Previously, we have discussed the role of contraceptives in allowing us to have sex without creating babies. Reproductive technology has further revolutionized child-bearing by allowing us to create babies without having sex. Indeed, childbirth is now possible as an individual project that can be pursued not only without marriage, but also without a partner. The impact this has had on our societal structure is profound, but beyond the scope of this discussion.

ART (pronounced A.R.T.) includes all techniques involving the direct manipulation of human eggs, sperm and embryos outside of the body. The first and still most common form of ART is in vitro fertilization (IVF), but many other related techniques are now available. Modern ART has revolutionized the treatment of infertility, rendering some treatments obsolete because ART is simply more effective and usually cheaper than traditional alternatives. It is now the automatic next step after infertility (the result of a wide range of problems) has been diagnosed; and there is no sign of the trend slowing down.

The number of ways in which human eggs, sperm and embryos can now be manipulated has been increasing at a rapid pace in recent years. This chapter contains a lot of technical detail, highlighting the fact that the very complexity of this technology presents a danger to those attempting to navigate the options. In this area in particular, those who wish to make godly decisions will need to apply themselves to understand what they are being offered. It is very tempting to decide it’s too hard, and just accept the judgements of the treating physician who is offering the chance of a baby.

IVF was developed as treatment for the infertility resulting from damage in the fallopian tubes.[1] The original idea was that a blocked tube could stop the sperm and egg from uniting, so by putting them together in a ‘test tube’ (actually, a flat petri dish is used), an embryo could be formed which would then be transferred to the woman’s uterus through the cervix, allowing normal development to take place. This use of medical therapy in the presence of disease is appropriate so long as no scriptural principle is violated.[2] Doctors can restore normal function to the reproductive system if they find a fixable problem.

With the expanding repertoire of ART, however, doctors are now employing procedures that go beyond just fixing what is broken. The demand in our community for biologically related offspring has meant that fertility specialists have kept pushing and pushing to provide an ever-widening range of options, not just for heterosexual couples with medical infertility, but also for those with ‘social infertility’—single parents, same-sex couples, and those who could have a child if they wanted to but would prefer someone else to do the hard work. This sometimes requires the donation of sperm, eggs and wombs, and means that our choices go way beyond simple remedial treatment.

The diagnosis of infertility is usually so distressing for a couple that they may not stop to think about the treatment before they begin. They are prepared to go to extraordinary lengths to get the child they desire. This passion for a child is not to be wondered at; in the book of Genesis, we remember Rachel saying to her husband, Jacob, “Give me children, or I shall die!” (Gen 30:1).

It is common for ethical dilemmas to develop in ART, which is not surprising when you think about it; ART is about the creation of human life. To avoid ethical pitfalls, it is vital that couples explore what is involved in ART before making any decisions. Many common ethical dilemmas arising from the use of ART cannot be resolved once action has begun, so thinking carefully before acting is worth it—even worth the frustration caused by delay.

I am sure you see the problem. Who wants to delay having a child when the specialist can tell you everything you need to know? However, the emotional vulnerability of infertile couples means they need particularly careful counselling in the early stages of decision-making, once the diagnosis of infertility has been made, so they do not in their enthusiasm agree to things they will afterwards regret. Johann said: We hadn’t ever seriously looked at IVF, but our backgrounds had formed opinions that Christians shouldn’t have IVF. So when we heard the news that our only chance at pregnancy was through IVF, we were greatly grieved as we initially thought we couldn’t do it as Christians. Also, there was the thought that God had created us this way, so to have IVF was to go against him. These were very challenging issues that we had to work through and we spent a year thinking through the issues, praying, doing research and talking to godly Christians.

Those who wish to honour God in all areas of their lives will not check him in at the door of the fertility clinic. They will take the time to consider all their options and collect the facts, so that their decisions are godly at all times.

Rocking the boat

Although some fertility clinics go out of their way to accommodate those whose religious beliefs are opposed to some common ART practices, in other places your distinctive requests will be seen as troublemaking. You might as well get ready for it before you start—it is so commonly experienced. I find that if you remain calm and pleasant you are unlikely to offend staff, but you may annoy them by wanting things to be done differently.

Consider the experience of Dennis and Anita. Anita recalls:

Our specialist and scientists’ goal was successful pregnancy, with no consideration of the amount of lives created. We were pressured to have maximum embryos created and to only implant embryos that were classified viable for life to give us the highest chance of pregnancy. This was very difficult, as we believed life began when an embryo was formed and this wasn’t respected by the IVF system. We chose to have only 6 out of our 11 eggs fertilized, yet despite the fact that we had clearly spoken our wishes to our specialist and put it in detailed writing, when we turned up for egg collection we were pressured to have them all fertilized by the scientist and were told that we were greatly limiting our chances and were made to feel foolish. I was quite emotional that morning already and to have our wishes undermined and not respected made the whole experience so much more stressful. We also had explicitly expressed that we wanted every embryo implanted (at different times) and given a chance at life in the womb. Despite this on day 5 after egg collection, we were told that only 5 eggs became embryos and only 2 were viable for life, so they would implant one that day and freeze one. We again had to state our wishes that the other 3 had started to multiply so we believed life had begun and we wanted to allow them to take their natural course in the womb.

They weren’t the only ones. Jill and Frank also had problems:

Infertility was a very hard time for us and we took a year of contemplating IVF before we began, and then, to face a system that didn’t respect our views made the process even harder. Although we are very grateful for the gifts given to the specialists and scientist by God to assist with fertility, the process could have been a lot less stressful for us if we had been listened to and respected.

Regulation of ART

This book is an international publication, so it’s important to note that the regulation of ART differs widely between countries. In 1991, the Human Fertilisation and Embryology Authority (HFEA)[3] was established in the United Kingdom to regulate in vitro fertilization (IVF), donor insemination (DI) and egg, sperm and embryo storage, and to license and monitor embryo research as well.

ART in Australia was regulated at the state level until 2002, when national legislation was introduced allowing destructive embryo research. Research is now under the supervision of the Licensing Committee of the National Health and Medical Research Council (NHMRC),[4] and clinical accreditation comes under the auspices of the Reproductive Technology Accreditation Committee (RTAC)[5], part of the Fertility Society of Australia (FSA)—which is basically a self-regulating body, though its standards remain high.

In the United States, different aspects of ART are monitored by different authorities in a patchwork approach that does not cover all areas of practice. The United States is among the least regulated of developed countries.[6] Keep this in mind while we discuss the various treatments available, because not all of them are available everywhere.

Treatment options

The treatments you are offered will vary according to the reason for your infertility.[7] You will remember from chapter 2 that the formation of an embryo requires the joining of a sperm and egg. If embryos represent early human life, what happens to them is morally significant. However, sperm and eggs individually do not represent human life, and their fate does not have the same ethical importance.

We will now run through the armamentarium of ART and evaluate each practice from an ethical perspective. Although several practices may be used together, I think it is easier to understand the ethical issues if we address them separately. Note that not all the options listed will be appropriate choices for those who wish to protect human life from the time of fertilization.

Intrauterine insemination (IUI)

If the man’s sperm count is moderately reduced, IUI may be recommended. The first report of a live birth from IUI was published in 1866, when Dr James Marion Sims described performing it in Europe.[8] This treatment increases the number of sperm that get into the uterus. Usually only about 10% of the sperm get there. In this procedure, the man’s semen is collected and ‘washed’ (prepared to select the most motile [mobile] sperm, to concentrate numbers, and to remove the seminal fluid). The prepared sperm is injected into the woman’s uterus through the cervix at her most fertile time (ovulation). The woman’s cycle is monitored with blood tests and vaginal ultrasound so that insemination timing is exact. The success of IUI is increased if the woman receives ovulation-inducing medication to increase the number of eggs available in the fallopian tubes each cycle.

Ethical issues

If the husband and wife use their own egg and sperm, this procedure will be aiming to remedy the problem the couple has in allowing their gametes (sperm and egg) to unite. In principle, it is ethical for Christians to use biotechnology to correct medical problems.[9] However, some couples find it difficult having clinic staff involved in what is intended to be a highly intimate experience, and any form of assisted reproduction is difficult during the period between the procedure and the subsequent pregnancy test, to see if it worked. Carol explained her own experience: The procedure of IUI was challenging. The first cycle, I was emotionally sensitive already about thinking about having children. But then, everything being new, doctors’ appointments, blood tests and everything left me very anxious. It surprises me how uptight I was about just going through the procedures.

Dana also found it difficult: Having gone through three IUI cycles has been emotionally draining. It hasn’t been overwhelming, but has definitely been a trial, riding the hope rollercoaster all over again. I think it is less of a challenge than it could have been as we started IUI after 8½ years of infertility; we’re pretty used to the idea of not being pregnant, but it still hurts when hope is stirred.

Although the presence of medical staff may be uncomfortable, it is not an ethical barrier.

See below for further discussion regarding the use of IUI with donor sperm.

Sperm collection

The standard technique for semen collection is to ask the man to masturbate in a room at the fertility clinic, with pornographic material for stimulation.

Ethical issues

While I do not personally believe masturbation is necessarily sinful, I realize that some Christian denominations believe ejaculation should never be separated from procreation. If this is your belief, I discuss your options below. Furthermore, in the clinic situation the use of pornographic material could cause lust to be a problem, which is definitely sinful for all Christians if your spouse is not the object (1 Thess 4:3-7).

There are usually alternatives available for those who ask. Some husbands take their wives with them into the collection room—if they can. There wasn’t even enough room for us both to turn around, said Ted. Alternatively, the husband could masturbate while filling his mind with images of his wife. Many clinics allow men to collect the semen at home with the assistance of their wife, if they live within an hour of the clinic. Timing is important because the sperm needs to be fresh. If a particular day is difficult, clinics will freeze the specimen to make sure the semen is there when it is needed. Some clinics have developed a system where condoms can be used—either a sterile condom for collection during intercourse (if masturbation is opposed), or a ‘holy condom’ (a condom with a pinhole in the end) for those couples that oppose contraception. Even if lust is not a problem for you, you may enjoy collecting sperm as a couple considering the goal you have in mind.

In vitro fertilization (IVF)

In basic IVF (natural cycle), the woman’s egg is collected in a natural unstimulated menstrual cycle. Usually this would only yield 1-2 eggs, and the success rate reflects the fact that any one embryo has a relatively low implantation rate. This method is used for women who cannot tolerate or do not respond to ovarian stimulation.

The woman is given a human chorionic gonadotropin hormone (hCG) injection when the egg follicle is mature, making it ready to release the egg at ovulation. Usually just one egg is collected from the woman’s ovary by inserting a needle through the wall of the vagina under ultrasound guidance. The woman is usually sedated but awake for this procedure, which rarely has serious complications. The egg will be placed in culture media (a fluid—containing water, salts and nutrients for cells—that is formulated to resemble the fluid in the fallopian tubes), where it will be incubated in the laboratory.

Sperm are collected from the male ejaculate and added to the dish. The sperm then work at getting through the wall of the egg. Around 14-18 hours later, if two pronuclei have appeared in the embryo (one from the sperm and one from the egg) this indicates that fertilization has occurred. The embryo will be allowed to grow for 3-5 days in the laboratory then it will be transferred to the woman’s uterus, through the cervix. Some clinics transfer the embryo when it has grown to the size of 8 cells at day 3, and some wait until it is a blastocyst (up to 100 cells) at day 5.[10] The woman is given hormones until a pregnancy test is performed 16 days after egg collection.

Ethical issues

If no embryos are destroyed, I can see no ethical problem with basic IVF. All that has happened is that the fallopian tubes have been bypassed, bringing the sperm and egg together artificially to create an embryo because barriers caused by disease won’t allow it to happen naturally.

In practice, it is more common for IVF to be combined with ovarian stimulation using gonadotropins, as this increases the number of eggs available for harvest. The success rate for IVF across all procedures and age groups is around 25%. Success rates differ according to age and treatment, and also depend on which clinic you choose. Success rates can also be misleading, as they tend to reflect the number of procedures per live births rather than the number of embryos transferred per live birth. The best results are seen in women who are younger. Most clinics report their success rates on their websites. Try to look at success rates according to age, as a more ‘successful’ clinic at first glance, may, in fact, just be focusing on treating younger patients. In the end, the safest recommendation is generally word of mouth.

Ovarian stimulation

Medication to promote ovulation can be used alone when the woman has eggs but is not ovulating properly; this may be enough to restore fertility. It is also used with IVF (see below).

The woman’s body has ‘messenger hormones’—called luteinizing hormone (LH) and follicle-stimulating hormone (FSH)—that are released from the pituitary gland in the brain to tell the woman’s body which hormones to produce at different stages of her monthly cycle. These hormones can be measured in the blood along with the oestrogen and progesterone released by the body.[11] Most fertility medications work by interacting with these messenger hormones.

