From nucleus - spring 2003 - Infertility Treatments [PP13-21]
Infertility is a symptom not a disease. The causes are a third male, a third female and a third unknown and it can result from defects either in gamete production, release or transport. Successful treatment depends on accurate diagnosis and a variety of tests can be carried out to assess sperm numbers, function and quality, and ovarian function and fallopian tube patency. The range of treatments and their speed of development is bewildering, but the most common include artificial insemination, intracytoplasmic sperm injection (ICSI), ovarian stimulation with drugs, in vitro fertilisation (IVF) and gamete intrafallopian transfer (GIFT). The availability of donor gametes (and wombs), as well as the ability to freeze embryos, sperm and now eggs, makes a bizarre range of options possible.
Since the birth of the first 'test-tube baby', Louise Brown, in 1978, a further 68,000 children have been born this way in Britain, with over two thirds of these in the last five years. The worldwide figure is about one million. By 1994, 38 countries had established IVF programmes, including Pakistan, Egypt and Turkey.
Overall 15-25% of IVF patients become pregnant in any one cycle and 80-90% of these go on to have live babies. The treatment costs about £2,500 per cycle (soon to rise to £2,800) and over 900,000 embryos have been produced in the UK, of which over 90% have been used for research or died before birth. Many thousands of embryos that were frozen for later use have now been thawed and discarded.
Following the birth of Louise Brown, the government set up a committee of enquiry resulting in the Warnock Report in 1984 and ultimately the Human Fertilisation and Embryology Act in 1990. The act is overseen by the Human Fertilisation and Embryology Authority (HFEA), a group of lay people and health professionals, whose function is to take submissions and advise on future directions that the law should take. The organisation is also responsible for and regulates the use of IVF and GIFT. In the UK:
1. Surrogacy is not illegal but surrogacy arrangements are not enforceable in law. Commercial interest (save refunding of expenses) is illegal.
2. Embryos can be created for fertility treatment but no more than two can be placed in the womb at any one time.
3. Excess embryos can be frozen for future use and used for research but, once thawed, must be destroyed by the age of 14 days.
4. Embryos can be specifically created for research from the eggs of living or dead donors, but a licence is required for each research project.
The HFE Act presumes that the human embryo can be disposed of or experimented upon legally and sanctions the following:
1. 'Contraceptives' that act after fertilisation like the intrauterine contraceptive device (IUCD) and 'morning after pill'.
2. The use of embryos for fertility, contraceptive and genetic research.
3. Genetic testing and disposal of abnormal embryos (so called 'pre-implantation genetic diagnosis' - PGD).
4. The production of cloned human embryos by nuclear replacement to treat degenerative disorders.
5. Lesbian and gay couples having children via IVF and gamete donation.
6. Cloning by embryo splitting.
7. Selective reduction - where 'defective' fetuses resulting from IVF are selectively aborted.
Genetic engineering of embryos, chimerism (production of cross-species embryos) and ectogenesis (human development outside the body) are not yet legal, but as it is very difficult to regulate what goes on in laboratories, they are already more than theoretical possibilities.
What are we to make of these developments as Christian doctors? Applying the Bible to contemporary medical problems is always challenging because we cannot simply look up words like 'gamete', 'embryo' and 'surrogacy' in a concordance. But nonetheless there are clear biblical principles that can help us negotiate the minefield and find an approach that is consistent with both God's compassion and his commands. We have to be kind and Christ-like towards those who suffer; but we also need to be careful not to let our hearts rule our heads.
First we must assert that it is God who is sovereign and in control. The Scriptures tell us not only that God creates us in his own image for relationship with him, but that all human beings also belong to him. Children are a gift of God and a blessing he provides. They are his on loan to us, a privilege for which we should be thankful, not a right and, like all gifts of grace, they are distributed as he wills. We are told that God has the power to 'open' the wombs of the infertile. It is ultimately he who 'settles the barren woman in her home as a happy mother of children'. In the same way he has the power to prevent people having children. Infertility and fertility are not the results of random chance events determined by an accidental roll of the dice. It is God who is in control of both.
