I remember the first time I publicly suggested that there was no ethical obligation for infertile couples to use assisted reproductive technology (ART) to have children. After my talk there was a line of women waiting to thank me.

ART is held up as a benevolent technology that compassionately allows couples their final opportunity to obtain their deeply desired biological child. It is still publicly considered to be the source of eternal fertility for women, many of whom keep ignoring their ‘biological clocks’ despite the warnings from IVF doctors themselves that the treatments become less successful as age increases. Many people continue to access treatment despite the obvious hardships involved.

As I have discussed in chapter 6, the creation mandate to “be fruitful and multiply” is not a command for each couple to have the maximum number of children possible. There is no moral obligation or imperative to use every possible means to have as many children as one can.

However, because the desire for children is so strong for so many couples, ART becomes an obvious next step. Some women talk about the ‘merry-go-round’ they can’t get off, ART being the inevitable step following tests for infertility, without any question of whether it is right or wrong for them and their husbands. Rachel commented, There are lots of groups to help you get started with ART, but who helps you say ‘no’?

Some couples do say no, for a range of reasons. In this chapter I want to cover some of these reasons, if for no other reason than the fact that for most couples on the ‘merry-go-round’, the reasons not to pursue ART will rarely be mentioned or discussed.

1. Poor success rates

The first and perhaps most obvious reason to think twice about ART is its failure rate. We often hear of the successes, but IVF failure is relatively invisible in public representations. I look at the advertisements for IVF clinics on my desk: gorgeous babies, happy (young) women with gloriously pregnant tummies, lots of pastel artwork. The truth, however, is that it fails more often than it succeeds. While ART has helped many couples, there are many more in its history that have not benefited from treatment and have suffered physically, emotionally and financially without taking the longed-for baby home. Even now, over 30 years since the first ‘test tube’ baby was born, the overall success rate per cycle is under 25%,[1] with cumulative live birth rate around 50%.[2] Cumulative live birth rate reflects the delivery of ≥ 1 live infants in ≤ 6 cycles. It does not count those who have dropped out. So the overall chance of success is actually less than 50%.

2. Costs of treatment

Despite its social acceptability, not everyone is comfortable with the process of ART. Among the couples I have spoken to, concerns about treatment included the lack of adequate counselling before treatment started and after it failed; stress on the marriage relationship, which peaked every time an embryo was transferred and the pregnancy test awaited; and feelings of personal guilt when treatment failed. Joe and Vanessa were given the consent forms to sign while in the waiting room, before they even saw the doctor. They proceeded despite their ignorance of what lay ahead. They admit now: We would have done anything to get a child at that point. Their lack of information caused them ethical trouble further down the track.

ART is very costly in terms of time, money, resources and energy. Many Christian couples have decided it is not the best use of the resources they have received to invest in years of ART treatment.

3. Theological objections

Theological opposition to ART has been expressed most publicly by the Roman Catholic Church. As previously explained, the Catholic position has been argued from the perspective of natural law.[3] According to their teaching, in keeping with how God designed us, all sexual relations in marriage should aim towards procreation as well as union (oneness in marriage). Both the procreative and unitive aspects of marital intercourse should be present in every conjugal act. Nothing is allowed that interferes with the natural process that results in conception of a child by the husband and wife.

The Catholic Church also teaches that technology should be used in keeping with the moral principles of natural law. The human embryo must be protected from the time of fertilization, and any process that results in its destruction is wrong. As husband and wife are to conceive children only with each other, the use of a third party (by gamete donation or surrogacy) is also prohibited. Anything that assists conception without replacing the conjugal act is allowed (such as fertility drugs to boost ovulation), but those things that do replace it (such as fertilization outside the woman’s body, or sperm collected by masturbation) are not allowed. Frozen eggs are excluded. No official position on embryo adoption has been issued, and theologians are divided on this subject.

In summary, according to Roman Catholic teaching, sex without procreation, and procreation without sex, are forbidden. These teachings were laid out in three Vatican documents: Humanae Vitae (1968), Donum Vitae (1987), and Dignitas Personae (2008).[4]

As already discussed, not all of the Catholic Church’s objections to ART are valid, particularly those that stem from a natural law approach to ethics.[5] However, Protestant theology would certainly agree that the human embryo should be protected from the time of fertilization.

4. Effect on population

Some commentators question the wisdom of ‘creating’ new babies in an overpopulated world. When there are so many orphans around the world needing adoption, why go to such lengths to create more children? They suggest that adoption rates will fall if reproductive technology is used instead.[6]

However, others are concerned that ART will actually reduce birth rates, at least in the West, because it leads many women to delay childbearing, assuming (mistakenly) that ART can overcome fading fertility at any age.