Several types of medication can be used—your doctor will decide which is appropriate.

Clomiphene citrate (Clomid, Serophene, Milophene)

These tablets allow low-grade stimulation of the ovaries. They work by blocking feedback to the pituitary gland so that it thinks it needs to secrete extra FSH. The higher FSH level stimulates the ovaries to develop more egg-containing follicles. Often the follicle growth is monitored with blood tests and ultrasound scans. An hCG injection is given as the follicles mature in order to stimulate ovulation at a predictable time (it mimics the natural LH surge that accompanies ovulation).[12] Intercourse—or other interventions, if assisted reproduction is used—is timed to coincide with the release of the eggs. Sometimes another injection (GnRH antagonist) will be given. This is designed to block the body’s natural LH surge, which might alter the timing of ovulation and risk the loss of the eggs.

Side effects

Some women feel emotional and irritable while taking Clomiphene. Side effects also include thickening and whitening of cervical mucus, vaginal dryness and hot flushes. Less commonly, there is abdominal bloating, breast discomfort, nausea or dizziness. Sometimes twins result, though this can be avoided if necessary by monitoring how many follicles are developing.

Gonadotropins

These are expensive and powerful medications that act in place of the normal messenger hormones (LH and FSH). There are several alternative preparations, all given by injection. Overall, current evidence indicates that they have similar efficacy, and each doctor has his or her own preference.

Injections of gonadotropins are more effective in stimulating multiple follicles than Clomiphene. A woman on this medication can develop 10-20 eggs (or even more) that reach maturity in a single cycle. This is why it is used in IVF. However, with every extra baby in the womb, risks for both mother and baby increase, so it is best to avoid a multiple pregnancy. Intercourse should be avoided at this time just in case the eggs are released early and you fertilize more than one egg by accident. Follicle growth is monitored with ultrasound and blood tests—usually more closely than with Clomiphene—and ovulation is induced with an hCG injection.

In some places, lower doses of gonadotropins are being used, producing fewer eggs, but also causing fewer side effects. Evidence is mounting that this is a preferable approach.[13]

Side effects

With the use of gonadotropins, a multiple pregnancy is a risk, with a 20% chance of twins. Bloating and mood changes are also experienced. I think I was emotional and teary the whole time, said Sara. A rare but dangerous complication is ovarian hyperstimulation syndrome (OHSS), occurring in a mild form in about 10% of women, with 1% at risk of developing life-threatening blood disorders.[14] The risk of OHSS increases with higher doses of gonadotropins rapidly increasing blood oestrogen levels, and high or repeated doses of hCG given to induce ovulation. Careful monitoring allows early intervention if problems occur. Transfer of the embryo may need to be delayed if this is a problem, just to be on the safe side.

Ethical issues

There are no intrinsic ethical issues in receiving hormones to stimulate ovulation, as it is a therapy designed to restore the body’s functioning to normal. But, as discussed above, ovarian stimulation is associated with an increased incidence of multiple gestation pregnancy.[15] While this might initially seem attractive to an infertile couple (instant family!), it is better to avoid it if possible due to increased risks for mother and children. For the babies, there are the risks of premature delivery, low birth weight and health problems because their organs did not have enough time to develop. They are also at increased risk of cerebral palsy and complications such as twin-to-twin transfusion, entangled umbilical cords and possibly stillbirth. The mother is at increased risk of having a caesarean birth, financial costs will be greater, and there is also the problem of coping with more than one baby after the birth. Multiple births result in significant reduction in maternal quality of life, health and functioning, marital satisfaction and quality of life scores. Some mothers regret ever seeking ART after having to manage with twins.[16]

And so in view of the inherent risks of a multiple pregnancy, it is important to adhere strictly to your doctor’s instructions, as it would be negligent to expose the mother and children to the risks of a multiple pregnancy unnecessarily. Biblical parenthood involves more than just successful fertilization.[17]

Similarly, doctors have an obligation to be diligent in this area. One of the traditional sayings in medicine is “first, do no harm”. The unquestionable risks of multiple pregnancy make the transfer of more than two embryos in an IVF procedure negligent. These risks have led to the introduction of laws in some countries, including Australia and the United Kingdom, which allow only a maximum of two embryos to be transferred at any one time. Research suggests that transferring more embryos does not increase the chances of a successful pregnancy, but simply raises the chances of multiple births.[18] Furthermore, when ART providers in Australia voluntarily moved to single embryo transfer, the reduction in the multiple birth rate led to substantial savings in hospital costs.[19] Those who wish to protect their unborn children will refuse to agree to the transfer of more than two embryos at any one time.

Another ethical issue is the fact that research into follicle stimulation has not identified which follicles are the most likely to produce a live birth. It has always been assumed ‘the more eggs the better’, but if it could be determined that only a small number of fully matured eggs will lead to blastocyst development, there would be no reason for the high doses currently used to produce a large number of eggs, with greater risk to the woman. Current evidence suggests that although eggs that are immature at the time of retrieval will usually mature in culture and often fertilize, they lead to relatively poor pregnancy rates.[20] This makes sense, as we know that the number of eggs harvested does not correlate with the number of live births. If it could be established, say, that the leading (largest) follicle was the most likely to give a live birth, it would change routine clinical practice. More work is needed in this area.

While there are no intrinsic ethical problems with the use of hormones to promote ovulation, there are potential ethical problems depending on how they are used. Given that more eggs will be produced with stronger stimulation, if they are all fertilized then the issue of freezing excess embryos will arise. This is discussed below.

Egg donation

Ovarian stimulation with gonadotropins is used in women who agree to offer their eggs for donation. Depending on a country’s laws, this is either done for free (altruistic) or for money (commercial). Most clinics prefer to accept egg donations from women under 35 years of age who have completed their own families, because a younger woman’s eggs will be healthier than an older woman’s. Donors are usually screened psychologically and counselled, then treated as an IVF patient. They are given the gonadotropins to promote egg production and to bring their cycle in line with the intended recipient, who is also receiving treatment. The donor’s eggs are harvested in the usual way and then incubated with the sperm, and any resulting embryos are transferred in the usual way.

In countries like Australia, where payment for human tissue is prohibited, I have not heard of any abuse of the system. Australian patients are encouraged to find their own donors. However, there is a huge shortage of eggs and clinics report long waiting lists of hundreds of women, with less than a dozen anonymous donors a year coming forward. Karen was unable to ovulate and was told that egg donation was her only chance of having a child of her own. She said, I didn’t like the idea of bearing a stranger’s child. Fortunately, my sister volunteered. It was easier with someone I was related to, but it was a big deal for her. I wouldn’t do it again and I wouldn’t ask her to do it again. I’m not surprised donor eggs are so scarce.

Because of the scarcity of donors when it requires an altruistic act, in some countries payment is allowed. Not only does this significantly increase the cost of IVF, but there is also growing evidence that in some countries this unregulated procedure has led to significant disease (and even death) from OHSS. Future fertility can also be affected. In some places, companies coerce young women to participate by promising large financial rewards. In the United States, advertisements are placed on college campuses and on the internet promising big payments—usually $5000-$10,000 for a donated egg cycle. Advertisements offering up to $50,000 per cycle have been seen at prestigious universities;[21] extra money is offered for beauty, brains and good family health history. Besides the offer of financial rewards, in the advertisements the girls are asked to “answer prayers”, “make dreams come true” and “give hope” with the recipient in mind. Hundreds of women are currently registered in databases for prospective parents to inspect (college transcripts are available on application, for the prospective parents’ attorney to peruse).

In the United Kingdom, following a public consultation in 2011, the HFEA announced it would allow an increase in the sum that could be paid to egg donors (from £250 to £750). It also announced the introduction of a £35 per visit compensation for sperm donors.

Some women who offer have generous motives. Katy said, This was something I could do for someone else that would make this huge difference to their lives. But most admit it is the money that makes them consider donation. Vicki said, It’s nice to know you’re helping someone, but I wouldn’t think of doing it except for the money.

Some centres in the United States have noticed an increase in the number of egg donors following the global financial crisis. One fertility specialist commented: “There’s no reason to think that suddenly there’s 30% more people who have suddenly had this inner feeling to help out people. And what’s changed? It’s the economy.”[22] The Center for Bioethics and Culture Network in California has sought to identify the extent of this problem. The Center’s President, Jennifer Lahl, interviewed a young woman who had gone through the donation process, who warned, You can possibly die from this, and it’s not a joke, or worth $5K or any amount of money. Losing your life would end your chances of making that money, period. I was a victim and will stand and speak about it. They are out preying on ones like me.[23]

It should be noted that, although there is no correlation between the number of eggs and the number of live babies born, there is a correlation between the number of donor eggs retrieved and how much a clinic gets paid. We should not confuse bad medicine with bad ethics, but they can coincide.

Ethical issues

The ethical problems surrounding commercial egg donation are multiple. If someone is pressured to be involved with a medical procedure that will not improve their health and that they might otherwise not have had, it is called coercion. Their decision is not entirely voluntary, and that means they are unable to give proper informed consent; this makes it unethical, according to the World Medical Association.[24] Offering significant financial rewards is a form of coercion or ‘undue influence’ that has the potential to exploit vulnerable women.

Currently, it is not known what health implications ovarian stimulation has in the long term, and this is not always explained fully before the procedure, which is another barrier to true consent.[25]

Also, if women give their eggs to strangers in a setting where ART is available to all members of the public without screening, are they avoiding their responsibility as potential parents to ensure the wellbeing of their offspring?

And lastly, I know it’s not strictly an ethical problem, but I am troubled by the posters advertising for egg donors that show the ‘satisfied customers’ (i.e. the donors) shopping (spending the payment for their eggs)! Are we really as materialistic as that?

Egg donation from the perspective of the recipient will be discussed below.

Freezing embryos (embryo cryopreservation)

The desire of fertility doctors to improve their patients’ chances of getting pregnant has led to the standard practice of giving hormones to the woman to stimulate the production of multiple eggs in the ovaries (as described above) and to harvest the maximum number of eggs. Clinics generally encourage couples to allow them to create as many embryos as possible by trying to fertilize all the eggs. Egg collection is an invasive and expensive procedure with the potential for serious side effects, so it’s better not to do it more often than necessary. And, obviously, it seems logical that the more times you place an embryo in the womb, the greater the chance of a pregnancy developing. Therefore, women are usually advised to collect and fertilize as many eggs as possible to increase the chances of a pregnancy without the extra risk and expense of another egg harvest.

Not all of the eggs will fertilize normally; a fertilization rate of around 80% is considered a good result. This could mean that over a dozen embryos are created, and the expectation is that not all embryos will result in a live birth. The best clinics only transfer one embryo at a time, usually the best-looking one (due to the risks of multiple pregnancy as discussed above)—so what happens to the rest of them?

If nothing is done, the leftover embryos will die. Most countries do not allow embryos to continue growing outside the body after 14 days. Despite its popularity in science fiction—from Brave New World to Avatar—I am not aware of anyone having succeeded in producing an artificial womb. Therefore the usual practice is to freeze (cryopreserve) the embryos and defrost them for use as needed. Some embryos don’t survive defrosting (around 50%-90%, depending on the clinic) and others may not develop once in the woman’s womb. To increase the chances for success, and to reduce the false hope the parents may have for a pregnancy, many clinics will only freeze the most robust embryos. They judge an embryo’s robustness based on its appearance. The problem is that you can’t always tell just by looking at them which embryos have the potential to develop. Embryos to me seem so fickle: good one day, bad the next, complained Rick. This is definitely an area of concern, and is addressed below (see ‘What makes an embryo viable?’).

Embryo cryopreservation has been available since 1983, revolutionizing the treatment of infertility.[27] Despite this, there is still no formula to accurately predict how many embryos are needed to produce one live birth; hence, many clinics suggest the more embryos the better, just in case you need them. As previously mentioned, infertile couples tend to be extremely emotionally vulnerable at the beginning of treatment and are understandably amenable to any suggestion that may improve their chances of success. But the implications of freezing embryos needs to be considered.

In 2010, it was reported that a baby boy had been born from an embryo frozen 20 years earlier.[28] There is no deterioration over time for frozen embryos.[29] They can be kept in the cryopreserved state almost indefinitely.

In 2004, the Supreme Court of Australia had to decide whether two children born from frozen embryos could share in their grandmother’s estate. It was decided that they couldn’t because they did not fit the definition of ‘survive’ in its ordinary sense, even though they were in the freezer at the time of her death.[30]

Jody and Tom had great concerns about freezing their embryos:

As we began to think more about it, we came up with more concerns. The success rate when we looked into it was 30% for fresh embryos and 20% with frozen.[31] That means our children we would create would have a 70%-plus chance of death. Add to that the defrosting process, which can lead to the embryo dying, and we didn’t like our children’s chances (and still don’t, even though the stats have improved). The freezing process doesn’t sit well with us. What if I [Jody] died and there were still babies in the freezer? What would you do with them? Also, my husband feels responsible for the care of his family and wonders how do you care for children in a freezer?

