The Psalmist reflects that, 'Children are a heritage from the Lord, offspring a reward from him. Like arrows in the hands of a warrior are children born in one's youth. Blessed is the man whose quiver is full of them'. (Psalm 127: 3-5)He goes on to speak of the blessing of each future generation: 'May the Lord bless you … that you may see your children's children'. (Psalm 128: 5-6)

We also read the heart-breaking stories of those longing for children, involving pain and marital struggles - Sarai , Rebekah , Rachel , Hannah , Elizabeth .

And we don't need to look very far on the internet or magazines to see pictures of adorable babies. Even our churches are children-focussed with groups and birth announcements advertised through services.

The pain of infertility is often silent, the suffering is not so visible and may only be known to a few close confidants. Although it is beyond the scope of this essay to write about fertility treatment or adoption for the single person, not being a parent is a pain that many single people experience too.

Subfertility is very common. Approximately one in seven heterosexual couples will struggle to conceive and one in six seek help. The causes for subfertility are multiple:

• Unexplained - 28 per cent
• Male - 25 per cent
• Ovulatory - 21 per cent
• Tubal - 15-20 per cent
• Endometriosis - six to eight per cent
• Sexual dysfunction - four to five per cent

It is worth noting in the above list the significant percentage of subfertile couples for whom standard medical investigation does not find a cause. This generally leads to a recommendation for IVF (in vitro fertilisation) treatment. However, it may be that further investigation or more research might find a cause for subfertility that could be treated by means other than IVF. We shall look at some of these treatments below.

There is no doubt that age plays a role in fertility, and the Western cultural norm for delaying commencing a family impacts on the ability to conceive. For women entering a career in medicine, deciding when to have children can present a particular challenge.

When does life begin?

When considering the precious gift of new life from God, Christian couples will want to witness to the goodness of that life by seeking to protect it as soon as it is created. And for this reason, it is important to consider when life begins and what impact that has on any fertility treatment being considered. Christians have different views on personhood and when protectable human life begins. (For a fuller discussion of this see: When does Life Begin 2019, Deadly questions on the status of the embryo 1998, The soul of the embryo 2004, and Begotten or made 1984 .)

Many modern fertility treatments rely on embryo 'creation' for their success . When we speak of creation with reference to embryo technology we really should mean pro-creation since God is powerfully and wonderfully creating these beings as he does with all new life - but we will continue to use the phrase embryo creation here for simplicity.

It is vitally important that Christian couples prayerfully discern the status of the human embryo before their involvement in any treatment that might jeopardise a tiny new being. Even if the couple were uncertain about the embryo's status but believed they might be human - made in God's image - it seems reasonable that parents would want to seek their embryo's protection.

In this CMF file, we will assume that protectable human life begins at fertilisation. Therefore, any treatment that would lead to loss of life after fertilisation - ie embryo loss - would be considered ethically concerning.

Family options

For Christian couples who find themselves unable to conceive spontaneously, there are several different options to prayerfully consider.

Is God calling them to be parents and to serve him in this way? Many Christian couples have found themselves (unwillingly) without children yet have had wonderful ministries. They have been able to devote themselves to service in ways which would not have been possible as biological parents.

Discerning ethically acceptable family options

Adoption
Adoption is an obvious option for those who desire to be parents and do not conceive. What a wonderful gift to offer a child whose birth parents cannot perform the child-rearing role. This kindly act is a picture of the way Christians are adopted as sons and daughters into Christ's eternal family and share in that inheritance: 'In love he predestined us for adoption to sonship through Jesus Christ, in accordance with his pleasure and will.'(Ephesians 1:4b-5)For couples who would prefer to adopt a baby, this can be a challenge (in the UK at least) since the average age for adoption is now three years and four months. Many children placed for adoption in the UK have physical and emotional challenges that will require additional support by the adoptive parents and others. It is also possible to adopt children from abroad. There are different legal processes and the challenge of bringing a child up in a different culture from their birth to consider (for more on adoption, see Adoption - not just a calling for the childless 2009 ).

Ovulation Induction and intrauterine insemination
Ovulation Induction is a medical treatment given to women who are not ovulating to stimulate egg release. Drugs are given at a certain time in the cycle, follicles are then observed by ultrasound, and the couple are advised to have intercourse on certain days to time the presence of sperm with ovulation. There is an increased chance of a multiple pregnancy (such as twins); hence if there are too many follicles, the couple will be advised to abstain until after the fertile period. This treatment works by treating a medical condition and restoring ovarian function. As such there should be no ethical concerns about using such medication.

