In vitro fertilisation
Antonio Pardo.
Published in the magazine Mundo Cristiano, III-96.
In vitro fertilisation (IVF) with embryo transfer has recently come to be considered as another technique available to medicine for the treatment of marital infertility. The media on speechcontinue to report extreme cases of its application: women in their 60s giving birth to twins, selection of the colour of the skin or the sex of the child, etc. At the same time, there has been no end to the ethical debate on either these extreme applications or on the socially accepted application. Some ethical reflections on IVF are presented here. But before going into them, it is necessary to know what we are trying to judge. It is therefore useful to explain the IVF technique as it is commonly practised.
1. The technique
a) Description
IVF with embryo transfer was a technique known for a long time in veterinary medicine. It was introduced in medicine to treat infertility due to obstruction of the fallopian tubes, through which the egg and sperm cannot enter contact. The solution proposed was to bypass the obstacle (the blocked tube) by taking the egg directly from the ovary on one side of the blockage, artificially fertilising it at laboratory, and depositing the newly formed embryo on the other side. In this way, women with tubal obliteration could be provided with a child.
Subsequently, the indications for this technique have been extended to the treatment of sterility of unknown cause, sterility in couples who do not have normal eggs or sperm (using gametes from donors), and even in cases where she is unable to become pregnant (using surrogate mothers employment).
The following procedureis usually used: Firstly, after a selection of couples who wish to undergo the technique, and after rejecting those who have very little chance of success, the woman's ovaries are hormonally stimulated; instead of producing one mature egg that month, the woman produces several. Normally, between 4 and 10 eggs are obtained, which are extracted from the woman by means of an ultrasound-controlled puncture, which is always uncomfortable and not absolutely free of danger.
The husband's sperm is then obtained (almost always by masturbation) and treated so that it acquires fertilising capacity. All the eggs obtained are then fertilised because, while eggs are difficult to preserve, young embryos can be frozen and kept at a very low temperature ( leave). These embryos are then observed under the microscope; those showing an abnormal appearance (irregular or non-existent divisions, damaged blastomeres, etc.) are destroyed. Three of the best-looking embryos are taken and transferred into the woman's uterus using a special cannula, in the hope that they will implant in the uterine cavity and thus bring about the desired pregnancy. The rest (the so-called "supernumerary embryos") are kept frozen and await employmentat a later date.
Three embryos are transferred because the chances of pregnancy increase with the issuenumber of embryos transferred. However, no more than three are transferred to avoid the risks of a high twin pregnancy, with the risk of premature delivery, and the danger that the technique will not achieve its goal: a live child for the couple. There is now a general consensus that no more than three embryos should be transferred.
b) Results
Relatively few transfers are followed by a pregnancy that goes to term. The most favourable statistics state that only 45% of couples end up with a child at home, provided that each candidate couple agrees to undergo five embryo transfers. This optimum result, published by the world's "star" centre, is found in young women (20-34 years), and decreases with age: it is only 28.9% if they are 35-39 years old, and drops to 14.4% for those over401. Other statistics give average figures of 18.7 per cent of pregnancies (only about 75 per cent will go to full term), a slight increase from 15 per cent in the mid-1980s2. As can be seen, the yield of the technique is meagre: to obtain a child, it is necessary, in the optimal case, to have employeea averageof 24 embryos: for each child born, 15 embryos are used in unsuccessful marriages (5 cycles x 3 embryos = 15) and, in the marriage that ends with a child, another 9 (accepting that pregnancy is achieved at third cycle: 3 cycles x 3 embryos = 9). This is equivalent to a 4% success rate, which contrasts with nature's success figures: it is estimated that between 25% and 65% of naturally fertilised eggs implant and result in a pregnancy that is carried to term. In less favourable IVF cases, the issueof lost embryos is multiplied, and the effectiveness is only 1%.
It is often claimed that IVF with embryo transfer has a similar or higher success rate than in nature. To make this claim they take the less optimistic figures for the natural result(25%) and the more optimistic figures of the issueof couples who come out of IVF with a child in their arms (45%). However, this comparison is flawed, as nature achieves this 25% (probably more) with one embryo, while the technique achieves it with twenty: IVF is incomparably less effective.