There are hundreds of thousands of frozen human embryos in freezers around the world. What does a frozen embryo represent? What should be done with these embryos? How long should they remain frozen and at whose expense? Is it ethical for Christians to freeze them in the first place?

Ethical issues

The freezing (cryopreservation) of embryos is standard treatment in modern ART clinics. But if embryos are human beings, is it morally permissible to freeze them? We don’t usually freeze people. A similar comment (“We don’t usually do this”) is usually made in the early development of any medical technology. We have already covered the reasons for cryopreservation—it saves the trouble, expense and risks of repeated egg collection. Eggs are a limited commodity. These are strong arguments, so why wouldn’t we do it?

I find the question of whether we should freeze human embryos one of the most difficult in the whole area of reproduction ethics. To go back to first principles: we discussed in the ethics chapter that the basis of Christian ethics is love—love for our God and love for our neighbour (Matt 22:37-39). If we believe that every embryo is a human being from the time of fertilization, then our loving action will be to protect each one from harm. The Christian will therefore need to give every embryo the best possible chance to live. Since this will require transfer to the uterus at the appropriate time, I believe that such transfer should be the goal for each embryo fertilized for treatment. However, this is not the same as saying that every embryo created must survive until it gets to the womb; we know that even in nature the embryonic death rate prior to implantation could be as high as 75%. It would be unreasonable to expect that all embryos would survive; but if they don’t, it should not be because we did not try to protect them. This will be the case regardless of judgements about the ‘quality’ of the embryo.

Peter noted: After our first son was born, and experiencing the amazing realization that he had been formed from tiny cells that they wanted to discard, I became overwhelmingly concerned about our two embryos left in frozen storage.

There is quite a range of protocols for dealing with human embryos, depending on where you are. In Italy, under the Medically Assisted Reproduction Law of 2004, human embryos must always be treated in a way that preserves life, which means they must all be implanted. An IVF mother can’t change her mind—once she has procreated through IVF, the embryos must be transferred to her womb. In the rare instance when this is not possible, embryo donation is required.[32] In fact, this law favours the adoption of embryos already in existence over the creation of new embryos.

In Germany, the strict protection of embryos is grounded in its constitution—which protects the dignity and life of all human beings—the Federal Constitutional Court having interpreted this as applying to unborn human beings as well as human beings already born. Unlike the United States Constitution—which protects citizens only against state interference with their fundamental rights—the German constitution also has a positive aspect, where the state has a duty to prevent citizens from harming one another, thus giving the state the responsibility to protect the unborn from harm. Germany’s Embryo Protection Act of 1990 allows up to three embryos to be transferred to a woman’s uterus, but the number of eggs that may be fertilized must be equivalent to the number it is planned to transfer. Then they must all be transferred in one go, regardless of quality, because embryo selection and storage by freezing is forbidden.

While I am aware there is much pressure in these countries to relax their laws, it goes to show that there are places where embryos are more highly regarded than in most of the English-speaking world.

There are several arguments against freezing that I am aware of:

• It is unnatural, unnatural being equated with immoral (natural law). As I have previously mentioned, I have reservations about natural law, where right and wrong are determined by human reason. This is because the Bible teaches that the Fall has affected the original creation, which includes man’s ability to reason properly. Natural law also reduces the importance of Scripture, if man can understand revelation without it.
• It introduces a ‘slippery slope’ or ‘thin edge of the wedge’ aspect to the treatment of embryos. This argument suggests that by allowing the freezing of embryos now, we are ‘normalizing’ embryo abuse. I think this argument is now out-of-date; with the legalization of human cloning and animal/human hybrids, we are probably near the bottom of the slope by now.
• Freezing embryos allows time to pass between when a couple decides to have children (enter the ART program) and when they thaw the embryo. During this period many things might change—for example, the couple may divorce. If the embryo was created for them both and one now wants to transfer an embryo (with a new partner), and the other opposes it, who should have the final word? At the moment the courts seem to be favouring the one who doesn’t want the embryo (although it was encouraging to see a 2011 judicial ruling in Argentina, which allowed that a woman can use frozen embryos fertilized with her ex-husband’s sperm to get pregnant again).[33] If an embryo was created as the first step of creating a family, should either parent be able to stop the process mid-stream? Or take another scenario: what happens to orphan embryos? A real-life dilemma was created when the wealthy parents of two frozen embryos died in a plane crash. In the absence of any other contenders, were the embryos heirs to the estate? What should the doctors do with them? Despite many offers to gestate the embryos (so long as the inherited fortune came too), in the end they were treated as property and destroyed.[34] This is a strong argument against freezing, because we freeze in anticipation of good consequences but we cannot foresee what will happen in the future.

Another problem associated with the freezing of embryos is that it creates the potential for leftover frozen embryos even if there are no relationship problems. The dread of remaining childless at the beginning of treatment can mean that the thought of having too many children doesn’t even cross the prospective parents’ minds.

When a couple has the number of children they want, or they stop treatment for another reason, they may find they have surplus embryos. What are they to do? On the one hand, they see the embryos as their own precious children. On the other hand, many couples feel there is a limit to how many children they can manage. ‘Cheaper by the dozen’ can be an overwhelming concept. Sadly, many Christians don’t think about this issue until they have embryos sitting there in the freezer and a ‘complete’ family.[35]

In fact, the most common fate of excess frozen embryos in Australia is that over time the persons responsible for them cannot be contacted and the clinic is no longer paid the fee to cover the cost of the freezing.[36] After the legal storage period has expired, the embryos are taken out of the freezer and left to thaw on the bench. This problem could be surmounted if just one or two embryos were created each time they were needed. I look forward to the day when eggs and sperm are routinely stored separately until an embryo is needed, so that no excess embryos can result.

An interesting development—to assist those with ethical and religious reservations about freezing embryos—is the practice of freezing eggs in the two-pronuclear (2PN) stage. This is done in Germany, Italy and Switzerland as a way of getting around the embryo storage ban, and it is also available in many other countries for those with moral objections to freezing embryos. The argument is that the embryo does not become a human being until the DNA of the egg and sperm combine (syngamy)—when the two pronuclei combine—so that when you freeze at the 2PN stage, you are only freezing the ‘pre-syngamy egg’: not an embryo. Mark said: At the time it seemed reasonable. It solved our problem. Looking back, I realize I had no idea what we were doing. Part of me didn’t want to know.

Opponents of the storage ban have argued that this practice is unsound as it means that embryo selection (for transfer purposes) has to be done at an early stage of development before you know which ones are of the highest quality.[37] I have argued in chapter 2 that human life begins when fertilization begins. In fact, it is the appearance of the 2PN that is used as an indication that fertilization has occurred. I would consider this practice to be no different ethically from freezing embryos at any other stage of development.

A different kind of argument against freezing is that it is unsafe for the embryos. The percentage of embryos that do not survive defrosting varies enormously between clinics. But, as mentioned earlier, embryos don’t deteriorate over time in the freezer like leftover chicken does. Any increased survival rate of embryos frozen more recently is more likely due to an improvement in culture media than to deterioration during the length of time an embryo is frozen.

But what if it wasn’t the actual freezing itself that damaged the embryos? What if it was just that only the embryos with development potential were able to survive freezing? In fact, there is (unpublished) evidence that all that happens during the freezing process is that the embryos which were never going to make it are weeded out—in which case, the process of freezing itself has not increased the risk to the embryo; it has just allowed self-selection to take place. (See below for a possible explanation of this mechanism.)

If it turns out that freezing of embryos does not decrease the overall risk of survival, and all embryos are transferred to the womb, then it is an ethical practice for Christians. See below for discussion regarding viability of embryos.

So the take home message is this: if you do decide to freeze embryos, create no more embryos than the number of children you are prepared to have. If you don’t want more than 6 children, don’t create more than 6 embryos. Make sure they are all transferred to the womb at some stage, if they do not pass away during development in the laboratory. It’s only when there are no excess embryos that the problem of embryo destruction is avoided.

What makes an embryo ‘viable’?

We have already discussed how Christians can use ART ethically when they respect all human life from the time it is created. And the challenge of protecting their embryos will become apparent to Christian couples right from the beginning of treatment. When eggs are fertilized in the laboratory and the embryos start to grow, decisions are made about which ones to transfer, which ones to freeze and which ones to discard.

These decisions are based on what the embryos look like (their ‘morphology’) at around day 2 or 3 in most clinics. As mentioned above, the problem is that it’s not possible to tell, just by looking at them, which embryos will survive transfer and then develop in a womb.[38] While there is a widespread belief that there is some correlation between the external appearance of an embryo and its likelihood of implantation and successful development, research has previously shown that appearances can be misleading.

Embryos can be sorted into three grades, and the ‘best’ of the bunch will be transferred. This means that a grade-3 (the lowest grade) embryo may be transferred, but only if it’s the best of a bad bunch (which is usually the case in older women). The only ones that would never be transferred are the ones that are already dead. But, in the current system, if there is a ‘good’ bunch then some of the ‘bad’ embryos won’t make the grade.

Systems for grading embryos vary from place to place, but they are all based on features including cell number, symmetry and shape, the extent of fragmentation in the cytoplasm, and the rate of cleavage (cell division). The ideal 3-day embryo has 6-8 cells of equal size and no fragmentation. Fewer cells, unequal size and more fragmentation reflect ‘poorer quality’, according to these systems. However, evidence suggests “that the best quality embryos on day 3 become the best quality blastocysts on day 5 in only 50%-60% cycles”.[39] Some unhealthy-looking embryos implant and develop successfully while some healthy-looking embryos fail to implant or have developmental problems.[40]

I am not aware of any method of embryo morphology assessment that has been proven effective or valid in terms of predicting the viability of IVF embryos. Unless definitive morphological criteria has been developed and verified, such selection criteria would be arbitrary. If there are any viable cells present, some clinicians would consider going ahead with uterine transfer despite unfavourable morphology, considering this the only way to determine true viability: if they grow, you know they were viable. It is my opinion that, in the absence of new information about the prediction of embryo viability, the viable/non-viable distinction based on morphology is invalid.

Consider Hal and Maddy’s story:

The results of our IVF treatment were we lost the first two embryos that were classified ‘viable for life’ and we have two beautiful boys from our third and fifth ‘non viable for life embryos’ (we lost the fourth embryo). We praise God that he convicted us about where we stood in regards to our treatment as, if we had given in to the pressures (to discard the ‘non viable’ embryos), we wouldn’t have met our two beautiful boys.

Extended (blastocyst) culture

Having said that, we do have a slightly better way of deciding which embryos are viable. It is called ‘extended culture’.

Although the first human birth from IVF (Louise Brown) resulted from the transfer of a blastocyst (an embryo 5 days after fertilization),[41] most transfers since then have involved younger cleavage stage embryos (day 2 or 3). The main reason for this is the lack of culture media that is able to reliably sustain embryos up to the blastocyst stage. Further research has led to the development of ‘sequential’ media, which is varied according to the stage of embryo development and is made to simulate conditions in the fallopian tubes or uterus—wherever the embryo would normally be at that stage.[42] Extended culture is not available at all clinics.

For years now, IVF specialists have justified the number of embryos that die during IVF treatment as a reflection of the large amount of wastage observed in normal reproduction. This is a reasonable theory, but there has not been any evidence to support it until fairly recently.

It is thought that by growing embryos to blastocyst stage (day 5), the true viability of the embryo is tested.[43] By this time, the DNA is functioning and so chromosomal problems may be identified. This is also the stage at which the embryo normally implants and so it is better suited to surviving in the new environment. Blastocysts implant at higher rates than younger embryos, but only about 50% of embryos make it to blastocyst stage.

It may be that those embryos that cannot get to blastocyst stage in the laboratory would not reach blastocyst stage in the woman’s body either. Therefore, growing embryos to blastocyst stage would avoid the problems inherent in choosing ‘viable’ embryos based on what they look like (because the ‘bad’ ones simply would not survive), and would possibly reduce the number of embryos transferred. It would also allow the effects of hyperstimulation in the woman to settle down before implantation.

Those who don’t support blastocyst transfer worry that if all the embryos are of poorer quality, there may be no embryos to transfer (because none survive to blastocyst stage at day 5), and perhaps they would have implanted successfully if they were transferred at day 3. It is true that you would not be able to proceed with transfer if all the embryos died in culture, but would they have continued developing even if they were transferred? Overall, it seems that blastocyst transfer improves outcomes, and this is probably because it allows for better ‘natural’ selection of embryos. Difference in morphology becomes more obvious on days 5 and 6 because there is more to look at in embryos of greater age. It would therefore be reasonable to use blastocyst morphology to decide which embryo to transfer first.