But does that mean that infertility was what God originally intended? Not at all. When God created the first human beings he told them to 'be fruitful and increase in number; fill the earth and subdue it', and he saw that all that he had made 'was very good'. Fertility is a blessing from God. Infertility is not mentioned until after man's rebellion against God, and the natural reading of Scripture is that it is one of the consequences of our disobedience. We now live in a fallen world tainted by the effects of sin. This does not mean that infertile couples are worse sinners than fertile couples; but it does mean that infertility is one result of the human race's rebellion against God. It is true of course that some infertility is the consequence of specific sin by an individual or population. This is especially true in those cases of tubal infertility that result from sexually transmitted disease or abortion. It is sadly ironic that the current high demand for infertility treatment has been fuelled largely by the falling number of children available for adoption (28,000pa in 1968 cf ~5,000 now), in turn secondary to the rapid rise in abortion (but also to the increase in numbers of solo parents keeping children who would have before been given up for adoption). But in the majority of cases of infertility, there will be no discernible link between an individual's behaviour and their fertility status, and if we are fortunate enough not to be infertile ourselves, we should be saying 'there but for the grace of God go I'.
Some people respond to this state of affairs by just accepting the status quo. But God is also gracious and merciful; he is in the business of healing and restoration. The command to 'fill the earth and subdue it' is a call to human beings to be God's co-workers in mastering the world he has created; not to exploit it, but to restore it, rather as a master artist might restore a flawed masterpiece. God has made us stewards of his creation, and wants us to use our God-given knowledge and talents to do good. This principle of stewardship validates scientific enquiry and application, for the purpose of helping other human beings. We can and should use our God-given skills to help alleviate infertility.
God is supremely sensitive to human suffering; and Scripture gives us many examples of him responding compassionately to the pain of childlessness. God hears Rachel's heart-cry to her husband, 'Give me children, or I'll die!' The Scriptures tell us that he 'remembered Rachel…listened to her and opened her womb'. As a result she gives birth to Joseph and responds by declaring, 'God has taken away my disgrace'. Similarly God responds to Hannah's tears of sadness over her longing for a son. She calls him Samuel, meaning 'heard of God', 'because I asked the Lord for him'. God understands the pain of childlessness (indeed he has experienced it himself - see Luke 13:34). It is striking that as well as Joseph and Samuel, Isaac, Samson and John the Baptist were all born to initially infertile couples. It is therefore, I believe, a wonderful privilege for doctors to participate in alleviating infertility; but of course we must do it in accordance with God's revealed standards of right and wrong. The end does not justify the means. We must not 'do evil that good may result'.
So how do we seek treatments for infertility that are in line with God's character and commands? I believe we do this by honouring life and upholding marriage.
Human life is precious because it is made in the image of God and belongs to him. 'Survival of the fittest' may be the law of the jungle, but the pattern of Christ's kingdom is that the strong lay down their lives and make sacrifices for the weak. The weakest and most vulnerable of human beings are worthy of the greatest respect.
Our society has gone in the opposite direction. Because human embryos are small, weak and physically insignificant, they are seen as expendable. Because they are not yet capable of communication, rationality or relationship they are viewed to be of less value than older and more developed members of our species. This bizarre approach to human life, which values human beings on the basis of what they can do or have achieved is completely at odds with the gospel, whereby the value of human beings is conferred by God's loving grace. Whether embryos can know love or relate is not relevant. They have value because they are loved, known and related to by God; who creates human beings for relationship with himself. As the psalmist declares, 'when I was woven together…your eyes saw my unformed body. All the days ordained for me were written in your book before one of them came to be.'[16,17]
This same principle of the sanctity of human life has been upheld in the ethical codes on which our profession is historically based. The Hippocratic Oath forbids abortion. The Declaration of Geneva (1948) stipulates that doctors 'should maintain the utmost respect for human life from the time of conception' and in like manner the International Code of Medical Ethics (1949) says that a doctor 'must always bear in mind the obligation of preserving human life from the time of conception until death'.
