the risk of multiple pregnancy that would follow if more were transferred. If possible, more than one is always transferred, to ensure the highest possible success rate.
After the transfer of some of the embryos produced, there are "leftover" embryos, which, frozen, can be used for further transfers: if the first transfer fails or, if successful, after the birth of the child from the first transfer, some or all of the available embryos are thawed and transferred to the mother.
Psychological aspects
The fivet technique is conditioned, from the parents' point of view, by their interest in having a child, their own and without defects. For this reason, the technique described above is, in fact, accompanied by a series of other actions:
Quality control of embryos is practised by means of in vitro or pre-implantation diagnosis of possible genetic defects or "biochemical malformations" of the embryo. Defective embryos are destroyed by what could be called "in vitro abortion". Malformed foetuses can then be eliminated by eugenic abortion. Although complete and sufficient information is not available, there is instructionsreason to suspect that the incidence of congenital malformations is somewhat higher after fivet than in ordinary pregnancies.
Although surplus embryos could be used to give a child to another infertile couple, parents are usually asked to donate them for use at research. The results obtained so far in experimentation on human embryos are certainly not very brilliant. An important part of researchis directed towards the search for new contraceptive methods. It is forbidden by law to transfer into a woman's uterus any embryo that has been the object of experimentation (including that aimed at curing her diseases).
The destruction of supernumerary embryos is common. If the first transfer is successful, the parents no longer wish to have more children and refuse to transfer the frozen supernumerary embryos. They are abandoned and condemned to be destroyed after a certain, legally pre-determined deadline.
Moreover, the relationships of the doctors who perform these techniques with the patients who undergo them as the last resourceto have a child are greatly disturbed by the commercial factor. Many infertile couples are willing to pay any price to overcome their childlessness. And doctors, under pressure from the couples who come to them, and not uninfluenced by economic incentives, are tempted to disregard certain elementary rules in their relations with patients: they usually do not adequately inform them of the limited and dubious success of these techniques and the moral problems they raise. The most optimistic estimates indicate that only one in four couples who undergo three embryo transfers have a child in their arms. programs of studyserious statisticians doubt the usefulness of IVF, because couples on waiting lists at IVF clinics have children with a similar frequency to those who undergo the technique.
Often, due to the need to repeat the procedure, the aggressive techniques and the anxiety with which the results are awaited, the woman suffers physically and psychologically. Some have described fivet, with its repeated analyses, hormonal treatments, invasive manoeuvres, as a very harsh and alienating procedure, in which the woman is reduced to the status of a reproductive mechanism. And all too often, they are left with the frustration of not having achieved, after such strenuous efforts, the child they so intensely desired. A few years ago, the press created an aura of happiness and scientific triumph around the fivet. Today, popular enthusiasm has waned. Fivet has not been resultthe panacea it was promised to be: strictly speaking, it does not cure sterility, but only gives a child to a married couple who, apparently (the diagnosis of sterility is often only presumptive), cannot have a child in a natural way.
Social demand in Spain
In order to give social validity to assisted reproduction, it is repeated time and again that the issueof couples who need to resort to it represent a quantitatively important sector of society, and that it is the State's obligation to respond, through legislation at purposeand the necessary aid, to this distressing problem.
We lack serious dataon the problem. First of all, because it is not easy to agree on agreementon the very definition of infertility. The estimates that have been offered indicate that, in Western societies, where sexual liberation has been operating for about 20 years, the proportion of infertile couples is between 10 and 15% of all couples. In the preamble of Law 35/1988 on Assisted Reproduction Techniques, it is stated that "it is calculated that in Spain there are some 700,000 infertile married couples of fertile age, admitting a percentage of 10-13% of the total, of which 40% could benefit from IVF or similar techniques and 20% from Artificial Insemination".
As the regulation management assistantrequired by this law has not been developed, it is not possible today to obtain official datainformation on the activity and results of the centres that practise fivet. Reliable information, although not guaranteeing the accuracy of the data, indicated that in December 1990 there were 17 such centres, although in very different Degreesfrom developmentand skill. Almost all of them operate in the private medicine area, as the administration does not seem very enthusiastic about diverting part of its resources to this specialization program. In fact, some groups that started their workin public centres have moved, in whole or in part, to the private sector.
In any case, it must always be stressed that the most effective solution to the growing prevalence of infertility is the fight against youth promiscuity and the related spread of sexually transmitted diseases. The unfortunate campaign in favour of condom use contained an illusory message of false security, whose most serious effects in the medium and long term deadlinewill perhaps have less to do with the spread of AIDS than with the spread of sexually transmitted diseases that cause sterility in women.
evaluationethics
The ethical evaluationof this technique has been very well presented in the document issued by the Holy See on Respect for Human Life at Birth and the Dignity of Procreation. In its degree scrollthe two factors that allow an ethical judgement of the fivet technique, as it is commonly practised, are pointed out. This evaluationdoes not immediately consider other alternative techniques (e.g. gamete intrafallopian transfer or GIFT, etc., or ideal cases which, in fact, do not occur in real life), but it provides very illuminating elements of judgement to make a moral judgement of them.