There is a higher rate of pregnancies per blastocyst transfer, leading to live births in shorter periods of treatment time. The definitive research has not been done, and it will probably never be done due to the costs involved and a lack of political will. But all current evidence points to the likelihood that by growing embryos to blastocyst stage, we are not ‘wasting’ embryos but merely distinguishing which ones were never going to survive.

Risks associated with blastocyst transfer include a possible higher rate of multiple gestation, as there is an increased incidence of monozygotic twins (4.25 times higher risk).[44] It is therefore even more important that only one embryo is transferred if it is done at blastocyst stage. Reports that blastocyst transfer has not reduced the incidence of multiple pregnancy is primarily due to how few clinics are willing to transfer only a single blastocyst in jurisdictions where transfer of more than one is allowed.[45]

Ethically, any embryos that reach blastocyst stage should be transferred to a womb.

Ethical issues

The decision about which embryos to keep and which to discard will need to be made relatively quickly, as in most clinics there will be a 3-day window (at the most) in which the embryos can be transferred successfully. In order to avoid being under pressure in their decision-making, couples should think about this issue ahead of time.[46] They may also need to mention it to their doctor, as some doctors would assume that couples are happy to discard those embryos labelled ‘non-viable’, so would not even ask them about it.

At such an early stage of treatment, when parents are extremely vulnerable and expecting treatment to be successful, I am very concerned about whether it is possible for them to be completely sure they will have no further use for the embryos. Doubtless they will expect that one of the viable embryos will implant. If none of the ‘viable’ embryos do implant, will they still think the ‘non-viable’ embryos are unnecessary? What if the parents’ choice ends up being between transferring a ‘non-viable’ embryo and none at all? This is a complex decision to make in only a day or so.

If there is any chance at all that those responsible for the embryos would ever not consider the ‘non-viable’ embryos to be excess—in the event that the ‘viable’ embryos failed to implant—it will be difficult to ensure that you have proper consent before the commencement of treatment.

For those who wish to protect human life from fertilization, if there is any possibility that the embryos in question may be viable, they should be transferred. The only distinction that is important is whether the embryo is alive or dead.

I realize that morphology is the only generally applicable, non-invasive guide we have for assessing embryos, but that does not mean it is reliable. I would hope the fact that ‘discarded’ fresh embryos are eligible for research purposes in some countries does not influence this debate.

Blastocyst transfer is ethically acceptable for Christians so long as other aspects of the treatment are morally correct.

Oocyte cryopreservation (freezing eggs)

One way to avoid the ethical problems of freezing embryos is to freeze the excess eggs collected from a woman and then defrost them as needed. As previously mentioned, eggs by themselves are not human beings and so their treatment does not require the same care as human embryos. Sperm is routinely frozen without a problem, and it is relatively easy to collect; but it is the difficulty, risk and expense of egg collection that has led to embryo freezing.

Egg freezing has been slow to develop because of technical difficulties and early concerns that it was associated with genetic (chromosomal) abnormalities.[49] The egg is the largest cell in the body, with a large surface area and high water content. In the past, freezing eggs was associated with damage to the spindles (part of the egg structure). The traditional method has had a low success rate, but a newer method—egg vitrification (see below)—is looking much more promising.

The first children to be born from frozen eggs were twins in Adelaide, Australia, in 1986.[50] Since then, egg-freezing technology has been made available as a method of fertility preservation for women with cancer (approximately one third of young women exposed to chemotherapy develop ovarian failure).[51]

More recently, single women—whose biological clocks are ticking—have been the marketing target of ‘insurance’ against the risk of either not finding a partner or not being ready to have a child before the alarm on the biological clock starts ringing and fertility plunges. Commercial fertility services have sprung up in several countries with executive women aged 30 and older as their object. While some doctors are concerned that provision of this service may raise false hope in women, others think that by freezing their eggs while they are young, these women improve their chances of becoming pregnant in the future.

Egg-freezing technology is also used by those who desire to avoid embryo freezing due to ethical or religious convictions that it is wrong, and in situations where it has not been possible to collect sperm at the time of egg collection. Interest has also been consistent in those countries where legislation has prevented the freezing of embryos—particularly Italy and Germany.

There are two methods used to freeze eggs.

1. Traditional (slow) egg freezing: The egg is cooled slowly as the temperature drops gradually to below freezing. During this process, ice crystals form inside the egg and damage cell membranes. Damage to the structure of the egg is common. Only about half of the eggs survive the thawing process, and they are usually of poor quality.
2. Snap freezing (egg vitrification): The egg is cooled rapidly which allows the water inside the egg to become solid instantly without the formation of ice crystals. Most of the eggs survive the thawing process, with a much better success rate than with slow freezing. This is the technique that has propelled egg cryopreservation into mainstream ART.

Cryopreserved eggs are difficult to fertilize due to hardening of the zona pellucida (outer membrane of the egg), which is accommodated by using intracytoplasmic sperm injection (see below) to fertilize the eggs.[52]

Frozen eggs have a potential similar to fresh eggs for embryo development.[53] Research has shown that the pregnancy rate per uterine transfer with egg vitrification is 63.2%.[54] So far, research indicates there is no increased risk to mother or child and no increase in congenital abnormalities compared to naturally conceived children, although obviously no long-term study has yet been done.[55] The bad news is that this technique is very expensive—usually over $10,000 per cycle. In some jurisdictions, deductions apply if it is used for medical reasons (e.g. related to cancer treatment).

Ethical issues

The development of the technology to freeze eggs is welcome as an alternative to freezing embryos, and it is hoped that it will continue to become more common. Freezing eggs is an ethical alternative for those who wish to protect embryonic human life, so long as associated concerns are addressed. Concerns about informed consent when ovarian stimulation is used are discussed above. Concerns about the possible donation of eggs to a third party are discussed in the gamete donation section below.

Ovarian tissue cryopreservation

Some research units have experimented with storing strips of a woman’s ovary in the hope that the eggs could be stimulated to develop and later used to create an embryo. This offers the possibility of restoring reproductive function in women after they have received treatment for cancer (it could also help women who need to have their ovaries removed for any reason). Although egg-freezing techniques are now more advanced, once cancer is diagnosed, there usually isn’t time to organize an IVF cycle before beginning cancer treatment. Also, with the improvement of cancer treatment for children, a growing number of pre-pubertal females will be interested in preserving fertility.

The technique has been successful in animal research, and while it is currently considered experimental in humans, in some cases it remains the only hope for some women to preserve fertility. At least 11 pregnancies have been reported worldwide from this procedure.

The main aim of this strategy is to re-implant ovarian tissue into the pelvic cavity, the forearm or abdominal wall once cancer treatment is completed and the patient is disease-free.[56]

Ethical issues

The development of ovarian tissue cryopreservation is also welcome as an alternative to freezing embryos. As an experimental treatment, it needs to be considered carefully. While it is an experimental technique, if it is proven to be safe in animals and it is the only way a woman can hope to maintain her fertility, it is an appropriate medical intervention. Fully informed consent would be required from the patient—in the case of a minor this becomes more complex—but if the risks and benefits are understood and the patient wants to proceed, it is ethically appropriate.

For possible alternatives to freezing ovarian tissue for women undergoing chemotherapy, see ‘egg freezing’ above.

Sperm cryopreservation

Sperm freezing has been available since 1953. Sperm are often frozen before use in ART to remove the risk of infection. They may also be frozen if the husband has a low sperm count (so multiple samples can be used at the one time) or if he will be away at the time of the wife’s egg collection. Sperm may also be frozen to protect the fertility of cancer patients, which can be affected by cancer treatment. In 2010, a baby girl was born having been conceived with sperm that had been frozen 22 years earlier.[57]

Children conceived from previously frozen sperm have no increased risk of birth defects. Although a significant number of sperm die in the process of being frozen and thawed, sperm usually come in large numbers (see above) and only one per egg is needed. Usually several sperm samples from a particular patient are frozen at any one time.

Ethical issues

As mentioned above, while there are no intrinsic ethical issues in the treatment of sperm—as gametes are not human beings in an early stage of development—care should be taken with collection. Cryopreservation of sperm is an ethical practice.

Gamete intra-fallopian tube transfer (GIFT)

Fertilization of the egg by the sperm normally occurs in the woman’s fallopian tubes (on the side where the egg was released from the ovary). It is known that ‘signalling’ occurs between the developing embryo and the wall of the uterus prior to implantation, and this knowledge led some researchers to develop a technique using the woman’s fallopian tubes to assist in establishing a pregnancy. (Note that this depends on the woman having normal fallopian tubes.)

In GIFT, ovary stimulation and egg retrieval proceed as in normal IVF. After this, the woman undergoes surgery (a laparoscopy) where eggs and sperm are transferred to her fallopian tubes. They are left there to work things out themselves. GIFT is not often used now that IVF has a much better success rate and usually does not involve the risk of surgery.

GIFT has a higher rate of ectopic pregnancy (tubal pregnancy) than IVF and a similar multiple pregnancy rate, unless only one egg is transferred.

Ethical issues

GIFT is an ethical choice for Christians as it involves manipulation of eggs and sperm, not embryos. Eggs and sperm, not being equivalent to a human being, are not morally significant. The extra medical risks and possibly the expense may be morally significant depending on the situation of the couple concerned.

Zygote intra-fallopian tube transfer (ZIFT)

ZIFT is a technique similar to GIFT. Ovarian stimulation and egg retrieval proceed as in normal IVF, as does the creation of embryos in the laboratory. Zygotes (one-cell embryos) are then transferred to the woman’s fallopian tubes the following day.

Risks are similar to GIFT, except that limiting the embryo transfer to one can minimize multiple births.

Ethical Issues

Ethical issues for ZIFT will be the same as for IVF. The only difference is that the embryo is transferred to the fallopian tubes instead of the uterus.

Intracytoplasmic sperm injection (ICSI)

This practice has been used with IVF since 1991 to aid fertilization. Tens of thousands of ICSI babies have been born since then. The need to use ICSI can result from a low sperm count, low sperm motility, previous failure to fertilize with IVF, or the presence of sperm antibodies.

In this process, a single sperm can be selected and directly injected into the egg. The sperm will be selected on the basis of its normal appearance and energetic swimming style. Sperm can be collected from the ejaculate, or it can be obtained by using a needle to withdraw it from the man’s testes (sometimes the sperm are unable to get into the semen due to a blockage in the testicular ‘plumbing’). Two methods of sperm retrieval are available: microsurgical epididymal sperm aspiration (MESA) or testicular sperm aspiration (TESA). A minimum number of sperm are necessary.

Although this technique was not thoroughly investigated before clinical use, it is now felt that a decade of experience has proven its overall safety. However, research indicates that offspring conceived using ICSI may be at increased risk of imprinting disorders (genetic problems), and male offspring may have fertility problems similar to their father. It is not clear whether this is due to ICSI itself or to the disease that makes ICSI necessary. Certainly having the doctor select the sperm instead of the sperm ‘selecting’ itself (by being the first to penetrate the egg) must make a difference. Using ICSI, therefore, will increase the number of infertility genes in the community gene pool, as men who previously were unable to procreate can now do so and can also pass on their genes. This shows how some of the side effects of ART take a long time to manifest themselves.

Ethical issues

As previously discussed, sperm do not have the ethical significance of embryos and so their manipulation is not morally troublesome in itself.[58]

Assisted hatching

‘Hatching’ describes what happens when the embryo breaks out of its ‘shell’ (the zona pellucida—the thick outside layer of the embryo) in order to implant into the wall of the uterus. The way this occurs in natural conception differs from IVF. In the laboratory, assisted hatching is recommended when embryos resulting from IVF or ICSI may have a reduced ability to hatch. This procedure is typically performed:

• for women who are 38 years and older
• for women who have embryos with abnormally thickened shells
• sometimes after freezing, which can harden the zona pellucida
• for those who have had difficulty becoming pregnant for other reasons.

Assisted hatching may be done in a number of ways. It is a microscopic surgical technique performed by an embryologist. While viewing the embryo through a microscope, a small hole is gently made in the embryo shell, or the shell wall is artificially thinned, so that the embryo can hatch several days after it is transferred to the woman’s uterus.

Assisted hatching may cause embryo damage and increases the risk of twins.

Ethical issues

If you are undergoing ART and your doctor believes that assisted hatching will increase the chances of a successful transfer, it is an ethical and responsible choice. Your doctor will weigh up benefits and risks when assessing whether the technique is appropriate.

Donor gametes (eggs and sperm)

Sometimes, for a number of reasons, the husband’s sperm or the wife’s eggs cannot be used. In this situation, donor sperm or donor eggs are often recommended. Those who support donor gametes consider the benefits of having at least one parent genetically linked to the child(ren), and the fact that it means your infertility usually remains a private matter. 