The Declaration of Helsinki (1975) says that in biomedical research 'the interest of science and society should never take precedence over considerations related to the well-being of the subject…In any research upon human beings, each potential subject should be adequately informed of the aims, methods, anticipated benefits and potential hazards of the study' and 'the subjects should be volunteers'. It goes on to say that 'it is the duty of the doctor to remain the protector of the life and health of that person on whom biomedical research is being carried out'.
Clearly embryo freezing, research and disposal violate these principles and highlight the fact that in the view of medicine and society human embryos do not now have the status of human beings. I beg to differ. Human embryos, as the most vulnerable of all human beings, must be treated with the utmost respect. They must not be bought and sold. They must not be engineered, cloned or selected. And, in my view, treatments for infertility that involve these techniques are fundamentally unethical, however much we may feel for the childless people involved. The end of alleviating their suffering does not justify such means.
When God created the first man he declared, 'It is not good for the man to be alone. I will make a helper suitable for him.' God invented marriage for intimacy, companionship and procreation and his clear pattern is of a life-long, publicly recognised, heterosexual, monogamous relationship. Jesus and Paul upheld these principles in their teaching.
The Bible clearly teaches that marriage is the only proper context for sexual intercourse and also God's ideal for the rearing of children. The family is God's provision for the protection, nurture and discipline of children and through this for the stability of society.
But the key question to consider here is whether the use of donor eggs or sperm somehow violates the marriage relationship.
Some ask the question, 'Is the use of donor gametes adultery?', but I think that is the wrong approach. Clearly using donor gametes does not involve intercourse outside the marriage relationship nor the cheating nor lust aspects of an adulterous relationship. Sometimes, particularly if the prospective parents know the gamete donors, everything may be done in a spirit of mutual care and concern. But this is not the point.
Marriage is a multi-level union between two people in which there is spiritual, emotional and physical union. Biblically speaking, the two become one. And each level of this relationship is important. Donor gametes, whether egg or sperm, inevitably introduce a third person into the relationship, a person who will be genetically related to the child, but will play no part in their upbringing. And the child will be biologically related only to one, or perhaps neither of his or her parents. He may not even look like them. And a parent who has contributed neither egg nor sperm to the child he or she is raising may not bond to them in the same way.
If the creator has designed life to be transmitted by the sexual union of a husband and wife who have been united by a bond of love and mutual commitment, the introduction of third parties runs the danger of depersonalising the whole process.
Furthermore, growing up under the protection of a stable committed marriage relationship gives a child security and a sense of identity. Many adopted children suffer from a loss of identity and need to find their birth parents in order to understand who they really are. We are beginning to see children who are the product of donated eggs and sperm asking the same questions: 'Who is really my father, my mother?' Such questions are impossible to answer meaningfully in scenarios like that with which we started this article.
While it is true that some couples are not good parents and it is equally true that some solo parents make a very good job of child-rearing, as a general rule the needs of a child are best met when he or she is brought up by their own biological, birth and legal parents.
Some Christians attempt to defend the use of donor gametes by appealing to biblical precedent. Didn't God approve of surrogacy/donor gametes in the cases of Hagar, Bilhah and Zilpah? But in fact in each of these cases God didn't. All of these extra wives were taken because of impatience or desperation and the results in all three cases were less than ideal: lack of identity, jealousy and marital and family discord.
Others object that God approved of Levirate marriage, in which a man adopted his brother's wife after his death. But in this case the original husband was dead, and so the first marriage in God's eyes was over.
I am left with grave reservations about the use of donor gametes in any circumstances.
To my mind enabling unmarried or homosexual couples to conceive, or using donated eggs or sperm threatens the 'public', 'heterosexual' and 'monogamy' aspects of what God has ordained.
So, where does this leave us? Which fertility treatments are admissible? My own answer is to accept those which are performed in a spirit of service and love, and which honour life and uphold marriage.
