Assisted Reproductive Technology: Biological, Ethical, and Social Considerations
Emily Haury
Goshen College
15 November 2004
Outline:
Thesis Statement: With the breadth and complexity of reproductive technology available today, it is important to explore not only the biological, but also the social and ethical implications of these procedures.
Procedures and Methods of Assisted Reproductive Technologies
Procedures and Policies at Oocyte Donation Centers
Controversies in Reproductive Technology
In the United States in the year 2001, 40687 babies were born as a result of 107587 assisted reproductive technology (ART) procedures (Wright, et.al, 2004). It has been estimated that one in six couples in the United States experiences some difficulty conceiving a child, and that 8.5% of married couples (2.3 million couples) in the U.S. are, in fact, infertile (Kilner, et.al, 2000; Wekesser, et.al, 1996). Assisted reproductive technology is becoming more widely available and efficient. In The Reproductive Revolution, it is stated that “considering the various configurations and technologies, there are at least thirty-eight ways to ‘make a baby’ today” (Kilner, et.al, 2000). But along with these innovations come many questions concerning the possible applications of these procedures. With the breadth and complexity of reproductive technology available today, it is important to explore not only the biological, but also the social and ethical implications of these procedures.
Procedures and Methods of Assisted Reproductive Technologies
Artificial Insemination
Artificial insemination is easily the oldest and simplest form of reproductive technology – it has been used for over a century. In this procedure, sperm, obtained through a donation of semen, are artificially introduced into the uterus to fertilize an egg that has been released naturally. Historically, this has been a very confidential procedure; anonymous donors are used, and often even the resulting children are unaware that they have different genetic and social fathers. The first sperm bank was established in the year 1950, and it is estimated that there could be around one million donor insemination adults in the United States today. (Wekesser, et.al, 1996)
In Vitro Fertilization
In vitro fertilization (IVF) involves combining egg and sperm in a petri dish and then transferring the embryo into the uterus. This procedure can be done with eggs harvested from the recipient or from an oocyte donor. In the case of more severe sperm abnormalities, a technique called intracytoplasmic sperm injection (ICSI) can be used to inject a single sperm directly into the egg. (Wekesser, et.al, 1996)
ZIFT and GIFT
Depending on the localization of the infertility problem, two other techniques may be used rather than IVF. ZIFT, zygote intrafallopian transfer, involves placing the fertilized egg into one of the woman’s fallopian tubes rather than into the uterus. GIFT, gamete intrafallopian transfer, entails placing the sperm and egg into the fallopian tube, which will be followed by fertilization and implantation in the uterus. (Wekesser, et.al, 1996)
Surrogate Motherhood
With surrogate motherhood, a woman agrees to gestate a child for a couple that for some reason is unable to do so, in exchange for monetary compensation. In the past, the surrogate was artificially inseminated with the sperm of the male partner, so the child was genetically her own. With the invention of IVF, it has become possible to use an egg from the female of the couple or from an oocyte donor. In some cases, the surrogate mother is actually a close friend or family member who has volunteered to carry the child.