Egg donation

When IVF was first introduced, women who did not have their own eggs were considered to be sterile. In 1983, the first successful egg donation was reported. Several techniques have been used, but nowadays the (usually younger) donor and the recipient both are given medication for ovarian stimulation and synchronizing cycles, and the eggs harvested from the donor are combined with the sperm of the recipient’s husband through the usual IVF process. The resulting embryo(s) are transferred to the uterus of the recipient. It can also be done through variations of GIFT and ZIFT.

Depending on the country, donors may be difficult to find. While there are many willing donors available on the internet (for a fee), in some countries (such as Australia) it is illegal to pay for human tissue and couples have to find someone themselves. If no friend or family member is able to help, couples usually place an advertisement in the newspaper. Kay and Steve had a lot of trouble finding a donor. Kay remembers: We did find one woman who was willing at first, but when she met me, she had a problem with my weight. I’m not all that heavy, but she pulled out because she said she didn’t want a ‘fat’ child. She didn’t seem to realize that it wasn’t going to be her child.

Recipients should be evaluated (screened and counselled) before donation because of the problems encountered by many couples using donor gametes. In addition, guidelines have been developed by ART regulating bodies such as the Fertility Society of Australia (FSA),[59] the American Society for Reproductive Medicine (ASRM)[60] and the Human Fertilisation and Embryology Authority (HFEA).[61] The kinds of things that are checked are the age of the donor (preferably under 35 so that eggs are still healthy) and the donor’s health. Standard pregnancy screening,[62] the donor’s own established family and psychological evaluation are also advised.

Once the donor has handed over the eggs, she has no legal parenting rights over the child who is born. Nadia remembers her experience of looking for a donor: I asked one of my sisters and she said ‘no’. In hindsight, it was wise as she has not had children and is now in the same predicament as her two older sisters, so there could have been resentment if I had children from her eggs. The counselling we received at the Fertility Centre was for a woman under 35 who had finished having her own children. I didn’t want to ask anyone for fear they would say ‘no’. So we prayed that God would provide the right woman. We waited—that was very hard.

Sperm donation: Donor insemination (DI)

Artificial insemination with sperm may have been done in humans for the first time in 1909 when Professor Pancoast of Philadelphia treated the wife of an infertile merchant. The donor was one of his medical students. Apparently the doctor didn’t tell the husband until afterwards and they both agreed never to tell the wife.[63]

DI is the most widely used technique in assisted reproduction worldwide. It is sometimes used if the husband is sterile or if he carries a genetic disease he could pass on and he doesn’t want to use preimplantation genetic diagnosis (see below). Nowadays, sperm samples for donation are collected after masturbation in the clinic. Usually there is a payment (usually less than $100), but nothing like the money given for eggs as the effort and risk involved is quite different. Sperm donors are screened for health and fertility, and can be located on the internet or through advertisements in a similar way to egg donors.

The donor insemination procedure is done the same way as IUI, except for the different source of the sperm. The semen samples are usually frozen before use to reduce infection risk. This can reduce motility, which is why the sperm are injected into the uterus and not just the vagina.

When I was a medical student, they would mix the donor sperm with the husband’s sperm so no-one ever really knew for sure…

Legal issues for gamete donation

Due to the difficulty of finding egg donors, anonymity of egg donors has never been as common as it has been for sperm donors. Sperm donation remained an anonymous activity for a long time after its commencement. But at the time of writing, anonymous gamete donation has been banned in Austria, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and some states of Australia as a result of lobbying by ART offspring regarding their right to know their biological heritage. In the United States, anonymous gamete donation is permitted,[64] but in 2011 the state of Washington made it possible for children conceived with donated gametes to gain access to the donor’s name and medical history, if the donor agrees (the ASRM opposed the law).[65] In the province of British Columbia in Canada, there was a legal ruling in 2011 that banned donor anonymity (the government has appealed the ruling).

However, although there is progress on donor identification in these places, the child who is not told they were born from donated gametes will still not know to enquire. Furthermore, without a current register, contact details become out-of-date and it can be impossible to locate the donor.

Where anonymous donation is no longer allowed, the gamete donor will usually be asked to undergo counselling so that they understand the implications of donating one’s gametes and the arrangements in place to allow the offspring to make contact in the future. Unlike the birth mother and her husband, donors will not be the legal parents and will not be responsible for the offspring after birth. In countries like Australia where counselling is required by law, it is done by qualified practitioners who are very careful to make sure that all parties involved understand the arrangements fully before proceeding; this reduces the likelihood of complicated transactions after the birth. In Australia, guidelines stipulate that counsellors will also discuss the needs of the offspring.

Laws have been introduced in some places to limit the number of offspring, or families of offspring, from any one donor.

Psychological issues for gamete donation

As donor offspring have grown to adulthood, we have become aware of the deep disturbance and confusion about identity that can result from the knowledge that they were conceived from donor gametes. It was once assumed that adopted children did not need to know about their birth parents, and that perhaps it was better if they did not even know about the adoption. We now know this is not true and that, in fact, it is normal for adopted children to want to know about their genetic heritage—whether it be from curiosity about their parents’ physical attributes or a need to know details like family medical history. We now also know that donor gamete offspring feel the same way.[66]

It is important to them to know their origins, and so even in places where it is not a legal requirement, donor offspring have tried to persuade donors to give details of their identity anyway. Here is Lila’s way of describing how she felt: half of my ancestors are ghosts. She and others like her have received a lot of support from donor conception support groups.[67] Yet governments are slow to develop the networks needed for donor offspring to be able to trace their roots.

This is the case in Australia. In a recent Senate enquiry investigating the need for a national register, one woman said:

I cannot begin to describe how dehumaniz[ed] and powerless I am to know that the name and details about my biological father and my entire paternal family sit somewhere in a filing cabinet… with no means to access it. Information about my own family, my roots, my identity, I am told I have no right to know.[68]

The Australian state of NSW introduced a central register in 2010, not only banning anonymity in the future, but also addressing past anonymity by making it possible for previous donors to add their identifying details to the register voluntarily.[69]

Some donor offspring feel so strongly the pain of ‘genetic bewilderment’ that they even feel angry they were ever born.[70] It is not clear that this is the majority view, but it is definitely a sincere concern of a section of the donor offspring population.

There is also a concern that where donor anonymity has been banned in those countries where only altruistic donation is permitted, donations have dropped off. As a result, IVF clinics have suggested the ban be overturned. However, the UN Convention on the Rights of a Child declares that children have the right to know their parents and that the state has a responsibility to preserve their identity:

Article 7

1. The child shall be registered immediately after birth and shall have the right from birth to a name, the right to acquire a nationality and, as far as possible, the right to know and be cared for by his or her parents…

Article 8

1. States Parties undertake to respect the right of the child to preserve his or her identity, including nationality, name and family relations as recognized by law without unlawful interference.

2. Where a child is illegally deprived of some or all of the elements of his or her identity, States Parties shall provide appropriate assistance and protection, with a view to re-establishing speedily his or her identity.[71]

Even though we know from research that donor offspring cope best when they are told about their origins early on—with better outcomes for depression, delinquency and substance abuse[72]—at most, only about a third of children are told by their parents that they were conceived using donor gametes.[73] The authors of one study, which found that offspring of lesbian parents learned of their DI origins at earlier ages than offspring of heterosexual parents, suggest that their findings could reflect men’s discomfort with their own infertility.[74] (Note that this study did not use a random sample.)

Whatever the underlying problem is, this situation has led to donor offspring requesting that their birth certificates contain some reference to their genetic parentage (so they can find out if donor gametes were involved)—but so far, without success. In fact, in Australia, where only two parents may be listed on a birth certificate as legal parents, things seem to be moving in the opposite direction.[75] Where previously sperm donors have been listed as ‘father’ on the birth certificates when no other male was involved, a 2008 law has given retrospective parenting rights to lesbian partners of women using ART. One man’s name was removed from his 10-year-old daughter’s birth certificate in 2011 and replaced with the name of the mother’s former lesbian partner.[76]

Ethical issues for gamete donation

Ethical issues raised by the practice of gamete donation are complex, and in many cases yet to be resolved.

Donor identification

The call to ban anonymous donation has intensified since the marriage in the United Kingdom of twins who had been separated at birth (annulled in 2007) sparked discussion about the ‘irresistible attraction’ often felt by reunited siblings and the concern that unwitting incest between half-siblings may occur.[77] The news that a British sperm donor had fathered 17 families despite the government limit of 10, and that an American sperm donor had fathered more than 150 children, has not allayed these fears.[78]

Mixing gametes

Mixing gametes of different parental origin, so as to confuse the biological parentage of the child, is never morally justified.

Anticipated consent

The ethical doctrine of anticipated consent requires that when a person seriously affected by a decision cannot give his or her consent to that decision, we must ask ourselves whether we can reasonably anticipate that, if they were present, they would consent. If not, it is unethical to proceed.[79] The feeling on donor offspring websites is that not only have they been relinquished by a parent at birth, but also the whole ART system has ignored their interests. Kim says: Donor conception has and always will serve the rights of the parents, while the child remains voiceless.[80]

The biblical perspective

Biblical examples of ‘third parties’ contributing to reproduction can be found in the Old Testament. But while polygamy is often mentioned in this context, it is not a parallel to gamete donation as any children were still offspring of a husband and wife. Perhaps a closer example was when Sarah gave her maid, Hagar, to her husband, Abraham, after years of waiting for the offspring promised by God. Without appealing to God, she decided to get ‘her’ offspring through her maid (Gen 16:1-3). Likewise, Jacob’s wives, Rachel and Leah, competed by using their maids to produce children (Gen 29:31-30:24). However, even if the ‘donors’ were not actually married to the father, both parents had a role in raising the child, which is not the case with donor gametes in the modern sense.

Another example cited to justify donor gametes is that of levirate marriage:

“If brothers dwell together, and one of them dies and has no son, the wife of the dead man shall not be married outside the family to a stranger. Her husband’s brother shall go in to her and take her as his wife and perform the duty of a husband’s brother to her. And the first son whom she bears shall succeed to the name of his dead brother, that his name may not be blotted out of Israel.” (Deut 25:5-6)

On the surface, this looks very similar to the previous example: the brother of the dead man (possibly already married) impregnates the widow, and the first son becomes the dead man’s heir. But once again, both parents are involved with the raising of the child, for the widow becomes the wife of the brother and her subsequent children are his.

The first son was needed to protect the family inheritance of the dead man. In the case of Ruth and Boaz, there was no brother, so a close relative performed the task; but again, Ruth married Boaz and they raised their son, Obed, together (Ruth 3-4). Therefore, the biblical expectation that parents take responsibility for a child after birth is met.

Theological problems arise with gamete donation, from both the receiving and the giving end. With regard to receiving donor gametes, while I would not say this is a form of adultery, Islamic doctors in Dubai (for example) would—that’s why governments control IVF clinics there. It does bring a third person into the ‘one flesh’ relationship, though, and I would suggest that it is contrary to Scripture. On a practical level, gamete donation can cause an imbalance in the marriage relationship; some men have reported feelings of sexual jealousy when they have seen their wife pregnant by another man, even though no actual sexual relationship has existed.

In terms of giving, the gamete donor is involved in child-bearing without the intention of fulfilling their parental responsibilities to nurture the child. Even when donation is no longer anonymous, opportunity for a relationship is often not possible until the child is 18 years old, although there have been court cases where donor parents have gained access to their children despite not having discussed prior to the birth any involvement in the child’s life. The involvement of both parents is closer to the biblical model.

Furthermore, once the gametes are donated, the donor has no say in what happens to the child that results from their use. What if the recipients decided to abort the child after finding an abnormality on the ultrasound, or even for no reason at all? What if the mother kept smoking and harmed the baby during the pregnancy? Allen recalled, My brother asked me if I would give him and his wife some sperm so they could have a baby. At first, it seemed like a reasonable thing to do. Then I thought about how they aren’t Christian and wouldn’t take the kid to Sunday school. I feel pretty uncomfortable about it now. Since the Bible teaches that the role of the parent continues after birth, these are all issues of concern.

I know there are Christians who disagree with me on this point and who report that DI has been used for years with few problems. They point to the numerous ways in which biblical couples overcame infertility, and they therefore see a place for modern creative thinking. However, in the end I believe that the biblical teaching of the marriage relationship as ‘one flesh’ and the ongoing responsibility of parenting indicate that gamete donation is not in the spirit of Scripture.

If you do decide to go ahead and use donor gametes, I would advise the following:

1. Both husband and wife should have counselling before deciding to use donor gametes so that you are fully aware of all the implications. In particular, make sure there is discussion about informing (or not informing) the child about their genetic origins.
2. Don’t go ahead if either of you have doubts, as this will add extra stress to your marriage.
3. Adopt a policy of honesty from the start regarding your child’s genealogy. If possible, make sure your child can contact the gamete donor once they turn 18. Consider only using a donor who is prepared to be contacted. (Note: there are internet groups that help donor offspring find their donors.)