Infertility treatments that compromise the survival of embryos or violate the marriage bond fall outside these parameters. This must include any IVF programme which involves:
There is also the high failure rate (75-85% per cycle) and the high cost of treatment to consider. Costs of £2,500 per cycle exhaust the resources of many couples and the emotional roller-coaster of raised hope and dashed expectation can exert its own damage, opening parents up to exploitation by those who wish to profit financially. However, having said all this, IVF may be acceptable if there is no freezing, experimentation or destruction and all embryos are replaced in the womb at the time in numbers likely to maximise survival.
One fairly recent development has been the use of frozen eggs. Previously it was thought that, whereas embryos and sperm can be frozen, the freezing of eggs led to irreparable damage, but this has not been borne out by the most recent studies. And if eggs can be frozen successfully there is then no justification for freezing embryos.
GIFT does not involve embryo destruction since fertilisation does not take place outside the body.
ICSI is used when sperm quality is not sufficient to achieve fertilisation through normal intercourse. It does not necessarily involve the destruction of embryos and hence in theory may be acceptable, but there is evidence that increased fetal malformations may result. In fact, recent research in Australia has shown that a group of infants born after ICSI and IVF had approximately twice the expected rate of major birth defects. It seems counterintuitive to 'help' already defective sperm.
Surrogacy again introduces the problem of donor gametes as well as problems in terms of the emotional bond between the child and the carrying mother, or the lack of this bond with the legal mother. Similar problems arise in adoption, but adoption makes the best of a bad situation, whereas surrogacy intentionally creates these problems.
Sex selection of embryos clearly violates the above principles, even when performed to avoid the transmission of genetic diseases. It is not ethical to avoid disease by destroying (through non-implantation) affected individuals. Even sperm sorting introduces the idea of a 'designer baby', which has its characteristics chosen on the basis of someone else's preference. Children are not consumer items and their needs are more important than their parents' preferences. They are a gift, not a right. They are not there to satisfy our needs but to be cared for as God himself cares for all his children.
If the principles of respect of the embryo, respect of the marriage bond and the needs of the child being paramount had been followed, then many of the more difficult cases that have emerged from Warnock's Pandora's box would not have been an issue. We would have no 'geriatric' mothers, no black babies from white parents, no cloning or designer babies.
Instead we would treat infertility in a way that combined loving service of the infertile with honouring life and upholding marriage.
There is also a role for patience and prayer - waiting for God's good time. I have been amazed at the number of Christian couples who have eventually gone on to conceive, either with ethical infertility treatment or naturally after a long period of waiting. Of course this does not happen for all, and God in his wisdom has left some couples childless despite good treatment and patient prayer.
There will always be mysteries beyond our understanding and answers that we will never have this side of heaven. In these circumstances we need to trust that God knows best. And yet I wonder if one of the reasons that God allows some couples to be childless is so that there are couples with a strong desire to be parents, who can either adopt children, or serve others' children in some way or be freed up for some other special purpose that God has for them.
In a very small way this has been my own experience. My wife and I have been blessed with three sons, for whom we thank God, but we lost our fourth child, a daughter, eighteen weeks into the pregnancy, and are unlikely ever to have another. This loss meant that my wife returned to work earlier than expected. As a community paediatrician working in adoption and fostering consultancy and as a school governor she has been able to make a valuable contribution to the lives of others; particularly in making the lives of other people's children better than they would otherwise have been. In addition it has meant extra income beyond our needs that we have been able to use in the Lord's service in building his kingdom. We don't know God's full reasons for our loss, but we can at least glimpse some of the way he is working for good through it.
In the end we must recognise God's sovereignty, be realistic about the fact that we live in a fallen world, and serve the childless with grace and compassion, whilst honouring life and upholding marriage. Whilst the final mysteries remain his, God can be trusted, and we can be confident that ultimately all will be put right in a new and perfect world when Christ returns to gather his own children to himself.