5. Social prejudice

Liberal feminists argue that any woman should be able to use ART if she wants to, since it harms no-one else.[7] This is part of the pro-choice stance that wants a guarantee of ‘reproductive rights’ for all women. It is claimed that the right to choose if and when to have a child is as important for the infertile woman as it is for the woman with an unwanted pregnancy.[8]

Infertility can certainly be personally devastating, with an enormous impact on our sense of self. But there is conjecture over whether this is due to individual judgement or to a social construct. Susan Sherwin thinks that the emphasis on ART as a solution to infertility has weakened the case for other options. It is part of the trend in our society towards offering a technological fix for problems that are actually interpersonal and social.[9]

It is also worth asking what it is about an ART child that makes it ‘a child of your own’. Brent Waters suggests that it can’t be a genetic connection, if donated sperm and eggs are used. It isn’t connected to actually carrying a child, if surrogates are used. Is it more about being in control and being able to produce offspring that meets your specifications? Waters defines a parent as “one asserting the will to obtain a child”.[10] This is far from the biblical idea of children as gifts from God.

Other writers also have concerns that there is a stigma in society against childless people, and contempt for infertile women. Renate Klein comments:

As long as ‘childless’ is seen by society at large as ‘deficient’ and ‘abnormal’, reproductive medicine and science will profit—in fact live off—the steady stream of women who have been made to believe that they must put themselves through the treadmill of baby-making, the roller coaster of exciting hopes and shattered illusions.[11]

Karen Throsby explains her concern that ART is seen in our culture as a “seductive image of benign, rational, efficient science giving imperfect nature a helping hand”.[12] Consider the advertisements of doctors in white coats, of gleaming laboratories, of smiling parents holding their ‘miracle’ baby in the background. She notes that these pictures of trustworthy professionals make us stop worrying about “meddling with nature”, and make ART seem normal, mainstream and unproblematic. This leads to a process of “technological creep”, where any concerns we might have about, say, IVF are made to seem unimportant by comparison with more radical and troubling technology—such as preimplantation genetic diagnosis (PGD), designer babies, stem cells and therapeutic cloning.

The normalization of IVF makes it seem as if we are obliged to use it, implying that those who do not have treatment are unnatural and abnormal. This normalization of IVF also makes it harder to have public conversations about the potential risks for women in relation to treatment. It also tends to minimize the significant social, financial and emotional costs of treatment, particularly when it is unsuccessful.[13]

A similar point has been made by Israeli feminists who are concerned at the development of widespread surrogacy programs:

It is our belief that perceiving pregnancy and childbirth for another couple or individual solely as a financial business transaction is inappropriate and unthinkable. The fact that surrogacy is a complex relationship which might be fertile ground for harm and exploitation must be recognized, especially when private organizations with financial interests are allowed to become involved. We believe, that surrogacy in Israel should be prohibited. In the least, surrogacy must not be allowed to becomes [sic] an accepted, routine procedure, and should provide a solution only in rare, very extreme cases…

Surrogacy is an experimental procedure with great potential for harm, especially if it will become prevalent and accepted. The distance between heroically presenting a unique human gift to a childless couple and time spent on a ‘fertility farm’, which uses human machines, is not large, and the ability to preserve this distance will diminish as surrogacy becomes more widespread and routine.[14]

Perhaps there is a new category of childlessness now, which is more acceptable— so long as you are willing to confess that you tried, and failed, ART.

6. Risks of treatment

Some risks of ART are well known. For example, it is established that multiple pregnancy is more common in ART pregnancies, pregnancy loss is more common, and children born following ART are at increased risk of birth defects compared with spontaneous conceptions.[15]

However, there are other risks that are suspected but currently unclear. For example, the long-term side effects of ovulatory stimulation drugs are unknown.[16] Risks of a different sort exist when experimental treatments are introduced to clinical practice too quickly. ICSI (intracytoplasmic sperm injection) was introduced without proper validation and now, years later, we are finding that there is an increased genetic abnormality rate in offspring.[17]

7. Embryo destruction

Some commentators are concerned about the morality of ART as an industry. They suggest that there is a problem of complicity (cooperation with evil) if we make use of ART, even if we do so without the destruction of our own embryos. This is because the destruction of embryos will always be implicit in the process itself, and by engaging with ART, we are implying that we accept the underlying assumption—namely, that destruction of human embryos is acceptable in the pursuit of a child of one’s own.