Intrauterine insemination (IUI) is a treatment for male infertility. The man's semen is collected and then inserted into the woman's uterus at a fertile time in her cycle. Masturbation to produce semen does require some discussion - the common use of pornographic material to assist this in a clinic would be something a Christian couple would want to avoid but clearly, this is not a requirement of the process!

The child is not conceived during a physical act of sexual intercourse, which might be a concern for some believers. However, the 'one flesh' nature of marriage between husband and wife is not interrupted by a donor (see below), and if physical intimacy between the couple is continuing, it does not seem to be a route that would go against upholding protectable life.

NaProTechnology (Natural Procreative Technology)
This approach seeks to investigate, diagnose and treat the causes of infertility in a more detailed way than many fertility clinics (as we saw above, 28 per cent of infertility is unexplained, but perhaps it is just yet to be explained). NaProTechnology uses techniques learnt through natural family planning and fertility awareness giving an understanding of hormonal imbalance and possible structural abnormalities.

NaProTechnology uses the Creighton Model Fertility Care System (CrMS model) to better understand the menstrual cycle, using biomarkers (eg cervical secretions) to identify ovulation and the fertile days of the month. Trained practitioners assess biological and hormonal markers and offer standard accepted medications and hormonal supplementation (and occasionally surgery). Although there are limited studies, their findings suggest this could be an effective treatment for some couples.

It is not ethically problematic as it seeks to restore fertility and therefore does not require couples to engage in the ethical challenges of IVF (see below).

GIFT - gamete intra-fallopian transfer
Gamete intra-fallopian transfer - GIFT is a little-known reproductive procedure that involves retrieving egg and sperm and placing them together laparoscopically at the entrance to the woman's Fallopian tube. If fertilisation occurs, the embryo can then develop naturally within the mother's body, thus avoiding any ethical concerns about and risks to embryos created outside the body. The downsides are that it requires a laparoscopy, at least one Fallopian tube to be open, there is an increased chance of multiple pregnancy and increased risk of ectopic pregnancy (although similar to that of IVF). The quoted live birth rates are similar to IVF cycles. However, there is very little recent published data.

Evaluating ethically concerning family options

Donor gametes - including donor IUI or IVF with donor
A common aspect of current fertility treatment is the use of donor gametes (egg or sperm) when either partner cannot produce a gamete, or they are deemed to be of insufficient quality to produce an embryo. This question is a significant one.

There are valid concerns that inserting another's genetic material changes the 'one flesh' nature of the marriage between husband and wife. Although physical adultery has not taken place, a child develops that is genetically unrelated to one or both parents. This has seemed to many an intrusion into the family unit. For it separates our understanding of biological and social parenting - the donor is not intending to parent the child and has no right of involvement in the child's life. There are effectively three parents involved - representing a significant variation from the structure of marriage and child-bearing as it was originally created.

There are Old Testament precedents to consider when a child was not forthcoming. In the case of Sarai and Hagar, the intrusion into the marriage that resulted from Ishmael's conception was not harmonious for the remaining relationships. Moreover, some point to the practice of Levirate marriage to justify donor insemination. However, in such marriages, the living sibling not only genetically fathered the child but took on parental responsibility - something quite different from the intention of gamete donors today.

Questions surround how the child that is born relates to both parents when and if it finds out that it is not genetically related. A child conceived by sperm, egg, or embryo donated after 2005 can request the identity and demographics of their donor once they are 18. If the donation was before this, individuals can undertake DNA testing and may be able to identify their biological parent(s). Hence the reality is that complete anonymity will be unlikely for donors.

If one parent is genetically related to the child, there is a potential mismatch for the couple, since their connection with the child is unbalanced because of the lack of an equal genetic link. This risks disunity and jealousy between parents and between the child and parents on discovering their genetic identity. There are enough concerns about the impact on marriage and the relationship with the child for us to caution Christian couples against the use of donor gametes while recognising that an option of giving birth to a child is removed.

Surrogacy
Surrogacy involves a decision between two or three parties, where a woman agrees to gestate a baby whom she is not intending to parent but will instead hand over to another after birth. This may be requested in a situation where the mother has no uterus (eg after hysterectomy for cancer). The surrogate may be genetically related to the child (the surrogate's eggs may be donated), and she may gestate an embryo that is either genetically related or unrelated to the receiving couple.