Procedures and Policies at Oocyte Donation Centers
The University of Washington Medical Center’s Oocyte Donation Center was established in 1988, and within its first twelve years of operation had performed over 200 cycles of IVF with donor eggs. The classic indication for this procedure is premature ovarian failure, but other recipients are genetically at-risk, postmenopausal, or may have had poor results or failed ART attempts with their own eggs. Following is a description of the policies and procedures followed at this particular facility; although guidelines vary from clinic to clinic, this provides a general overview of the oocyte donation process. Understanding these policies and procedures can help one to be informed to consider their ethical implications. (Cohen, 1996)
Evaluations
Recipient: Obviously, the female recipient must display some symptom of infertility or genetic risk, as described above. The upper age limit for a donor oocyte recipient is 50 years old, due to increased mortality rates for mother and child in older mothers. Any recipients over the age of 45 require a routine medical screening, including a mammogram, glucose levels, complete blood count, electrocardiogram, and a stress test. Both the recipient and her male partner are serologically tested for hepatitis, HIV, Chlamydia, syphilis, and rubella. The recipient must also be free of substance abuse for at least one year prior to the procedure. (Cohen, 1996)
Donor: The oocyte donor must be a healthy 21-34-year-old with no genetic risk factors or history of infertility. Although the clinic does advertise for donors, most hear of the program by word-of-mouth. Potential donors are given routine medical screening and serological testing. An extensive interview with the clinic coordinator includes discussion of motivation for donating, life stressors, coping skills, interpersonal relationships, sexual practices, reproductive health, and concerns regarding the procedure. The interview is also a time to screen the donor for psychological disorders and discuss with her the importance of monogamy or celibacy throughout the procedures. (Cohen, 1996)
Most often the oocyte donation process is extremely confidential, but occasionally a friend or relative may offer to donate eggs to the infertile couple. In this case, the donor goes through the same screening, but the constraints on genetic risk factors are fewer, because it is assumed that a donor from the same family would be just as likely to carry a faulty gene as the recipient. In the case of a known donor, it is also important to verify that she is not being coerced by the recipient couple. (Cohen, 1996)
Male partner: In addition to the serological testing, the male partner is subjected to a medical and genetic history. A semen analysis is also done to detect possible subfertility and identify if sperm microinjection or donor sperm should be used. (Cohen, 1996)
Counseling
Counseling of oocyte recipients includes discussion of any medical risk factors to the mother, in addition to the risks of gestational diabetes, hypertension, cesarean section, and multiple gestations. Alternatives to the procedure are also considered. The counselor devotes “attention to psychosocial, ethical, and legal issues,” including disclosure to the child, donor anonymity, possible legal matters, and the impact on the marital relationship. (Cohen, 1996)
Active Cycle
The steps of an active donation cycle include donor stimulation, hormone therapy, egg recovery and insemination, embryo transfer, and pregnancy monitoring. Egg recovery is done under conscious sedation, followed by insemination on the same day. Appointments are carefully scheduled at different times of day to ensure anonymity of the donor. Forty-eight hours after recovery, 3-4 embryos are transferred, depending on their quality. Remaining embryos are often cryopreserved for future use. (Cohen, 1996)
The oocyte donor is compensated $1500 per egg recovery procedure. The recipient is responsible for all charges, which amount to around $9000 total. The University of Washington Medical Center reports a 30% pregnancy rate per transfer, with 42% of those pregnancies resulting in multiple births. No serious donor complications have occurred. (Cohen, 1996)
Controversies in Reproductive Technology
Is Reproductive Technology Beneficial or Harmful?
Often the success stories of reproductive technology are well-publicized, but in truth, 75% of couples end fertility treatments without a child (Wekesser, et.al, 1996). Should this technology, despite its imperfections, remain available to the public? What are our rights concerning reproduction? Does assisted reproductive technology need to be further regulated?
Many argue that infertile couples should have the right to procreate using the available technology. The family is the “foundation of society” and the government shouldn’t intrude into that fundamental matter; even the United States Constitution declares the essential right to “conceive and raise one’s children” (Wekesser, et.al, 1996). The Reproduction Revolution describes social goals of reproduction as the survival of humanity and the survival of one’s culture and community (Kilner, et.al, 2000). The personal values of procreation, on the other hand, are “participation in the creation of a person, affirmation of mutual love, contribution to sexual intimacy, link to future persons, experience of pregnancy and childbirth, and experience of child-rearing” (Strong, 1997).
Based on these strong social and personal desires to procreate, infertile couples persistently pursue expensive, unsuccessful treatments. Reproductive technology is deified, rather than simply respected. Couples feel obligated to employ any technology available to solve their problem. While some would consider reproductive technology a miracle of modern science, others disagree. Robyn Roland, a social psychologist states that “reproduction is a complicated intellectual and technical feat performed by teams of highly skilled men who use as raw materials for their achievements, the body parts of a variety of interchangeable females” (Wekesser, et.al, 1996). Many feminists feel that reproductive technologies allow male physicians to control and mechanize the process of procreation and see women’s bodies simply as vessels.
