Thesis: It is necessary for everyone to become educated about reproductive technology in order to be better equipped to deal with the moral and ethical issues that this new technology brings to today's world.
I. Introduction
II. Background
A. Infertility
B. Causes of Infertility
III. Assisted
Reproductive Technologies (ART)
A. Artificial Insemination
1. Intrauterine insemination (IUI) & Intracervical insemination
(ICI)
2. Surrogate Mother
B. In-Vitro
Fertilization (IVF)
C. Gamate
Intrafallopian Transfer (GIFT)
D. Zygote
Intrafallopian Transfer (ZIFT)
E. Intra Cytoplasmic
Sperm Injection (ICSI)
IV. Issues
Surrounding Reproductive Technology
A. Health
1. Effects of fertility drugs on women
2. Health of children born by ART methods
B. Cost
C. Psychological
Effects
D. Social
1. Results of using donor eggs and sperm
2. The effects of ART on overpopulation
E. Surrogate
Mothers
F. Left-over
Embryos
V. The Role of Reproductive Technologies in the Faith Community
VI. Conclusion
Reproduction is the ability of a species
to perpetuate and in the human species it is looked upon as a
right in today's society. Males and females alike feel pressure
that in order to be fully male or fully female they must procreate
(Conrad, 1997). While this is not true of
all men and women, for many married couples the ability to have
children is important. It is only recently that infertile couples
have been provided with options that would allow them to conceive
a child. These options include the various forms of reproductive
technology that have been developed over the past 20-25 years.
While these technological advances have brought joy and hope to
many infertile couples, the advances have also brought along a
myriad of moral and ethical dilemmas as well. It is necessary
for everyone to become educated about reproductive technology
in order to be better equipped to deal with the moral and ethical
issues that this new technology brings to today's world.
Infertility is defined as the "inability of a man to impregnate or of a woman to conceive" after a year of having regular intercourse without any form of birth control (Wekesser, 1996). Surprisingly enough in a 1992 study, one in six couples were found to be infertile (Blank & Merrick, 1995). This statistic has held static since the 1980's but had been previously increasing. In looking at just the United States it has been estimated that infertility affects approximately 2.8 million couples out of the 600 million Americans who are of reproductive age (Infertility Tests, 1996).
Contrary to what most believe to be true, infertility is caused by as many men as by women. In fact, about 40% of cases are attributed to men and about 35% attributed to women. The remaining 25% of cases are because of a combination of multiple factors of the two partners or of unknown causes (Infertility Tests, 1996).
Causes of Infertility
The main cause of male infertility is oligospermia, which is too few sperm in semen to give a high probability of fertilization (Austin, 1989). Other reasons include poor sperm quality, low sperm motility, blocked vas deferens or epididymis, or azoospermic, which is the lack of sperm in semen (Infertility, 1999). Sperm quality deteriorates with age but its rate of change is not as quick as egg quality deterioration in women.
Causes of infertility in women cover a
wider range of possibilities. Poor egg quality, irregular ovulation,
and blocked fallopian tubes are the most common causes. Reasons
for blocked fallopian tubes include infections, endometriosis,
scar tissue, and damaged fimbria (Infertility,
1999). This is important because even if a woman is able to
ovulate regularly, the egg is unable to enter the uterus which
makes is impossible for the sperm to come in contact with the
egg (Infertility, 1999). Less common
causes include polycystic ovaries, primary and secondary amenorrhea,
which is when menstruation never started or ceased respectively,
pelvic inflammatory disease (PID), hostile cervical mucus, and
damaged or missing reproductive organs (Austin,
1989). Cancer therapy, repeated abortions, and miscarriages
have also been found to increase the chance of infertility (Infertility Tests, 1996). However,
with the variety of different causes there is still 5-10% of infertile
women who do not have a known cause for their infertility (Austin, 1989).