Surrogacy is legal in the UK, as long as there is no commercial interest. Surrogacy brings up several legal and ethical concerns for the Christian couple. (See 'Surrogacy' 2019 for a more detailed discussion). The time in utero and the bodily relationship of mother and baby are so important biblically. As the Psalmist says, 'You knit me together in my mother's womb'. The bond of love forms very early; hence there are real worries about the impact of separation at birth - for both the baby and the surrogate. Because of these concerns surrounding surrogacy, it seems reasonable that it is not a family option that should be recommended for a Christian couple.

In Vitro Fertilization (IVF) with spare embryos
IVF entails the creation of embryos outside the human body. Eggs are retrieved surgically (often using medication to increase ovulation) at the correct time in the cycle and sperm is supplied by the man. These are fertilised and then replaced into the womb between two to five days post-fertilisation.

IVF clinics will, in the vast majority of cases, create more embryos than they intend to put back. This practice enables clinics to choose the 'best' embryos to replace; to undergo pre-implantation genetic diagnosis (for conditions such as cystic fibrosis or Huntingdon disease) if is being carried out, and to limit the number of egg retrieval procedures. Because of the complications associated with multiple pregnancies the Human Fertilization and Embryology Authority (HFEA) stipulates that in most circumstances only one embryo can be re-inserted in an IVF cycle. This very often leads to 'spare' embryos being created.

'Spare' embryos
It is difficult to determine how many embryos are 'spare' (stored and available for use in IVF or awaiting eventual disposal) - at any one time. In 2019 in the UK 222,192 embryos were created, 62,144 were stored for possible future pregnancies, and there were 18, 925 lives births. Patients aged 35-37 had a live birth rate of 25 per cent per embryo transferred.

The Human Fertilisation and Embryology Act in the UK allows frozen embryos (and gametes) to be stored for a maximum of ten years . They can be stored up to 55 years with a demonstration of medical need, (eg if a young person had gametes removed prior to fertility-damaging chemotherapy or surgery). However, the government intends to change that time period so that gametes and embryos can be stored in renewable ten-year periods up to a maximum of 55 years. This would very likely increase the numbers of frozen embryos stored in the UK.

If Christian couples want to avoid embryo destruction, then the morally safest option is to only create the number of embryos at each cycle that will be replaced in that cycle. Even embryos created for future pregnancies are at risk because of an unforeseen situation happening in the couple's life. There are cases where one or both parents dies, and a decision must be reached about the fate of their frozen embryos. Moreover, a difficult pregnancy, maternal health, financial circumstances, or the experience of parenting, may all change how a couple feels about a future pregnancy. If we believe that life begins at fertilisation then these embryos are in fact protectable lives. Of course, they cannot come to birth without a womb to gestate them, but they should not be discarded or destroyed because they are no longer required. They are precious gifts of new life, loved by God their Father and they should be treated as such.

Pre-implantation genetic diagnosis (PGD)
Where one member of the couple has a recognised genetic condition or a previous child has been so affected, the couple may be offered genetic screening of early embryos (see HFEA for conditions that can currently be tested for ). As well as the concerns about creating spare embryos, we must be concerned about selection and active decisions to choose not to gestate some children. Of course, living with a genetic condition may well be hard for both a child and their parents. While God loves all of us, his creatures, from conception, PGD can tempt parents down a slippery slope of selecting for the 'perfect' baby, and away from welcoming all and any children God gives them. For both these reasons PGD should be avoided.

Family options which need prayerful discernment

In Vitro Fertilization (IVF) without creation of spare embryos

If a couple wishes to avoid creating spare embryos, they could request that their fertility practitioners only create as many embryos as can be implanted in each cycle. (For a further discussion of IVF practiced in this way see 'Facing Infertility - Guidance for Christian couples considering IVF' ).

Clinicians may be reluctant to do this, as the live birth rate will be lower. They may also cite the risk of each egg retrieval procedure as an objection. One solution to this would be freeze several eggs and then thaw and fertilise each egg with fresh semen for each IVF cycle. While this procedure has its own ethical considerations, they are not those associated with the creation of spare embryos.

With these options in mind, we need to consider whether there are any moral concerns about the process of IVF itself. For example, what effects on parents' relationship with their offspring might follow from allowing a third party to engage with these embryos, in their earliest state?

The Scriptures talk about 'begetting' children - the concern is that the practice of IVF may tempt us (and the embryologist) to believe we are 'making' children as a product of our technological expertise rather than engaging in pro-creation in the sense described above. The language here is interesting. Clinics talk about a 'take home baby rate'. Is this the commodification of God's precious gift of human life?

It is also worth considering the use of a reproductive technology that relies for its existence on embryo research. IVF's success relies not only on previous experimentation and multiple embryo destruction, but on current research and practice where embryos are destroyed.