Surrogacy

A surrogate mother is a woman who agrees to carry a child through pregnancy and deliver it on behalf of another. Surrogate mothers may also be called gestational carriers. The commissioning/intended/contracting parents arrange for a surrogate to carry a pregnancy on their behalf, on the understanding that after birth she will relinquish the child and transfer custody of the baby. The commissioning parents will then be able to raise the child as its legal/social parents. They may or may not also be its genetic parents. Therefore, a number of different situations are possible:

• Traditional/genetic/full surrogacy: The surrogate is the child’s genetic mother.
• Gestational/partial surrogacy: An embryo is transferred to the uterus of the surrogate and she carries a child with whom she has no genetic relationship.
• Altruistic surrogacy: The surrogate does not get paid for carrying the pregnancy and there may be no enforceable contract, although medical and other reasonable expenses may be covered.
• Commercial surrogacy: The surrogate receives compensation for carrying the child, as well as reimbursement for medical and other expenses.

In Australia and the United Kingdom, surrogacy for commercial gain is against the law, and in many European countries both commercial and altruistic surrogacy are also banned. Although altruistic surrogacy is claimed to be not-for-profit, in reality it is difficult to distinguish from commercial surrogacy as the line between what is a ‘reasonable expense’ (which can be covered by the commissioning parents in altruistic surrogacy) and what is only ‘compensation’ is difficult to define, and there is no bar to gift giving. It would not be unusual for an altruistic surrogate in the United Kingdom to receive around £10,000 for expenses.

In many countries, all forms of surrogacy are legal, although that does not always mean that contracts can be enforced. Rates of surrogacy vary.

Why do people consider using a surrogate?

Surrogacy would usually be considered after the failure of IVF as a way for a couple to have a genetically related or partially genetically related child. It is also considered when the woman is unable personally to carry a pregnancy, perhaps because she has no uterus (from birth, or as a result of surgery), or is unable to bring a pregnancy to term for other reasons. Increasingly, surrogates are also being used by homosexual male couples to enable them to have a child who is genetically linked to themselves. 

Why do women choose to be surrogates?

Research has been patchy in this area. Certainly, there are examples of women who selflessly carry a child for complete strangers out of the kindness of their hearts, wanting to give others the gift of a child—something they find so fulfilling in their own lives. This happens even in commercial settings. Most have reported that they find personal fulfilment in surrogacy, and that it adds something to their lives (such as increased self-esteem). Few surrogate mothers report doing it just for the money.[81]

Surrogacy in society

Community acceptance of surrogacy has been slow, and is associated with a growing recognition of the changing nature of the family in society. Some have compared it to adoption, emphasizing improved outcomes for surrogate offspring because they are with their parents from the start. I do not think this is a valid comparison. First, adoption is an act of charity for a child already born—quite different from the conscious decision involved with a surrogate birth. Second, there are insufficient surrogate offspring in the teenage years to really know yet what their identity issues will be, if indeed they develop any.

One issue of concern to authorities is that the socioeconomic status of intended parents has been shown to be significantly different from that of surrogates. Commissioning mothers tend to be older and better educated than surrogates, raising concerns that surrogate mothers may be at risk of exploitation. Although there is little evidence that this occurs in Western countries, the long-term effects of surrogacy have not been examined. Some surrogates have reported feeling betrayed if they were told they would be permitted to keep in touch with the baby and this promise was later rescinded.[82]

Commercial surrogacy—cause for concern

A more worrying trend is the ‘rent-a-womb’ businesses appearing in the developing world. In India, a recent investigation by the London Sunday Telegraph reported that according to a senior Indian government official, up to 1000 IVF clinics are currently operating across the country. Reproductive tourism is expected to earn $2.3 billion in 2012.[83] The primary appeal of India is that it is cheap, legal but barely regulated, and relatively safe. Surrogacy can cost $50,000-$100,000 in the United States, while many Indian clinics charge $22,000 or less. Local women find the work tempting for financial reasons, though they earn only a fraction of the fee collected by the clinic. A woman can expect to earn at least 300,000 rupees (US$6,000/£4,000), with a bonus if there are twins. If a surrogate miscarries during the first term, she will get a third of the cash. One pregnancy can be enough to get her out of the slums, while two may educate her children to university level.[84] It’s easy to see the temptation for these women, even though death is occasionally the result. (Life insurance is now available.)

In order to increase efficiency for their customers, PlanetHospital provides an ‘India Bundle’ that includes 4 embryo transfers into 4 separate surrogate mothers at the same time. If the customers end up with more pregnancies than required, some commissioning parents find the extra money while others just abort the ‘spares’.[85]

Thailand is also becoming known for its surrogacy industry. The Babe-101 website announces that they are based on eugenics: “We could create the finest procreation condition for your baby, mainly through the efficient embryo refining” (they also mention the importance of fertility in the Chinese culture).[86] They list the benefits of hiring a surrogate mother, including:

3. [You] can continue to work without worrying about losing job or business intermission. It is quite suitable for the women who desire to have kids but no time for pregnancy.

4. Unnecessary to fear the pain of birth pangs.

5. Unnecessary to worry about out of shape on your stature, neither to fear the intimacy fading…

7. …However the baby is 100% blood relationship with you.[87]

It doesn’t mention how you will manage to have time for a baby when you didn’t have time to be pregnant.

The use of commercial surrogacy arrangements in any country is banned in parts of Australia.[88] In 2011, France refused to give citizenship to twins of French parents, born through a surrogate in the United States, because of their own national ban.[89] Germany decided that not only would they not issue a passport to a child born by a surrogate mother in India, but also that the legal parents are the surrogate and her husband.[90]

Further complicating the potential abuse of commercial surrogacy is the news that a California attorney who championed surrogacy was found guilty of selling babies. Apparently, Theresa Erickson and her partners recruited women to act as surrogates, and arranged implantation with donated gametes in the Ukraine (thereby bypassing the usual formalities). When the second trimester was reached, Erikson advertised the babies for sale, fabricating false records that suggested the children were the result of a cancelled legal surrogacy arrangement. Couples were charged $100,000-$150,000 per baby.[91]

The techniques used for surrogacy are the same as standard ART (with or without donated gametes), but the legal, ethical and psychosocial issues can become complex.

Legal issues

In those places where the birth parents are recorded on the birth certificate, the social parents may not get custody of the child for months or years. This means, for example, that they are not legally able to consent to surgery in an emergency. The problem is reduced when the surrogate and the intended parents have an ongoing relationship, as is required in some jurisdictions. If the child is born in a different country, as noted before, citizenship in the parents’ country cannot be taken for granted. Some countries with an established surrogacy industry are requiring intending parents to prove the child can be repatriated, before the surrogacy is finalized.

International surrogacy isn’t the only source of problems. An English couple, having already lost custody of a child to a surrogate mother (the biological mother) who changed her mind, was ordered to pay £568 (A$900) per month in child maintenance because the husband is the biological father. He plans to appeal.[92]

If surrogacy is intended, it is important that all parties receive counselling and legal advice at the outset, so that they know where they stand.

Ethical issues

Surrogacy has often had a bad name due to high-profile media cases where, for example, the surrogate refused to give up her child (1987),[93] or the commissioning parents sued a surrogate for bringing twins to birth when they only wanted one child (they had wanted an abortion for one of the twins; 2001).[94] However, the fact that it does work sometimes means that not all problems are insurmountable.

Supporters of surrogacy argue that life through surrogacy is better than no life at all; that it respects marriage by rejecting adultery or divorce as a way to get a child; and that it is not harmful. In response to these supporters, I would say that arguing about whether life through a surrogate is better than never being born is really an invalid thought experiment, since life is the basic good on which we measure other goods. I agree that it is better to avoid adultery and divorce as ways to get a child. Yet surrogacy is not the only alternative. Is surrogacy really not harmful at all?[95]

There are many factors that can potentially create problems in a surrogacy transaction.

One potential problem—and an argument against surrogacy—is its effect on the child born. The concern is that it is a transaction that starts to treat the child involved as a commodity to be bought and sold.

Of course there will always be exceptions, but the testimony from children born through assisted conception is clear: their biological identity is important to them and every time an extra parent is added to the mix, it increases confusion and reduces their sense of belonging. When you consider that children born through surrogacy may have to contend with, potentially, up to five parents (egg donor, sperm donor, surrogate and two social parents), what will these children say when they are old enough to speak for themselves? They have had no opportunity to consent to these experiments. It is possible they will have similar concerns to children born with donor gametes (see above), as it seems that most parents do not plan to tell their children about the surrogacy,[96] and in most jurisdictions the birth certificate denotes legal parentage, not genetic parentage. And if donor gamete children feel they were relinquished at birth, how are surrogate children going to feel?

Feminists, on the other hand, are very concerned about the effects of surrogacy on the surrogates themselves. They believe surrogacy debases women by reducing them to their reproductive functions. They argue that it demeans the meaning of motherhood to use these women to ‘manufacture’ a ‘product’. It turns children into commodities of exchange, which is degrading for them. Pregnancy becomes a service rather than a relationship.[97] They also argue that it is not acceptable to solve one woman’s pain by creating it for another.

I certainly agree that commercial surrogacy is wrong, particularly as it is practiced in developing countries where women can be exploited through financial incentives. An Indian friend suggested that I was trying to take away a lucrative source of income for those poor women, and that they were free to make their own choices. I agree the choice is theirs, but can it be completely voluntary when the money is such a coercive factor?

Surrogacy, whether commercial or altruistic, also introduces a third party into the marriage relationship, which is not consistent with the ‘one flesh’ teaching of the Bible. This risks the surrogacy arrangement having a negative impact on the marriage. Some women report feeling like an outsider when they are ‘bypassed’ by the surrogacy. Vera said, We thought about it, but I didn’t think I could handle seeing another woman pregnant with my husband’s child. Some couples see it in a more practical way: We want a biological child. I have eggs, he has sperm. Why not use a surrogate so we can get what we want?

Even though I am hesitant to recommend legal surrogacy, I believe that if no donor gametes are used, altruistic surrogacy is not necessarily inherently immoral. This is not to say, however, that it is a wise choice. By definition, surrogacy requires a woman to break the relationship she has formed with the child she has been carrying for 9 months. I do not believe it is ever right to suppress the bonds of love between parents and children. Grief resulting from giving up a child for adoption, even when it is voluntary, is well known.[98] It is natural for a mother to bond to her unborn child, and surrogacy goes against the biblical idea that parenting a child involves responsibility beyond the birth. It is also reported that the natural children of the surrogate mother experience a sense of loss of a sibling and abandonment anxiety (that their mother has given away one child and they may be next).[99] No long-term research has, as yet, studied what effect their mother’s surrogate birth has on them.

The scenario is further complicated by the ethical problems that could develop for both commissioning and surrogate parents. What if one party demands an abortion against the wishes of the other? What if the child is disabled and none of the parents want it? What if the surrogate disagrees with how the social parents choose to bring up the child, particularly if her egg was involved? These are not just hypothetical questions.

There is no law that ensures the commissioning parents will adopt the commissioned baby. Just as a surrogate can keep the baby, so a commissioning couple can refuse to raise a child born as a result of their arrangements. In 2010, a surrogate pregnancy in Canada resulted in a baby with Down syndrome. The commissioning parents requested an abortion. The surrogate mother refused. The commissioning parents insisted and eventually the child was aborted:

The case led to lively discussion in the Canadian media. “Should the rules of commerce apply to the creation of children? No, because children get hurt”, Juliet Guichon of the University of Calgary, said in the National Post. “It’s kind of like stopping the production line: ‘Oh, oh, there’s a flaw’. It makes sense in a production scenario, but in reproduction it’s a lot more problematic.”

On the other hand, a surrogacy broker, Sally Rhoads of Surrogacy In Canada Online, said that the parents needed to be protected. “The baby that’s being carried is their baby. It’s usually their genetic offspring”, she said. “Why should the intended parents be forced to raise a child they didn’t want? It’s not fair.”[100]

Clearly they didn’t want just any baby—only a perfect baby.

The issue of the surrogate mother’s consent is troubling. Giving up a child is not as easy as one might initially think. The experience of gestation and the hormonal changes in the surrogate mother can dramatically change her perspective of what is involved. If her motivation for volunteering to be a surrogate was the need for self-affirmation, are we happy for it to be achieved this way? It would be tragic if such a situation led to the vulnerable woman being open to coercion. Even more difficult may be the situation for a closely related woman who is pressured by her family to be the surrogate, against her will, for an infertile relative. If she decides she wants to keep the baby, most courts would decide in her favour. Intuitively, this feels right to me.