Assisted Reproductive Technologies (ART)
Assisted reproductive technologies (ART) are a way in which people can combat infertility. While these technologies do not fix the problem per se, they attempt to bypass the problems associated with infertility from "sex cell rendezvous and fusion to early embryo development, transport and implantation in the uterus" (Thomasma & Kushman, 1996). Additionally, all of these methods require clinical manipulation of sex cells and/or embryos that are smaller than the size of a period (Thomasma & Kushman, 1996). These technologies include artificial insemination, in-vitro fertilization, gamate intrafallopian transfer, zygote intrafallopian transfer, and intra cytoplasmic sperm injection along with a variety of others.
Artificial Insemination (AI)
Artificial insemination is the simplest and oldest method of mechanical reproduction. A well-known English doctor performed the first effective human insemination in 1790 (Nelson, 1973). It was not until 1866 that the first American AI baby was born. Since then the different techniques of AI have been developed and improved. There are three types of this technique: artificial insemination by the husband (AIH), artificial insemination by donor (AID), and surrogate motherhood.
There are three main techniques involved in AIH and AID. Intrauterine insemination (IUI) is the most common way to be artificially inseminated. IUI does not involve egg retrieval or embryo transfer. It does require the woman to undergo fertility drugs in order to stimulate an increased production of eggs; however, the dosages are reduced comparatively to other forms of ART because only 3-4 eggs are wanted (Cooper & Sarasohn, 1998). Sperm are collected and analyzed in the lab and then when the timing is right, they are inserted into the uterus (Assisted, 1999). Intracervical insemination (ICI) is preformed in the same manner as IUI. The only difference is that the sperm are placed into the cervix instead of directly into the uterus (Cooper & Sarasohn, 1998). An additional type of AI is intratubal insemination (ITI) which is when the doctor places the sperm into one or both of the woman's fallopian tubes. This last procedure is the least common of the three. Generally, these methods are performed on several consecutive days because the timing of ovulation is not certain (Blank & Merrick, 1995). If the partner's sperm are used, it costs less than $500 per treatment (Assisted, 1999). In addition, there is a reported success rate of 80% pregnancy within several months of treatment (Blank & Merrick, 1995). In the United States alone, 500,000 children have been born using artificial insemination (Thomasma & Kushman, 1996).
A surrogate mother is used when a woman is unable to carry a baby to term but her husband is capable of producing viable sperm. The couple draws up a contract with a woman outside of the marriage to be the surrogate mother. She is artificially inseminated with the husband's sperm and then carries the baby to term. After birth the parental rights are transferred from the surrogate to the couple who then can adopt the child (Conrad, 1997). New technology has made it possible for women who are able to produce eggs but not carry the pregnancy to have their eggs retrieved, fertilized in vitro with the husband's sperm, and then transferred to the uterus of a gestational carrier (Cooper & Sarasohn, 1998). This is the most expensive of all ART methods because it involves the cost of the surrogate herself, the cost of AI or in-vitro fertilization to inseminate the surrogate, and legal fees. The total cost can range from at least $15,000 to well over $35,000, which does not include pre-natal care or delivery (Assisted, 1999). Additionally, the cost could be higher if more than one treatment is needed.
In-Vitro Fertilization (IVF)
IVF made its first appearance in 1977 when two English doctors joined the sperm and egg of a couple, which resulted in the birth of Louise Brown in 1978 (Bohle, 1979). It was not until 1981 that this new human reproductive technology was allowed to be used in the U.S. Since then, this type of high tech infertility treatments has become the most common method chosen today comprising more than 70% of all ART procedures (Assisted, 1999). There have been at least 45,000 IVF births in the U.S. alone since 1981 (Assisted, 1999).