Couples must weigh up whether their conscience will allow them to participate in such a practice (with the caveats discussed above) which continues to destroy embryos even if they can be confident that the embryos begotten from their own gametes are not being destroyed. It may be that a couple decide not to pursue IVF in order to uphold the goodness of embryo life. They may feel the temptations to create additional embryos or to view children as something we make are too great. Christians are called to flee temptation and to bear witness to the goodness of creation, often in sacrificial, costly ways, thereby honouring our creator God and Father who gives life and takes away.

Discerning what to do with 'spare' embryos?
Some couples will be seeking advice when they already have 'spare' embryos. These couples have often had to suffer an extended period of stress and disappointment during the process of receiving treatment for subfertility.

There are stories of couples (and especially women) in anguish over what to do about embryos which they have frozen. The pastoral concerns are evident - it may be that couples did not fully understand the status of their embryos when they embarked on such a path. They may have been persuaded about the benefits of over-creation by an enthusiastic clinic. It may even be that their journey into parenthood has convinced them of the creative power of God in their new children's lives. These circumstances require much prayer, patience and sacrificial love from those involved. But the church must be able to offer a supportive, hopeful option.

Embryo adoption
Embryo adoption, where spare embryos are donated to another couple, is a practice which might seem attractive. It allows the embryos to be given a home and hopefully come to birth in accord with the intention of their genetic parents. Using a donated embryo might be an option in the UK in a situation where neither parent is able to produce gametes. The embryo is donated by another couple who have 'spare' embryos.

In the USA a Christian organisation called Nightlight runs the 'Snowflakes Embryos adoption Programme'. Such a programme does not exist in the UK and the language of donation is used rather than adoption. Although some parallels can be drawn, the process of child adoption is somewhat different - both legally and ethically.

Embryo donation is a complicated path to take; whilst we would want to protect such an embryo, its gestation in a different woman and parenting by a couple who are genetically unrelated leads to the issues discussed previously with donor gametes. Although it might be a better option than destruction it does not seem right that the possibility of embryo donation should sanction the creation of more embryos than necessary for a reproductive project as discussed earlier.

Embryo replacement
For a couple who uphold life from conception and the faithful union of marriage as the place to beget children, we can conclude that the only faithful option for those 'spare' embryos would be the continued implantation of each embryo at a fertile time in the wife's cycle in the hope that children - the natural and good aim of the reproductive project - will develop and be born. This will require the acceptance of a long and costly process, continuing to participate in IVF, possibly leading to a large family (in practice, the live birth rate from each cycle of IVF is approximately 25 per cent and this figure declines with maternal age, which raises the likelihood of a range of conflicting emotions which the couple will need support to process). This option may not be possible if the health or menopausal status of the woman prevented pregnancy. But perhaps the church can help such a couple attempt to raise a large family and provide a witness to the goodness of these lives.

Conclusion

Responding to couples facing subfertility
Firstly, Christians should respond with the kindness and gentleness of Christ to those with longings to parent children. We should recognise the goodness of these desires and mourn when these are unfulfilled. Pastorally we need to recognise the impact on marriages and seek to support both partners. There has not been space to explore the pain of miscarriage, but this is something that couples suffering subfertility may also experience. We need to recognise that couples may have gone through invasive investigations and procedures that involved significant personal and financial cost. They may be mourning the loss of their embryos, their children's early lives and future hopes; hence we need to be sensitive in the way we talk about children.

Secondly, since subfertility is so common, it is something we should be addressing in church and small groups. It should be discussed when considering a relationship and in marriage preparation so couples understand each other's hopes for children and what considerations they would give to treatment options. We should be discussing the appropriateness of current UK fertility treatments so that couples are not considering these matters for the first time when facing a difficult situation. We should enable couples to question healthcare providers about such treatments and to discuss alternatives. And we can celebrate the ministries of couples without children and help those who foster or adopt to provide homes full of love and grace (see Home for Good ).

Thirdly, we need to understand the strong and good desires to parent and that there is pressure both from church and society to uphold those desires. We need to be aware that subfertility is painful and, at times, poorly understood. Couples will be getting lots of treatment information, much of which we would want to pause and question as Christians, particularly in relation to embryo creation techniques. We want to bring other options into the foreground so they can be explored in good time.

Finally, we need to recognise both that all children, however they are conceived, are precious gifts from God. God's ultimate call is for each follower of Christ is to be faithful to him who called us out of nothing and made us as his children through his Son, that we may serve him wholeheartedly through the whole course of our lives.

Claire Hordern is a Senior Registrar in Obstetrics and Gynaecology