I can think of only one scenario where surrogacy may be the best choice ethically. This would be if a couple who had frozen embryos in storage suddenly found themselves unable to transfer their embryos because, for example, the wife developed an illness preventing a safe pregnancy, or needed to have her uterus removed. If a woman close to the family was happy to act as a surrogate in order to avoid the destruction of the frozen embryos, this would be preferable to either destroying the embryos or giving them away. Because of her relationship with the family involved, the surrogate could have an ongoing relationship with the child and thereby continue a parenting role of sorts. Meanwhile, the genetic parents would be able to raise their own child. This is not to say the scenario is free from problems, but it could help solve the dilemma for a couple who, through no fault of their own, found themselves with frozen embryos but no means to carry a pregnancy to term.

Two beautiful daughters were born to Julie and her husband before Julie was diagnosed with cancer. The surgery for cancer included removing her uterus; so they knew she could never have their last embryo transferred. We thought of the embryo as one of our children and just couldn’t let it die, but we weren’t happy with adopting it out and have someone else bring up our child. We were always planning to use all the embryos. It was such a blessing when my sister, who has a family of her own, offered to be our surrogate to give our embryo a chance at life.

If surrogacy is contemplated, it should be a last resort. It is important that all parties receive independent counselling regarding the physical, emotional and legal implications of the process. Fully informed consent on the part of the surrogate would require her to be at least 18 years old and the mother of at least one living child. Even so, she should be warned that it is hard to predict in advance how she will feel about giving away her child after a 9-month relationship.

Children need to be told about their origins “early and often”.[101] While a toddler may not understand the intricacies of sperm and egg, they will understand that there were two people who really, really wanted a baby, with perhaps a ‘tummy mummy’ thrown in there too.

Embryo adoption (donor embryos)

With the surplus of frozen embryos accumulating as a result of the policies discussed above, one of the options open to parents who find they have excess frozen embryos at the end of their treatment is to donate them to other couples for reproduction. This option is discussed from the point of view of donating in chapter 14. Here we consider the decision to accept a donated embryo.

Embryos intended for donation will generally stay frozen in the treatment clinic until a couple is identified as recipients. If the clinic does not offer embryo adoption, it may be necessary to store them in a clinic that does. At this stage, the donor parents pay the cryostorage fees. Once the embryos are transferred to the care of the recipients, the recipients take over payment for storage; they do not pay for the creation of the embryos, so this tends to be cheaper than IVF. The embryos are then thawed and transferred in the usual way.

Transfer of donated embryos is a relatively new phenomenon. The success rate depends on many factors, but one report assessed the success rate for frozen donor embryos at 27.3% live births per transfer, compared to 23.4% per transfer for frozen non-donor embryos.[102]

Benefits of pursuing embryo adoption include some advantages claimed for ART over adoption generally. The baby can be cared for from the beginnings of the pregnancy (unlike adoption, where the biological mother’s behaviour is beyond the control of the adoptive parents); and the couple can experience pregnancy, birth and breastfeeding.

Ethical issues

I believe embryo donation is ethical for Christians. This may surprise you. Why, when I am unenthusiastic about gamete donation and surrogacy, do I approve of embryo adoption? For two simple reasons: first, the ‘one flesh’ principle is not challenged unequally within the marriage, as both husband and wife are accepting another’s gametes instead of their own, so the jealousy factor is unlikely to be a problem. Second, they are making it possible for the embryos to have a chance at life they otherwise would not have had. A third reason is that it is good stewardship of resources such as time, money and energy, as the donor embryos have already been formed.

Cytoplasmic and germinal vesicle transfer

The main problem for older women trying to have a baby is that their fertility is reduced because their eggs are less healthy. Initially, it was thought that the eggs might become healthier and embryo development be improved if the mitochondrial function (energy production) in the cell was better. This led to the practice of cytoplasmic transfer, where some of the cytoplasm (the contents of the cell apart from the nucleus, consisting of fluid and everything it contains) is taken from a younger woman’s eggs and injected into the older woman’s eggs. Alternatively, the germinal vesicle (the nucleus in an immature egg) can be transplanted into a younger woman’s egg after the nucleus is removed.

Since 1998, more than 30 children have been born after the direct injection of cytoplasm from fresh, mature or immature, or cryopreserved and thawed, donor eggs into recipient eggs through a modified ICSI technique. It is not completely clear what benefit it gives, and there is no evidence that it improves the development or implantation of the embryos subsequently created. Nonetheless, it is astonishing how quickly cytoplasmic transfer in humans has been applied, especially given the lack of extensive research to evaluate the efficacy and the possible risks of the method.

Both of these techniques aim to combine the nucleus from the older woman’s egg (containing the DNA) with the cytoplasm of a younger woman’s egg (containing the mitochondria [energy]), to enable the older woman to have genetic offspring. An alternative use of the technology allows a woman with hereditary diseases of the mitochondria (mitochondrial myopathies) to have genetic offspring without passing on the genetic defects to her children. This is still an experimental technique, which has yet to prove its efficacy and safety. Therefore, researchers maintain that the indications for applying this technology in human clinical practice need to be clearly defined. Although there may be theoretical benefits, research into the potential side effects of these techniques must not be neglected. At present, in the absence of validation by proper cell culture experiments or detailed animal research, the application of such therapies in humans is difficult to justify.[103]

Ethical issues

Apart from the issues of using a technique that is not proven to be safe, this technique is troublesome because of the genetics involved. Although the main part of our genetic inheritance comes from the DNA in the nucleus, there is also DNA in the mitochondria. This means the offspring in this situation will have three genetic parents—one father (sperm nuclear DNA), and two mothers (egg nuclear DNA and egg mitochondrial DNA—mtDNA). Humans do not inherit mtDNA from the father, so this means that the ancestry of the offspring will be confused. While perhaps not an absolute reason for prohibition, evidence from ART offspring suggests that this may present a problem for the child. In my personal experience, the community in general is also uncomfortable with the thought of a child with three genetic parents.

Preimplantation genetic diagnosis (PGD)

Our understanding of human genetics has grown enormously in recent years,[105] and this has been associated with the identification of the genetic basis of many diseases. PGD has been available since 1990 to genetically screen embryos created through IVF, before transfer to the woman’s uterus.

Typically, the technique involves taking one or two cells from an 8-cell embryo, examining them under a microscope, and determining the genetic characteristics. While PGD of the egg alone has been performed (preconception genetic diagnosis), it is technically more difficult and less definitive than PGD of an embryo’s makeup and thus less common.

There is concern that PGD may cause damage to the embryo, though this has not been proven. It is not clear whether the removal of up to 25% of the embryo’s mass affects its development. Microarray comparative genomic hybridization (CGH) is a recent development that allows blastocysts to be genetically analysed. This causes less damage, but leaves little time for genetic analysis before the embryo must be transferred. This is not a problem in fertility centres that have the technology to facilitate rapid genetic screening (such as 24sure methodology, known as Advanced Embryo Selection), which allows the selection of chromosomally healthy embryos that are more likely to implant. In the past, biopsied embryos were more likely to be damaged by freezing and thawing, but with modern freezing techniques there is less concern.

Technically, each of the cells removed from the embryo for analysis has the potential to become an embryo, since the cells are still totipotent at the 6-8 cell stage (meaning that they still retain the ability to develop into a human individual). This is an argument against PGD itself—regardless of whether the initial embryo is damaged—which is used in countries such as Germany to prohibit the practice.

Currently, we can test for a lot more disorders than we can cure, so the only ‘treatment’ available if a disorder is detected is to discard the abnormal embryos and transfer the ones that are thought to be ‘normal’.

Supporters of PGD see it as an opportunity to remove abnormal genes from the community by screening the embryos of couples that carry serious genetic disorders. This allows them to have a healthy child without the ‘practical and ethical problems’ of experiencing the abortion of an affected child after traditional prenatal diagnosis (chorionic villus sampling and amniocentesis).[106]

After undergoing PGD, Sennia became pregnant after 13 years of trying. I was afraid to even think I could have a baby, and now I’m having twins! And they are beautiful boys. It can seem so cruel to criticize this technology. Robert Winston, the British doctor who first performed PGD, is not concerned that this technology will change humans significantly. Education, economics and the care of families makes people what they are, he said—the most important being human love. An orthodox Jew, Professor Winston does not believe embryos are truly human, but he does believe that the use of PGD by parents with a family history of genetic disease is simply “a matter for the individuals concerned”.[107]

PGD was first used to screen for serious life-threatening diseases; then it was used to screen for diseases that were treatable, or had their onset in adulthood, or were associated with risk of disease rather than a definite diagnosis. Now PGD is used in many places to choose the sex of the child, with completely normal embryos discarded because they were not the gender preferred by the parents. Chromosome abnormalities are found in over 50% of embryos examined. Some commentators have suggested that all ART pregnancies should be screened with PGD—at least for Down syndrome and cystic fibrosis—whether the parents have a history of genetic disease or not, in order to reduce the incidence of genetic abnormalities in the community.[108]

Ethical issues

It’s important to note that for PGD proponents, abortion is seen as an ethical problem while discarding embryos is not. I have seen PGD specifically recommended by fertility clinics as a way for Christians to avoid abortions. In fact, I have been accused of not caring about women having abortions when I have opposed PGD!

But this approach assumes that the human embryo is not a human person who deserves protection. Discarding an embryonic human because they do not have certain characteristics is discriminatory and not consistent with treating each human as one who is made in the image of God. Discarding abnormal embryos also risks increasing prejudice against the disabled in our community. Discarding embryos that are not completely normal but are expected to survive is different from discarding embryos that will definitely not develop (because they are dead). The latter is ethically appropriate and avoids unnecessary medical procedures for the woman.

As discussed earlier, consent is another ethical issue. Would the parents feel differently about the discarded (abnormal) embryos if no others were available? One would want to be convinced that the parents—at such an early stage of treatment when they will be extremely vulnerable and expecting treatment to be successful—were completely sure they had no further use for the abnormal embryos. Doubtless they will expect that one of the non-affected embryos will implant. Are the genetically affected embryos still considered ‘excess’ if the parents’ choice is between a genetically imperfect child and no child, rather than between an affected and a non-affected one?

Although some parents say they would like to screen so they can be prepared for whatever problems the baby may have, they should consider whether the risk to the embryo is worth satisfying their curiosity. I suspect it is not. One also needs to consider whether their resolve to have the child might be weakened if an abnormality were revealed. Or would they be pressured to change their minds?

Some limits must be put on what conditions can justify discarding embryonic humans. While clinical specialists such as Professor Winston say the decision is just a matter for the individuals concerned, we already have the recommendation for PGD to become routine in order to abolish the existence of a certain kind of human in our midst. What started as an expression of free choice could become an obligation if intolerance of imperfection becomes widespread.[109]

As the human genome project delivers more information, allowing the number of conditions we can test for to increase exponentially, we must decide as a community which humans we will continue to exclude from the human race on grounds of faulty genetics.

If embryos are screened for multiple conditions, we may find at times that all embryos created in one cycle have a fault of some sort. Will parents then need to choose which of several diseases they want to inflict on their offspring? (“Would you rather they have breast cancer or Parkinson’s disease?”) Will they be encouraged to go through another cycle of IVF and try again? How many times can they try again? How will their offspring feel about it?

The use of PGD for the purpose of discarding certain embryos is unethical for those who wish to protect human life from its beginning.

Sperm sorting

Sperm sorting is a technique used to select specific sperm for use in fertilization. It can sort out which sperm are the healthiest, and it can determine more specific traits, such as which sperm are X- (female) and Y- (male) chromosome bearing. The resultant ‘sex-sorted’ sperm can then be used in conjunction with other ART methods, such as IUI, IVF and ICSI, to produce a child of the desired gender. It is not 100% accurate. It remains in the ‘experimental’ category and has limited availability.[110]

Ethical issues

Since sperm is not equivalent to an embryo in moral significance, there is no problem with using sperm sorting to identify healthy sperm. With regard to gender selection, it is preferable to PGD in that the choice is made prior to conception, so no embryos are discarded. One concern with any technology that aims to produce specific characteristics in the offspring is that there may be psychological implications for both the parents and the child if the procedure does not produce a child of the desired gender. Furthermore, problems may also arise if the gender-related expectations of the parents are not subsequently fulfilled by the child. (What if the rugby-playing boy you were hoping for decides to take up ballet?) The Bible expects parental love to be unconditional, and unmet expectations will make this harder. This concern is not a reason to avoid using sperm sorting, so much as a reason to consider carefully the motivation for its use.

Issues of access: who should use ART?

In most jurisdictions there is no limit on who has access to ART—not even infertility is a prerequisite—and the desire for a genetically linked child continues to drive an increasingly wide range of treatments.