The first step of IVF is giving the woman fertility drugs which stimulates ovulation in order to produce numerous mature eggs at one time (Assisted, 1999). Fertility drugs are not necessary but they greatly increase the odds of several different things. The first is that there is a higher probability of obtaining a good quality egg, the second is the increased chance of retrieving an egg that fertilizes and results in a good quality embryo, and the third is a better opportunity of the egg implanting in the uterus (Cooper & Sarasohn, 1998). The woman's blood hormone levels are then carefully monitored so the doctor is able to retrieve the eggs when they are mature but before the woman ovulates them herself (Cooper & Sarasohn, 1998). The doctor then retrieves the eggs by giving the woman a local anesthetic and then inserting a needle through the vaginal wall. An ultrasound enables the doctor to locate the eggs in the follicle (Assisted, 1999). The follicle contents (including the eggs) are then drawn up the needle by gentle suction and afterwards placed in a dish in the laboratory (Austin, 1989). Around 50,000 of the partner's best quality sperm are selected, added to the dish as well, and allowed time for fertilization to occur (Cooper & Sarasohn, 1998).
After two days, fertilization can be confirmed and the embryos are evaluated. Usually 2 to 4 of the best quality embryos are transferred to the uterus through the cervix by a thin catheter (Infertility, 1999). The number of embryos transferred is increased according to the woman's age (Cooper & Sarasohn, 1998). When the process is successful, the embryo will implant in the uterine wall and continue to develop (Assisted, 1999). If there are extra embryos of good quality that were not transplanted, they can be frozen in case the transplanted embryos do not implant in the uterine wall or if the couple wants to have more children later and not go through the entire process over again (Yoder, 1998).
The cost of one cycle of treatment, from administering fertility drugs to implantation, can average between $6000-$10,000 and the length of one cycle is 4-6 weeks (Assisted, 1999). IVF has about a 20% success rate (viable pregnancies) which is equivalent to normal intercourse (Rogers, 1988). Not all women will become pregnant using IVF and not every woman who becomes pregnant will end up delivering a baby. However, since more than one embryo is used, there is often a 20-30% chance of having a multiple birth, which also increases the risks of miscarriage and other complications (Assisted, 1999). IVF is one of the oldest ART procedures, so many studies have been done on children born by IVF. These studies have not found medical problems associated with IVF children (Assisted, 1999).
Gamate Intrafallopian Transfer (GIFT)
GIFT is the next most popular method used, entailing 6% of the ART procedures (Assisted, 1999). The method involved in producing and collecting eggs and sperm is identical to IVF. The difference occurs after the sperm and eggs are placed into the dish together. Immediately after they are placed in the dish, the doctor uses a fiber-thin tube called a laproscope to place the egg and sperm directly into the fallopian tubes through a small incision in the female's abdomen (Assisted, 1999). This enables natural fertilization to take place in the fallopian tubes, which is a better, more natural incubator (Cooper & Sarasohn, 1998).
The cost of one cycle of GIFT is $8000-$10,000 and the length of one cycle of treatment is the same as IVF (4-6 weeks) (Assisted, 1999). The success rate of GIFT is a little higher with 27% of couples delivering a baby (Assisted, 1999). One reason behind this is because the embryo reaches the uterus naturally and does not disrupt the uterus lining (Conrad, 1997). One drawback is that GIFT does require minor surgery including general anesthesia (Thomasma & Kushman, 1996). GIFT also involves similar risks as IVF in that there is a higher chance of multiple births which increases the chance of miscarriage or other complications. The reason some people prefer this method to IVF is that since the sperm and egg are handled separately outside the body and delivered before fertilization can take place, they are relieved of some of the moral, ethical, and/or cultural problems often associated with ART procedures (Thomasma & Kushman, 1996).
Zygote Intrafallopian Transfer (ZIFT)
ZIFT is considered the most invasive of all the ART procedures and as a result it is chosen only by 2% of people that decide to use reproductive technology (Assisted, 1999). The methodology of collecting sperm and eggs is the same as in IVF and GIFT. Once the eggs and sperm are joined in the lab, they are monitored closely for about 1 day to ensure the eggs become fertilized (Cooper & Sarasohn, 1998). The fertilized eggs, or zygotes, are then inserted into the fallopian tubes as in GIFT. To do this, the woman undergoes minor surgery in which the doctor makes a small incision in her abdomen and then uses a laproscope to place a zygote into one or both fallopian tubes (Assisted, 1999). The process is identical to GIFT from this step on.