Let’s go back to the beginning: IVF was developed in England by scientist Robert Edwards, who started work in the 1950s. Gynaecologist Dr Patrick Steptoe later assisted him.[18] Edwards performed IVF on 1200 women before any studies were reported on primates.[19] (It is traditional in medicine to do the animal studies first to reduce the use of human subjects.) Edwards wrote:

…[eggs] and embryos were grown during early… investigations without the intention of replacing them in the uterus…

This preliminary period is by no means completed, even in hospitals and clinics where many pregnancies have already been established by IVF. Improved methods are needed to assess the normality of growth of the embryos, and to sustain or monitor their development without impairing the development of those which are to be replaced in the mother.[20]

Edwards is saying here that non-clinical embryo research is necessarily part of the process. Those working in the field have always wanted to improve outcomes for their infertile patients, so they have continued to search for improvements in treatment, thus requiring more embryos on which to test new techniques and develop new procedures. The motive is good; the question is whether the end can justify the means, when the means is experimentation upon and destruction of large numbers of human embryos.

Bioethicist Wesley Smith has reflected insightfully on the development of the ART industry in the United States:

Supporters of unregulated IVF promised us that the technology would be limited to married couples who could not otherwise have children. Those who raised concerns about the consequences and potential societal costs of removing reproduction from intimacy and placing it literally into the hands of laboratory technicians were castigated as alarmists—people whose fears were disproportionate to the very limited changes in reproduction that IVF would bring. The syndicated columnist Ellen Goodman put it this way in a column called ‘Making Babies’, published in the Austin American Statesman on January 17, 1980:

A fear of many protesting the opening of this [the first IVF] clinic is that doctors there will fertilize myriad eggs and discard the ‘extras’ and the abnormal, as if they were no more meaningful than a dish of caviar. But this fear seems largely unwarranted… We have put researchers on notice that we no longer accept every breakthrough and every advance as an unqualified good. Now we have to watch the development of this technology—willing to see it grow in the right direction and ready to say no.

It has been 31 years since Goodman wrote those words and we haven’t said no yet.[21]

Earlier in his article, Smith says:

The baby manufacturing industry also has an aggressive political lobbying arm, ever on the ready to castigate those who question the wisdom of the current laissez faire system as being cruelly insensitive to the pain of barren families. No wonder cowardly American politicians have yet to muster the true grit to enact even modest regulations.

The argument is this: the practice of ART necessarily requires an ongoing supply of embryos to facilitate further technological development, such as improvement of culture media, training of ART staff, and quality control in laboratories. If we really believe we should protect human life from the time of fertilization, should we cooperate with an industry that normalizes embryo destruction?

Many Christian writers approve ART so long as embryo wastage in minimized.

8. ART errors

The ever-growing incidence of treatment errors within ART clinics is considered by some to be a reason for avoiding it entirely. As mentioned in the previous chapter, we might view this as a reason for more careful selection of a provider, as is the case for any medical intervention, rather than a reason to avoid ART entirely. Everyone makes mistakes, and even ART has its share of negligent providers. However, most errors do not have a happy ending, and the embryo may not be the only one to suffer. Consider just a few examples:

• A Northern Ireland family sued their IVF service for using the wrong sperm, which resulted in their children being born with darker skin than expected. They had requested a white sperm donor, and the technician who retrieved the sperm had misunderstood the label ‘Caucasian (Cape Coloured)’. ‘Cape Coloured’ refers to South Africans of mixed race.[22]
• A Singaporean Chinese woman and a Caucasian man discovered that their IVF baby had a different blood type from either of them. On genetic testing, they found that the baby shared the mother’s DNA, but not the father’s.[23]
• An Australian couple sued their IVF clinic for their son’s medical expenses (for life) and compensation for their emotional pain, after finding that their child carried an inherited gene for cancer. They had used preimplantation genetic diagnosis to screen out a cancer gene carried by the mother, and insisted that they would have adopted a child if they had not been promised a disease-free child by the clinic.[24]
• Then there is the couple that returned to their IVF clinic to have further treatment only to find their embryos gone, probably because they had been implanted in someone else.[25]

Often when a couple finds out they have been implanted with the ‘wrong’ embryo, they have an abortion. Not all do, however. A Christian couple in the United States who were accidentally impregnated with the wrong embryo decided against abortion, and generously gave the child to its biological parents with no strings attached.[26]

~

Whether you should make use of ART is a decision you and your spouse will need to make together, but do not feel there is an obligation at any level to do so if you have any doubts. This is not ‘just a medical decision’. This is a moral decision, and God claims all of our lives for his service (Deut 10:12).

It’s not just the embryos destroyed in IVF research or IVF accidents that concern Christians—what about all the ones still left in the freezer? Dealing with the leftovers is an ongoing dilemma discussed in the next chapter.