Furthermore, when it comes to discussing the effectiveness of IVF, it is very difficult to obtain reliable data. Despite the existence of several medical journals specialised in this field topic, articles on researchthat attempt to compare the efficacy of different IVF centres and variants often give a biased data, as the attraction of clientele to IVF clinics depends on their offering higher success rates than those of skill. The resultof this peculiar sociology is a jungle of numbers from which it is difficult to draw a clear conclusion. In any case, it can be stated that only one in six couples who start IVF procedures end up with a child in their arms (the 45% figure mentioned above refers only to the most favourable cases and in the most efficient centre).
This figure forces us to question the efficiency of IVF at all. In fact, we have already mentioned that, although IVF was thought of as a procedureto treat couples with sterility of tubal origin, its indications were later extended to couples with other causes of sterility or sterility of unknown cause. In fact, nowadays, most couples who come to IVF clinics have the latter diagnosis, which is presumptive. Let us clarify this issue:
A married couple does not necessarily have children as soon as they marry. By chance it may take some time before the first pregnancy occurs. After two years of childless marriage, programs of studyis carried out on the spouses to try to identify any known cause of infertility, and often none is found. The couple is then given a presumptive diagnosis of infertility, which does not mean that they are infertile. In fact, while on waiting lists at IVF clinics, between 10 and 15% of these "infertile" couples have children as a result of their ordinary conjugal relationships. Therefore, if, on the waiting list, without any treatment, there is a fertility rate of around 15%, and the effectiveness of IVF is 15%, it is reasonable to think that some of the children born with these techniques are the result of the couple's normal relations. In short: for couples with (presumed) infertility of unknown cause, IVF is of doubtful usefulness.
Finally, it has been proven that children born through IVF suffer from malformations slightly more frequently than normal, even after the quality control carried out in IVF clinics to eliminate defective children through embryo selection or eugenic abortion. It is thought that the causes of this increase in errors at developmentlie in the influence of the hormonal stimulation to which the woman is subjected in order to obtain several eggs, which seems to induce chromosomal aberrations, and the fact that fertilisation is carried out in a different place from the natural one, in strange environmental conditions, which weaken the natural systems for controlling the fertilisation of each egg by a single sperm, with multiple fertilisations producing non-viable embryos.
2. Ethical reflections
Once the usual IVF technique has been explained (not a non-existent ideal case), we are in a position to make an ethical judgement. In order to do so, we will separately assess various intertwined questions: those concerning respect for human life, those concerning respect for the values of human sexuality, and those concerning the ethical requirements of the medical internship.
a) Respect for human life
We have seen that the technique commonly used for IVF involves the loss (in reality, the death) of numerous embryos. These deaths are not intended (they are not intended), but they are voluntarily accepted or tolerated and therefore morally blameworthy. If IVF practitioners maintained complete respect for human life, even from its very beginning - fertilisation, where a new human being begins - they would not risk manipulating it by placing it in grave danger of death. There is no doubt that IVF practitioners have a good motive: to provide a child for a couple without offspring. But the goodness of the motive does not imply that everything that follows is morally justified.
For this reason, as long as the medical team, their assistants, or the couple themselves who undergo these techniques, are aware of the inevitable loss of human beings in the embryonic state, they are morally responsible for these deaths (each according to the partnershiphe or she is responsible for the whole process), and act wrongly3. In any case, the couple usually receives no or little information about the loss of embryos and, for this reason, cannot be judged in the same way as the medical team.
It has been argued that, in the first moments of development, it is not clear whether the embryo is already a human person and that, therefore, it is not clear whether it is worthy of the respect that persons deserve. It could be treated as a thing until the moment when it begins to be a person, a moment which, they say, can be situated around day 15 of the embryonic development; from that day onwards, respect should begin to be given to the embryo.
This way of arguing has appeared on the scene just when IVF has made it possible to manipulate the human embryo in its early stages. Previously, all embryology textbooks were at agreementin affirming that human life begins, to all intents and purposes, with the new biological identity, i.e. at the moment of fertilisation of the ovum by the spermatozoon4. The argument that seeks to delay the humanity of the embryo seems only an attempt to remove any moral responsibility for the loss or dangerous manipulation to which these embryonic human beings are subjected.
It has also been argued that the terms under discussion are: on the one hand, the certain absence of human life (of offspring for the infertile couple) and, on the other hand, the possibility of new human life (that of the child that will arise from IVF). And a possibility of new human life would clearly be preferable to its total absence.