Reproductive technology allows for the formation of non-traditional families. Some countries deny sperm donations to single women or lesbian couples for this reason, citing evidence that no-father children are at risk. One proposed regulation is that this technology should only be made available to married heterosexual couples (Wekesser, et.al, 1996). Strong (1997) states that “there is an obligation to avoid procreating when there is a significant likelihood that the child’s right to a decent minimum opportunity for development would be violated.” In the case of single parenthood or homosexual couples, evidence has not shown that the child-rearing environment is significantly less effective than in a traditional family. (Wekesser, et.al, 1996)
Along with increasing technology comes an increasing need for regulations and uniform procedures. In the past, records on donors were not well-kept, resulting in difficulty later in matching donors to their resulting biological offspring (Wekesser, et.al, 1996). It is also important for donor screening to be required to thoroughly check for possible transmittable conditions. Another proposed regulation could assure that only clinically infertile patients are allowed to use this technology, preventing abuses by the affluent.
As with any technology, sometimes cases arise where the outcome is very undesirable. Such has been the case in legal battles where couples were fighting for custody of their frozen embryos or doctors were found to have given “extra” embryos to another couple without the genetic parents’ authorization (Callahan, 1995). The possible abuses of this technology must be carefully considered to determine if the potential dangers outweigh the potential benefits. One must remember that “[science] can give hope – and wreak havoc” (Wekesser, et.al, 1996).
In 1993, a 59-year old British woman gave birth to twins; the next year, a 63-year old Italian woman gave birth to a baby to replace her teenage son who had died in a car accident (Wekesser, et.al, 1996). With the technology of in vitro fertilization using donor oocytes, postmenopausal women are capable of giving birth to children, and this possibility is causing many debates. Currently, women over 40 years old are not accepted in most U.S. clinics, and Great Britain has outlawed the procedure for any postmenopausal woman (Wekesser, et.al, 1996).
Among the arguments for disallowing the procedure are increased risks in pregnancy and child birth for older women, difficulty for older adults raising young children, and the increased likelihood of parental death (Strong, 1997). Some say that these older women are often having children for selfish reasons or personal fulfillment, and are not able to take responsibility to raise the children for a significant amount of time. Arthur Caplan, of the University of Minnesota Center for Biomedical Ethics, argues that it is “imprudent and immoral public policy to intentionally create orphans” (Wekesser, et.al, 1996).
On the other hand, it has been shown that grandparents do just as well a job of raising young children as their younger parents do (Wekesser, et.al, 1996). It has also been pointed out that older fathers in their 60s and 70s are fairly common and well-accepted, while the opposite is true for women. One must decide whether possible suffering from the death of a parent at a young age would outweigh the positive aspect of the child actually coming into existence.
When employing a surrogate, a child can end up having three mothers: genetic, gestational, and social. Historically, the surrogate was also the genetic mother of the child, but new technology allows an oocyte donor to be used, which means that the social mother of the child is not participating in the pregnancy or contributing genetically to her prospective child. With this arises the question of which woman has the strongest claim as the true mother of the child.
Some see surrogacy as violating the covenant of marriage, because the surrogate’s oocyte is being fertilized with sperm from the male partner. Ethicist Joseph Fletcher says that it is “love, not genes, that gives parenthood its meaning and richness” (Wekesser, et.al, 1996). In this case, conceiving a child with a woman other than one’s spouse would be seen as adulterous. Allowing another woman to carry the child would detract from the family’s well-being.