So I am concerned about the reduction in efforts to take the welfare of ART offspring into account where decisions about access are concerned. First, the issue of child safety: does the adult have a history of child abuse or psychotic disease? Should this at least be checked at the outset? Opponents point out that normal parents aren’t screened, so why should we screen ART parents? I would say that if we are using public funds to subsidize ART then we have an obligation to make sure basic standards are met. And I am not interested in the idea that the government should have no say in reproduction; it has always had a say in issues of reproduction, prohibiting incest, rape in marriage and paedophilia, for instance.

At one time, many legislatures included the child’s need to have a father in regulations for ART, but this is gradually being removed as single women and lesbian couples access these services. However, in the biblical model of family, a child ideally has one parent of each gender.

Further discussion on the topic of access to ART in general is beyond the scope of this book.

Older parents

In 1994, Italian fertility researcher Severino Antinori helped a 63-year-old woman get pregnant through IVF. Newspaper commentary was vigorous. But that was before two 70-year-old women delivered children following treatment in 2008. When asked whether this was prudent, considering they had one foot in the grave (I didn’t ask the question!), one of the fathers said cheerfully, “Oh, that won’t be any trouble. We have a large family and there will be plenty of helpers”.[111]

Commercial companies are popping up all over the place to take advantage of older couples wanting a family. They are in it for profit. Christy Jones, an entrepreneur who was setting up her egg-freezing network Extend Fertility in 2004, was asked at the time what would happen if a woman wanted to have children at the age of, say, 82. She said, “My aim is to be the enabler and not the one guiding the ethics”. Her market is primarily those women who are not ready to have children in their twenties or early thirties. “I am part of a generation of women who have been told we can have it all. The only thing that is holding us back is our biological clock. Egg freezing is the missing link. Many have described it as the most revolutionary and empowering science since the birth-control pill.” She was confident of success: “Really, it just gives women the opportunity to have a child. It’s hard to argue with.”

I think she’s right there. While it is likely that Ms Jones had professional women more in mind than geriatrics, it is interesting to consider whether it is ethically appropriate for an older Christian couple to use ART, using their own cryopreserved gametes.

The most common objections to older parents that I hear centre on the notion of what is in the best interests of the child involved. What are the risks involved in having a parent who is older than the norm? Obviously, the possibility of the parent dying while the child is growing up is increased. Yet the likelihood of this event occurring would be so difficult to predict, on average, that it seems a risky basis for judgement. Would we extend the same restriction to a younger parent with a strong family history of heart disease? It would also be difficult to establish that the loss of a parent is such a disaster that the life of the child is unjustifiable.

What about energy levels? Four-hourly night feeds are a struggle for many young parents and a parent taking up backyard cricket in their mid-sixties may flounder in the outfield. Yet we do not screen younger parents for their athletic capabilities. And older fathers, often the parent more interested in outdoor sports, have been the norm in many cultures for centuries. It soon becomes apparent that in fact opposition is not to older parents, so much as to older mothers.

Are there any advantages to being an older parent? In terms of the last criticism, one should remember that the older parent is more likely to be financially secure than their younger counterpart. If the 4-hourly feeds are too much, they could hire a nurse, and employing similar strategies as the child grows would mean they could save their energy for more sedentary occupations. In fact, the older parent is more likely to have ‘quality’ and ‘quantity’ time with their child, as they would be less likely to be obliged to spend long hours at work establishing their career.

I have heard it said that it is selfish for a couple to have a child later in life—but why do any of us have children? Would you say that carrying on the family name, or having someone around to care for you, or fulfilling an overwhelming biological urge, were less selfish reasons?

If what is at stake is access to the artificial reproductive therapies that make postmenopausal child-bearing possible, the arguments above would make it difficult to justify exclusion on grounds of justice, when similar grounds for exclusion are not applied to younger mothers with similar impediments. However, the misgivings can remain.

Could it be that we are ambivalent about this issue because in our hearts we know the value of family relationships and the joy they can bring, and we hesitate to deny them to others? Yet when we think of a woman in her sixties or seventies, we imagine not a new mother, but a grandmother. In this instance, ART is not treating a disease but a normal stage of female life—menopause. Our increasing technological control over natural life processes has allowed us as a society to blur the lines between the once-inevitable ‘seasons of life’. Our objection to the older mother is not that allowing access to ART would be wrong so much as that it might not be wise. Traditionally, the seasons of life have matched our physical capabilities with our life changes. Now we have the technology to overrule these seasons. I would like to see an open community discussion about whether we want to do this.

Post-mortem gamete collection

A 34-year old man is brought into emergency after a traffic accident where he sustained a fatal head injury. He dies soon after arrival at the hospital. When police contact his wife to notify her of the death, she requests that sperm be extracted from her husband as they had been trying to have a baby.[112]

Dianne Blood conceived her two sons using sperm taken from her husband, Stephen, shortly before he died from meningitis. She battled the British government, first to use the sperm, and then to have Stephen’s name recorded on the boys’ birth certificates as their father.[113]

In 2011, an Israeli court allowed parents to harvest eggs from their dead 17-year-old daughter. They then wanted the eggs to be fertilized with sperm from a dead donor. The second request was denied, but had it proceeded, any child born would have had parents who were dead before the child was conceived.[114]

Legal issues

Laws concerning the collection of gametes (sperm or eggs) after, or around, death will differ between jurisdictions, but generally they cover the issues of consent to collection and regulation of use. Usually the donor will have had to give clear consent to the use of their gametes after death. Written consent is preferable in order to remove ambiguity about the deceased’s wishes and to help a child deal with the circumstances under which they were born.[115]

In May 2012, the United States Supreme Court ruled that children conceived through IVF after the death of a parent were not automatically eligible for Social Security survivor benefits.[116]

Ethical issues

The biblical model for family is that a child has a male and a female parent. While children do grow up with only one parent because tragedy takes the other away, this is not the same as deliberately creating a child who can never know one of their parents. Apart from issues regarding consent, this is another situation that may not be wise, although it can’t be described as definitely morally wrong.

If, on the other hand, there were frozen embryos in storage, following that person’s death it would be ethical to transfer these embryos. This is because the fact that the embryos have been formed proves beyond doubt that the parent intended to have the children, so there are no doubts about consent. Also, it is ethically correct to protect the lives that have already been created.

Safety for ART offspring

Although the majority of ART children are normal, there are concerns about the increased risk of adverse pregnancy outcomes. More than 30% of ART pregnancies are twins, triplets or greater gestation, which means they will be at greater risk of prematurity, with all the consequent complications. We have already discussed the role of single-embryo transfers in reducing this statistic. But even single ART pregnancies demonstrate increased rates of perinatal complications—small for gestational age infants, prematurity and stillbirth, as well as maternal complications such as preeclampsia, gestational diabetes, placenta praevia, placental abruption and caesarean delivery—when compared to non-assisted pregnancies.[117]

Research also shows that children born following ART treatment are at increased risk of birth defects compared to spontaneously conceived infants.[118]

In addition, problems particularly associated with ICSI include urogenital malformations such as hypospadias (where the opening of the urethra is on the underside, rather than at the end, of the penis), genetic (imprinting) disorders—although these disorders remain extremely rare—and male infertility.[120]

It is not clear whether these abnormalities result from ART procedures themselves or if they are associated with the underlying infertility for which ART is sought. Whatever the cause, those considering ART should be aware of the risks.

Further risks

We have looked at an enormous amount of information in this chapter as we have considered the rights and wrongs of various procedures. However, even when ART is ethically permissible, it may not be right for every Christian couple that considers it. While thinking about whether it is the right choice for a marriage, the following should be considered:

1. ART involves physical risks, especially for the woman. The risk of side effects from the drugs used to stimulate ovulation is not fully understood. Also, invasive procedures have inherent risks, and increased risks are associated with any ART pregnancy.
2. ART is emotionally traumatic for all couples. A cycle develops where the transfer of an embryo is followed by a period of intense anxiety as they wait to see if the embryo will ‘take’. Every time menstruation recurs, it takes those involved down an emotional rollercoaster of disappointment before they build themselves up to try again. Bess remembers: The uncertainty of IVF is awful. You desperately want to have a baby, you see the embryo under a microscope before it is transferred and you pray that it will ‘stick’. When you get the phone call to tell you that you’re not pregnant, no matter how much you have tried to not have high hopes, you are devastated. It is hard to hold it together. Your family is disappointed for you as well. Fortunately my husband was strong for us and helped me hold it together. We were third time lucky getting our first daughter—we knew she was a miracle. With only two embryos left we didn’t expect to have another child, but God was amazingly generous and blessed us on our lucky last embryo with our second daughter. Even now, I feel quite emotional reminiscing on the experience more than four years ago.
3. ART is time-consuming and distracting. The investigations, the visits to the clinic and the distraction of putting life on hold while trying to grow a family are unavoidable. Those in a Christian marriage need to consider if it is God’s will for them. Geordie and Pam recall, From the start, we were very aware of how all-consuming trying to conceive could be. So early on, we prayed and tried to prioritize contentment in God rather than being consumed with getting children at all costs. Initially IVF was off the cards for that reason—I didn’t think I could hold it together—being content whether God gave us children or no children, at the same time as making children.
4. ART is expensive. Financial costs quickly run into thousands of dollars and not all therapies are covered by insurance: Financially IVF was out of the question for us for a long time, as we were students. Even now, we’d struggle if we wanted to, said Billie. Paying for IUI hasn’t been a huge stress—I just take a deep breath, hand over my card and then try and forget that another $1800 is spent this month! According to the American Society of Reproductive Medicine, the average cost for an IVF cycle in the United States is about $12,400. It’s also possible to calculate how much it costs to get a baby: in Australia, the cost of an IVF baby to a woman aged 30-33 years is $27,000. The cost to women aged 42-45 years is $131,000.[121] I am now hearing stories of couples finding themselves with excess embryos because they can’t afford to have them transferred.

The clinical aspect of ART can be a source of tension—it is a dehumanizing experience for many people, in what should be an intimate and pleasurable process. Think of the collection of sperm into plastic cups and repeated hormone injections.

The difficulties of negotiating the ART process are obviously stressful for any marriage, and not all marriages survive. Knowing where to get support can be difficult. Counsellors suggest it is unlikely that couples will be able to adequately support each other, given that they are both trying to cope. It is prudent to think about sources of support before starting.

And in your deliberations you should also consider that you might want to avoid some morally troubling options. Will your doctor help you do this?

What questions should a Christian couple ask before starting ART?

Here are some important questions a Christian couple should think through before beginning a course of ART:

1. What is involved? (Get the facts.)
2. Will the specialist respect your theological views?
3. Will the number of embryos created be limited (this number should not be higher than the number of children you are willing to have), and can they all be transferred regardless of appearance?
4. What is the cost and can you afford it?
5. How important is it to you to have a biological child?

Cowboys

Some initiatives by specialists in the ART arena have not been acceptable, even to their ART colleagues—for example, the French brother and sister who had a child together by a surrogate in California;[122] the British IVF specialist who faked embryo transfers;[123] and the American physician who transferred 12 embryos at once, an action that resulted in the birth of octuplets.[124] Then there are the accidental transfers of the wrong embryos to the wrong women. Fertility clinic accidents are often in the news, but overall such events are uncommon. They should not make you disregard ART so much as use your judgement in choosing a clinic.

However, as a society, the fact that these events occur at all should make us pause and consider whether we need to start placing limits on these technologies. Perhaps the most bizarre story I have read came from a paper published in 2006.[125] A 55-year-old Russian woman used IVF surrogacy to have a baby using her dead son’s sperm with donated eggs. In the absence of any identified live parent the courts declared that the child did not exist, and refused to issue a birth certificate.[126]

Moving on

Sometimes, through all the technology, God allows a child to be born. This is absolutely wonderful when it happens. But be aware that the success rate of ART is variable. Not everyone gets to take a baby home.

Sometimes, even when every morally permissible technique is tried over and over again, no pregnancy develops. Deciding to stop treatment is a very difficult issue.

It can be helpful to have a frank talk with your doctor about what has been happening in the ART process. If the feedback is that you have very little chance of becoming pregnant, it may be time to stop. As a woman, you may be checked for your blood anti-Müllerian hormone (AMH) levels, which can give some indication of how much ovarian reserve is left. Take into consideration your chances of conceiving, given how many attempts you have made. These days, most women under 37 years should become pregnant within 3 cycles, though many doctors would suggest that trying 6 times is reasonable. Also consider how you are going: how is your mental, physical, emotional and spiritual health, and how is the state of your marriage? What is the cost? Is it worth continuing?[127]

You may have been meticulous about obeying God’s word every step of the way, and in the end he may still withhold the gift of a child. It can be heartbreaking. Hilda said, In the end we planted a tree, to remember all the children we never had. It was so sad. But it helped me move on.