The technique, as described in the first section, is a disregard for the human life of embryos, which is sacrificed for the sake of the desire of infertile couples to have a child. The issueof embryos that die for each child born is very high: if we assume the optimistic figure that one in four couples who undergo the technique leaves with a child in their arms, we must assume that, due to the technique itself, all the embryos transferred to women in whom fivet has not been successful die: three women, for three embryos transferred, for three transfers per woman (which is usually the norm), equal to twenty-seven human lives lost in order to obtain a child. To this should be added the embryos that are frozen and never transferred, as well as those that die in the transfers prior to the one that produces the pregnancy and gives the desired child to the woman who undergoes the technique.
This cost of human lives, embryonic, but human lives, is unjustifiable for the simple desire to have children from a sterile marriage, however intense and justified it may be. It is disproportionate.
Moreover, from the same point of view, eugenics is systematically practised in conjunction with fivet. Embryos are observed before transfer and those with a defective appearance are discarded, although there is no reliable data on what appearance of an embryo means that it has a genetic defect or other abnormality. Already during pregnancy, diagnostic tests, often not without risk to the life of the foetus (such as chorionic villus sampling), are performed to ensure the health of the child on the way. If a genetic defect or abnormality is discovered, eugenic abortion is performed. There have been cases where, after the abortion, the child was found to be healthy: one can imagine the enormous indignation and frustration of the parents; prenatal diagnostic tests are not infallible.
This internshipof "in vitro abortion" or eugenic abortion that virtually always accompanies fivet is a further reason for its condemnation from an ethical point of view.
The second argument for judging fivet from an ethical point of view is often less well understood than that of respect for human life. Given the scientistic mentality of the West, in which procreation is reduced to reproduction (a simple biological phenomenon), it is difficult to see why natural reproduction is acceptable, while artificial reproduction is condemned.
However, it is clear that human procreation is not simply biology, since the conjugal relations that normally give rise to a new human being derive from the love of the spouses. In procreation, in addition to biology, there is the mutual submissionof the spouses, which makes a human act out of what in animals is purely instinctive behaviour.
The production of children through fivet makes the human content of procreation disappear. In fivet, reproduction takes place without the exercise of sexuality, since the artificial implantation of the embryo in the woman does not follow from the conjugal union. Reproduction no longer follows from the spouses' submission. And in man, this mode of reproduction is not appropriate to his nature: it is an unnatural and therefore ethically incorrect mode of reproduction.
Furthermore, the internshipof fivet, as it is usually performed, implies an unnatural employmentof sexuality on the part of the male, since masturbation is practically always required of the husband to obtain the semen to fertilise the egg. This use of sexuality is also ethically wrong.
Finally, it must be considered that fivet is diverting the efforts of doctors towards giving children to couples who do not have them, instead of directing them towards investigating the causes of sterility and treating them adequately. If we add to this fact the alterations suffered by the correct attentionof the patients in the context of their internship, we can say that, from a medical point of view, this technique, as it is commonly practised, introduces unacceptable corruptions in the internshipof Medicine.
Legislation and Jurisprudence
Law 35/1988 of 22 November 1988 on Assisted Reproduction Techniques covers practically all legal aspects related to subject. Its preamble aims to illustrate the medical, social and moral aspects of these techniques, to warn about their dangers and deviations and, above all, to justify the progressive and dehumanising nature of the legislation on the imposition of "civil ethics" and the notion of "pre-embryo".
The law has already been criticised by various legal experts at programs of study. Some of its prescriptions have caused a strong commotion in other sectors of positive law, especially in family law. The necessary coordination and harmonisation, which should have been carried out by giving this piece of legislation the status of an Organic Law, has yet to be done.
Two and a half years after its promulgation, however, all the administrative regulations that should control its application have yet to be developed. At the end of 1990, the Ministry of Health and Consumer Affairs, through its General Administrationof Health Planning, prepared and sent to enquiryto different bodies a series of draft RRs. to develop Law 35/1988, but it seems that the ministerial readjustment has slowed down the process.
In contrast to the United States, France and the United Kingdom, there has been practically no jurisprudential activity on fivet in Spain. In the summer of 1990, the case of a mother of five children who wanted to be artificially inseminated using techniques for the preconception sex selection of the neo-conceived child, as she wanted to have a girl, gained a great deal of public notoriety. The issue, after a strong legal discussion, is still pending resolution.