The reason ZIFT is sometimes preferred to GIFT is because fertilization can be determined before transferring the zygote to the woman (Cooper & Sarasohn, 1998). Like GIFT, the fallopian tubes are used to incubate the eggs although for less time (Cooper & Sarasohn, 1998). One of the downfalls of this process is that often it is more expensive because it involves more lab work (fertilizing the egg outside of the body) and the extra costs of surgery (Assisted, 1999). Additionally, like IVF and GIFT, multiple births are more probable. Considering how similar GIFT and ZIFT are, if the woman's fallopian tubes are in tact, GIFT seems to be a better option for couples to choose. Additionally, there does not seem to be a difference in the length, cost, or success rate of ZIFT in comparison to GIFT (Assisted, 1999).
Intra Cytoplasmic Sperm Injection (ICSI)
ICSI, introduced in 1992, is the newest of the ART methods. It is a breakthrough in helping male infertility because it bypasses the need for the sperm to swim through the woman's reproductive tract and for the sperm to penetrate the egg (Hinman, 1999). As with the previous methods mentioned, the woman is first given fertility drugs to stimulate the maturation of numerous eggs. Then at the appropriate time the eggs are collected using the process discussed before. The man provides sperm simply by giving a sample. The highest quality sperm are then chosen. A lab technician isolates these sperm and then injects a single sperm into the cytoplasm of the egg while holding the egg with a glass pipette essentially causing fertilization (Cooper & Sarasohn, 1998). This is all done under a microscope. After two days the doctor transplants 2-4 embryos into the woman's uterus through her cervix as in IVF (Assisted, 1999). Hopefully, one of the transplanted embryos will implant itself into the uterus wall.
The length of the entire process is similar to that of the previously mentioned methods. One of the main hindrances of ICSI is that it is difficult to deliver sperm to the egg without damaging the egg itself (Thomasma & Kushman, 1996). Additionally, because ICSI bypasses the long process of the sperm struggling to get to the egg, weaker sperm, which before were not able to get to the egg, are now able to fertilize the egg. Because this technology is so new, it is still unknown if there are long-term health and development problems linked with using whatever sperm are available (Assisted, 1999). A study has been done recently comparing one-year-olds conceived through ICSI and one-year-olds conceived by IVF, and the study seems to point to slower mental development in children of ISCI (Assisted, 1999). However, with all of these questions, ICSI gives men with a severe male infertility factor (very low sperm count) the best chance of conceiving a biological child (Assisted, 1999). It is also beneficial for men who are missing their vas deferens or who are unable to reverse a vasectomy (Assisted, 1999).
Other ART methods
Other ART methods exist with a variety of names. The methods are basically the same as AI, IVF, or GIFT but they can differ in what exactly is transferred to the woman, whether it is sperm, eggs, or a zygote. The maturity of the transplanted cells also varies from method to method. One example of this is Pronuclear Stage Transfer (PROST) which inserts pronucleate eggs into the fallopian tubes or the uterus (Austin, 1989). Another example is Round Spermatic Nuclei Injection (ROSNI) which uses immature sperm isolated from the testes of the male and then fertilized using ICSI (Thomasma & Kushman, 1996). Methods also vary in the placement of the cells. For example, Intraperitoneal Insemination (IPI) is when the sperm are delivered by syringe into the peritoneal cavity near the opening of the fallopian tubes; however, this method is becoming obsolete (Austin, 1989). Methods can also have different names when special precautions are taken. Tubal Ovum Transfer (TOT) is a prime model of this. TOT differs from GIFT mainly in the way that sperm are collected. A couple is asked to engage in two occasions of natural intercourse. During the second occasion the man wears a perforated condom in order to collect sperm. From this point on the methods of GIFT are followed (Austin, 1989). The reasonings behind this are that masturbation does not have to be used and there is no contraceptive effect (Austin, 1989).