This argument is biased, as it does not look at the actions of those involved in these techniques and counts only the results5. If one looks at the actions, what is being judged is the production of a series of human beings (embryonic, but human beings nonetheless) in order to ensure that one develops, even at the cost of putting them all at risk of death. This is done to satisfy the (otherwise good and legitimate) paternity desires of a sterile couple. Considered in this light, it is inadmissible: what is being done is not right, nor is the good to be achieved in proportion to the evil to be tolerated6.
In conclusion, we can affirm that, from the point of view of respect for nascent human life, current IVF techniques with embryo transfer do not respect the life of the newly conceived human being and are therefore ethically condemnable.
b) Human sexuality
The respect of IVF techniques for the values contained in human sexuality does not derive from the mere presence or absence of technical assistance: this can exist in many other circumstances of reproduction, without it being something condemnable7. A further subjectof reflections are pertinent.
Human sexuality is completely different from animal sexuality. Although physiologically similar to that of other mammals, its content is different. While in animals it fulfils a purely reproductive role, governed by instinct, in humans this role is integrated and assumed in a properly human context. Human sexuality is the physical facet of the loving submissionbetween a man and a woman, submissionwhich is promised at the celebration of marriage and is carried out throughout married life. Human sexual gestures only make sense within that properly human submissionmutual loving .
The element core topicof human sexuality is therefore spousal love, of which it is the manifestation and sign. For this reason, the various possibilities of exercising sexuality that do not respond to a spousal love are dehumanising: it is contrary to the human sexual inclination (and we are not talking about biology) to exercise it outside the context of a loving marital submission8. Thus, fornication, adultery, masturbation, prostitution, rape, etc., would radically contradict the natural complexion of the human being in the field of sexuality, and are ethically condemnable. For this reason, IVF is to be condemned because, as it is normally practised, it requires masturbation of the male partner in order to obtain the sperm he uses.
The exercise of sexuality in men is normally followed by the arrival of children. This is not simply a (self-evident) biological consequence, but also has a properly human component. In the marital commitment, by which spouses give themselves to each other, there is a natural tendency towards children (again, we are not talking about biology), which explains the natural desire for offspring and the frustration that married couples experience when children do not come. In other words: spousal love is open to children; if the couple's relationship is not open to children, it is not spousal love, even if the sexual relations it produces have the same appearance (for example, sexual relations maintained while denying openness to children with the employmentof hormonal contraception)9. And, like the practices discussed in the previous paragraph, such sexual relations that are not the fruit of spousal love are ethically condemnable, even if they have the outward appearance of marriage.
The relationship of true spousal love with the birth of children is very reasonable if we consider that children, in order to reach their full human and affective development, need to be born in a family environment forged by mutual love, in which they can reach maturity as men and as Christians. For this reason, spousal love is the only means provided for the generation of children. Expressed in reverse, it can be said that children have the right to be born in a family as the fruit of their parents' love10.
IVF frustrates precisely this last aspect in a radical way. The act of parents producing children in vitro has nothing to do with the mutual bodily submissionof spousal love. The resultmay be the same - a child - but the parents' action is not to love each other, but to produce (by technical manipulation of their sexuality) the child they desire. Although there is nothing wrong with this desire (it is normal in any marriage), it is wrong to satisfy it at the cost of instrumentalising sexuality and the child that is to come. This instrumentalisation of sexuality in order to produce a child is also criticised from non-Christian points of view: feminists complain that IVF techniques and, above all, surrogate motherhood, instrumentalise women in order to produce children, and they are absolutely right. For this reason, IVF is also an ethically reprehensible internship. And if the "normal" form of IVF is to be condemned for this reason, there is even more reason to condemn other, more or less aberrant forms, such as surrogate motherhood or egg and sperm donations: in these cases, even the possibility of maintaining clear relations of paternity and filiation disappears11.
c) Medical ethics
Finally, one must consider the particular ethical requirements that affect doctors who perform IVF. On the one hand, doctors, by cooperating in or performing some of the reprehensible actions we have seen above, are behaving improperly. On the other hand, however, their dedication to the medical profession requires them to behave in a particular way.
The professional practice of medicine is driven by compassion for the suffering person. In the face of suffering, the doctor tries to cure, if possible, to alleviate and console. Faced with the sick, his vocation demands a particular dedication of kindness and beneficence12. For this reason, behaviour that is disrespectful of human life, or, in general, of the persons entrusted to their care, is particularly serious in the case of physicians, who have a vocational commitment to care for all with their best will.