Another problem has arisen in the commercializing of the surrogacy process. When the surrogate is portrayed as providing a service or delivering a commodity for a set fee (usually around $10000), it is demeaning to her and the child as a human beings. This occurs especially when the payment is contingent on a live birth, rather than compensation for the surrogate’s time and inconvenience. Often the gestational mothers become very attached to the baby, and in several cases, have attempted to keep the child. Counseling and screening of candidates is important to identify those who are at a high risk of flight. (Strong, 1997)
In drafting a surrogacy contract, it is important that the surrogate and the couple discuss the course of action to be taken in case of complications. In some cases, the recipient couple has insisted that a fetus be aborted because of some genetic abnormality. In other cases, a surrogate has argued that she should have the right to make any medical decisions, including those related to abortion, because her body is at risk as well. Other areas of concern include agreement on certain behaviors (i.e. smoking and alcohol) or tests, such as amniocentesis, during the pregnancy. (Kilner, et.al, 2000) Use of a gestational mother can create a wide range of ethical dilemmas because of the serious risks and the huge time investment the surrogate agrees to provide.
Pre-implantation Genetic Screening
New technology is allowing doctors to screen embryos for genetic disorders before they are inserted into the uterus. This technique can currently be used to detect muscular dystrophy, Huntington’s disease, hemophilia, cystic fibrosis, sickle-cell anemia, and Down’s syndrome (Strong, 1997). It can also be used to select the sex of the embryos to be implanted. Although this one-time procedure is very expensive, it may save the family the money and hardship of caring for a handicapped child in the long term.
One can imagine many abuses of this technology becoming possible in the future. A eugenics movement could arise, allowing those who had the money to have designer babies – selecting for cosmetic traits and talents. Although this idea seems fairly ridiculous, it is difficult to determine where we should draw the line. Should doctors be screening embryos for minor diseases, conditions that are easily treatable, or adult-onset diseases? What about multifactorial genes, or genes that simply cause susceptibility for a disease? And if this technology becomes readily available, would it be unethical to not use it?
In one survey, it was found that 1% of parents would consider aborting a fetus if they discovered it was not the gender they were hoping for. 6% would consider abortion if the baby was susceptible to Alzheimer’s, and 11% if the child was prone to obesity (Strong, 1997). If the technology to select “perfect” embryos was available, society as a whole would begin to view a person’s imperfections differently, perhaps placing blame on the parents who allowed their child to be born with those flawed genes. Genetic “differences” could come to be known as genetic “defects.” Insurance companies are already applying this technology by refusing coverage in some cases if an abnormal fetus is not aborted (Wekesser, et.al, 1996). In 38 states, where life is considered to begin at conception, disposal of these “flawed” embryos would also become a controversial legal issue.
Assisted reproductive technology has grown to a $2 billion a year industry, with over 300 clinics nationwide (Wekesser, et.al, 1996). In 2001, ART contributed to almost 1% of the approximately 4 million live births in the United States (Wright, et.al, 2004). Although some see this technology as a modern miracle, others are horrified by the repercussions that come along with this procreative power. In many cases, it is debatable to what extent a particular procedure to be used and at what point the line should be drawn. One must weight the possible benefits and negative outcomes, as well as the underlying moral implications, in order to determine his or her personal position regarding the forms of assisted reproductive technology available today.
Callahan, J.C. (1995) Reproduction, Ethics, and the Law: Feminist Perspectives. Bloomington and Indianapolis: Indiana University Press.
Cohen, C.B. (1996) New Ways of Making Babies: The Case of Egg Donation. Bloomington and Indianapolis: Indiana University Press.
Kilner, J.F., P.C. Cunningham, and W.D. Hager. (2000) The Reproduction Revolution: A Christian Appraisal of Sexuality, Reproductive Technologies, and the Family. Grand Rapids, Michigan and Cambridge, U.K.: William B. Eerdmans Publishing Company.
Strong, Carson. (1997) Ethics is Reproductive and Perinatal Medicine: A New Framework. New Haven and London: Yale University Press.
Wekesser, C., et.al. (1996) Reproductive Technologies. San Diego, CA: Greenhaven Press.
Submitted 23 November 2005
By Emily Haury