The exact procedure that is chosen by
a couple is partially determined by their cause of infertility.
If the woman's fallopian tubes are blocked or absent, IVF is the
option of choice (Wekesser, 1996). However,
when one or both are open, any ART procedure can be used, providing
there is adequate number of good quality sperm available (Cooper and Sarasohn, 1998). When the male is
infertile but fertilization is possible, IVF is most often the
preferred method. But if the sperm is unable to naturally fertilize
the egg because severe sperm abnormalities, ICSI is the best method
(Wekesser, 1996). Whatever the cause,
the final decision lies with the couple.
Issues Surrounding Reproductive Technology
Couples contemplating the use of artificial reproduction need to be aware of the many social, moral, and ethical issues that surround this topic. This decision is not one that can be made in a vacuum because it does not affect only their lives but the lives of the potential child, their already existing families, and to some extent the world around them.
There are many health issues that play into the usage of reproductive technology. Considering that fertility drugs are used in about every form of ART, one needs to look at the implications for women using these drugs. Studies have been performed indicating an increased risk of ovarian cancer with women who have used fertility drugs (Thomasma & Kushman, 1996). However, different studies have been done such as recent study of 2500 Israeli women, and these studies do not show an association between fertility drugs and ovarian cancer or between fertility drugs and breast cancer (Assisted, 1999). On a different note, this same study does support a link between the usage of fertility drugs and endometrial cancer (Assisted, 1999). Whatever the claim, more studies need to be performed to gain more support for either side.
It is also necessary to look at the health issues of children who are born through the use of these reproductive technologies. Research was done in Australia which associated a 2-3 times greater risk of suffering from neural diseases such as spina bifida in children conceived with IVF (Conrad, 1997). However, American researchers have found proportional percentages of birth defects in children of the general population to those born by ART methods (Thomasma & Kushman, 1996). The long-term risks are unknown because reproductive technology is so new and consequently long-term studies have not been done.
Cost is another big issue that couples need to think about before they decide to use reproductive technology. Most health insurance companies do not consider infertility a medical condition, and consequently, treatment to combat infertility is not often reimbursable (Cooper & Sarasohn, 1998). However, since 1997 there are now ten states that require health insurance companies to offer or cover the cost of reproductive technology (Cooper & Sarasohn, 1998). In spite of this, employers often do not choose a plan that includes infertility treatment (Cooper & Sarasohn, 1998). The result is many people who would be good parents but are not able to have biological children because they can not afford ART methods (Cooper & Sarasohn, 1998). The average cost of each cycle is between $8000 - $10,000 but often 3-4 treatments are required for a successful live birth. The cost for a successful delivery can be anywhere between $44,000 - $212,000 (Thomasma & Kushman, 1996). Is it right to pay so much money when the treatments have a fairly high chance of not being successful? Is it ethical to pay to conceive a child, when funds are needed for basic health care and food for the thousands of children already born (Rogers, 1988)? Should we be going to extreme efforts to produce more children when there is already an abundance of children who could be adopted?
The main problem with these questions is that parents want biological children. Whether it is only to carry on the family genes or because they want to see part of themselves in their children, their desire for a genetic link is valid. Yet is this validity enough to justify the issues that are carried with this technology and the distinction between who is the genetic parent and who is not? Problems can arise when only one partner is able to contribute genetically to the offspring. It is feared that the parent who does not donate his or her genes will not feel as bonded to the child as the genetic parent does (Yoder, 1998). Additionally, the resulting child could end up being a symbol of the achievement of one partner but the failure of the other (Nelson, 1973). In a different type of situation the genetic mother could feel a psychological bond with the man who donated the sperm for the child which could result in distancing herself from her husband (Conrad, 1997). The opposite is true as well with the genetic father feeling connected with the surrogate mother or egg donor. Not only could this bring negative connotations in the parent-child relationship but in the relationship of the couple as well. The big question is do ART methods threaten marriage in such a way that the fabric of the larger social community is threatened as well.