In the IVF process, doctors subject embryos to the risk of almost certain death, which is particularly abhorrent from this point of view13. Their role should be just the opposite: to put a stop to the unreasonable demands of their patients whenever these demands are against other people. This is the case with the demand of a married couple for IVF.
Moreover, physicians carry out their humanitarian work through the scientific study of the human body, and of the effectiveness of the curative interventions they perform on it. They are obliged to use only procedures of proven efficacy, and never procedures of doubtful efficacy14, especially if they subject the patient to a burden of pain, discomfort or excessive financial burden15.
IVF is exactly that: an expensive, ineffective and dubious procedure, which subjects the couple, and especially the woman, to a great deal of physical discomfort, uncertainty, anxiety, etc. For this reason, the actions of the IVF doctor are unethical. This technique would be admissible, and only from this point of view, when, after diligent animal experimentation, it had a proven efficacy and did not cause the discomfort and expense that it currently causes16. In fact, its inconvenience for such leaveefficacy has led to the rejection of patients: from optimistic beginnings in the early 1980s, with the proliferation of IVF clinics, we have moved on to the current disillusionment, with many of them going bankrupt due to lack of clientele.
Finally, it should be noted that IVF is not a medical procedurein the normal sense of the term, but a technique with a medical appearance. The medical technique is, as we have just said, aimed at curing, alleviating or consoling. However, IVF does not fit into this dynamic. Even if, in some cases, the couple leaves the IVF clinic with a child, they remain as sterile as before: they have not been cured or relieved. In the rest of the cases, if there were coherence with what really happens, the IVF technique should be followed by mourning for all the embryos that have died in the technical procedure, which is far from a possible consolation. IVF provides a "solution" to the problem of sterility, which has more to do with the satisfaction of a satisfied consumer than with medicine. The latter, abandoning its north, has limited itself to producing a child for this marriage, nothing more.
This diverts human and technical resources towards the manufacture of children, taking away efforts from the real work that the medical ethos demands for this status: finding a curative treatment for real or presumed sterility17. Thus, while children are mass-produced and quality-controlled, the study of many questions of reproductive physiology and of the mechanisms of sterility of undetermined origin is still in the shadows, and there is a slow pace of researchand internshipin the prevention of sterility. The problem is vast: approximately 15% of married couples suffer from sterility or infertility problems. For these reasons, the ethics of medical practitioners who practice these techniques, often motivated by purely profit motives, are particularly condemned18 .
Notes
(1) Tan SL, Royston P, Campbell S, Jacobs HS, Betts J, Mason B, Edwards RG. Cumulative conception and livebirth rates after in-vitro fertilisation. Lancet 1992; 339: 1390-94.
(2) FIVNAT (French In Vitro National) et al. French national IVF registry: analysis of 1986 to 1990 data. Fertility and Sterility 1993; 59: 587-95.
(3) Cf. Sacred Congregation for the Doctrine of the Faith. Instruction "Donum Vitae" on Respect for Human Life at Birth and the Dignity of Procreation, sectionII, introduction. Cf. also Royal Commission on New Reproductive Technologies of Canada. Final Report, averagesummary, Ethical framework and guiding principles: "Respect for human life and dignity: All forms of human life and tissue must be treated with sensitivity and respect. Even if embryos are not considered by law as persons, they are bound to the community by their origins and potential" (p. 6).
(4) Cf. Instruction "Donum Vitae", sectionI, 1.
(5) Cf. John Paul II. Encyclical Veritatis Splendor, n. 79.
(6) Cf. Instruction "Donum Vitae", sectionI, 3.
(11) Cf. idem, sectionII, 2 and 3.
(12) Cf. Código de Ética y Deontología Médica, article4.1, and the corresponding commentary in Gonzalo Herranz, Comentarios al Código de Ética y Deontología Médica (Pamplona, Eunsa, 1992, 260 pp.).
(14) Cf. idem, Articles 21(1) and 24(2).
(16) Cf. Royal Commission ...: "employmentappropriate use of resources: There are many needs but resources are finite, so we need to use resources wisely. Public resources should not be spent on ineffective treatments, and a assessmentof technology is needed to manage resources" (p. 6).
(17) Cf. Code ..., article32.1.
(18) Blackwell RE et al. Are we exploiting the infertile couple? Fertility and Sterility1987; 48: 735-9.