The social implications of reproductive technologies could be great. As a result of children being born by donor sperm or eggs, they could unknowingly marry a close relative. As a result of this, a donor is now "retired" after there is documentation of 10 live births from that donor (Thomasma & Kushman, 1996). Additionally, what is the role of the biological parent who is very clearly not planning on being a part of his or her child's life?
The role of reproductive technology and sperm and egg donors in a world heading for overpopulation remains unclear to many. Is it fair or ethical for people to be allowed to donate sperm or eggs creating numerous children when the world is already heading towards overpopulation? In the light of overpopulation, is it right for society to encourage reproductive technologies in the form of health insurance? Should infertile couples be encouraged to adopt? On the other hand, would we be creating a double standard in which infertile couples would be discouraged to bring additional children into the world, but fertile couples were not told the same thing (Nelson, 1973)? The questions abound, but the answers are not so clear because every side has valid points as with any ethical situation.
A situation involving a surrogate mother is one of the most complicated in the realm of reproductive technologies. Is it ethical to make a woman outside of the marriage go through the process of ART when complications with the surrogate's health or well being could result? The surrogate is financially reimbursed, but does this cover the cost of the emotional and psychological issues of being pregnant with a baby and then having to give up the baby to someone who paid for it? Is it right for women who do not want to deal with being pregnant to use a surrogate mother? What happens if the baby has a birth defect and then the couple does not want the baby? Who then are the parents? Questions like these have moved some states to make paid surrogacy illegal (Assisted, 1999). The contract that is set up is complex because all possible situations need to be discussed with the couple and the surrogate mother and included in the contract so that parental rights can be successfully transferred after the child's birth (Yoder, 1998). However, for women who can not conceive, surrogacy can create a chance for couples to parent a child who is partially or completely biologically theirs.
A moral question that couples need to
face before using reproductive technologies is what to do with
the frozen embryos once they are created. For now embryos have
no legal rights so there is no legislature that says what can
and cannot be done to embryos. As a result, embryos created during
IVF are often frozen for later use but if the parents do not end
up using them or just do not want them, they are discarded (Yoder, 1998). Other people donate the embryos
to research (Cooper & Sarasohn, 1998).
The biggest factor in deciding what can be done with the embryos
is what the couple believes the moral status of the embryos to
be. In other words, when does the couple think life begins? Many
clinics that offer ART methods make the couple decide what they
feel about the moral status of embryos before the process is started
to prevent the clinic from having an excess of frozen embryos
and not knowing what to do with them.
The Role of Reproductive Technology in the Faith Community
The role of reproductive technologies
in the faith community brings up even more questions for Christians.
Does God approve of people using these methods or is it an issue
of humans trying to play God? The Roman Catholic Church views
artificial insemination as adultery (Nelson,
1973). Even if the husband's sperm is used it is not acceptable
because it is not considered part of the natural process (Yoder, 1998). People of the Jewish faith also
view artificial insemination as wrong, but they do not consider
it adultery (Nelson, 1973). Other Christians
feel ART methods are sinful because the act of reproduction is
separated from sexual intercourse, the method God provided for
procreation (Conrad, 1997). Conversely,
others view the act of intercourse as secondary to the actual
relationship between a husband and wife (Conrad,
1997). As a result, they believe reproductive technologies
are only building on the prior divine gift of human reproduction
(Rogers, 1988).
With one in six couples being infertile,
people in today's world will most likely encounter situations
in their own lives that require them to face the moral and ethical
questions that reproductive technologies raise. It is necessary
that people are educated about the technology that is available
and learn about the pros and cons of each alternative. Once they
understand the technology and have analyzed the moral and ethical
issues surrounding it, people are in a better position to then
evaluate how ART methods fit into their own personal value systems
and make decisions about how reproductive technology fits into
their own lives.
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