They are the words you never want to hear. During your ultrasound, the sonographer or doctor looks up at you with a worried expression and says, “I think there may be something wrong”. Or as your child is finally born and you reach for your baby, you notice that the midwife looks worried. Faye says, By the time they told me, I knew something was wrong. When he looked at me and said he was so sorry, I just started crying. I couldn’t even tell (my husband on the phone) what was wrong. I couldn’t even think. I didn’t know what to do. When your baby is found to have an abnormality, everything changes.

Parents experience many feelings at such a time. There will be shock and bewilderment, and many feel guilty because they feel they are in some way responsible for what has happened. Some are angry because it seems so unfair. Others are ashamed that there is something wrong with their child, and do not want anyone to know. And so there may be silence, stigma and taboos that mean they can’t even talk about it. Inevitably, there is unbelievable sadness.

During one of my pregnancies I was told that our baby might develop some problems, and it was recommended that I have an abortion. My doctor knew me well enough not to spend a whole lot of time on it, but all of a sudden our lives seemed out of our control. At no time did my husband and I consider abortion, but boy, did we pray! We prayed that God would give us the strength to cope with whatever happened, but we also prayed for a healthy baby. All parents have expectations and hopes for their children and it is difficult when these are threatened. I have never been so aware of God’s sovereignty as during that pregnancy.

Birth defects are a major cause of suffering and death in young children, causing significant emotional and financial cost for the families involved. With the advent of widespread prenatal screening for congenital abnormalities, more parents than ever are finding themselves in the unbearable situation of hearing that there is something wrong with their child and there is no treatment available to fix it, not even in this modern day and age. As I found out, the medical recommendation for an unborn child who has something wrong can often be to terminate the pregnancy.

But do we have to? Are there options? How should Christians respond when they discover their child has a disability? In his experience, neonatologist John Wyatt has discovered that in an abnormal pregnancy there is nearly always an alternative better than abortion.[1] Another neonatologist, John Whitehall, in his experience has found two factors that compound the misery for patients who proceed to abortion. First, the abnormality in the baby often seems worse in the mind than to the eye; second, the burden of guilt and grief in the mind from the abortion may be heavier than bearing the disability in the child.

Whitehall recalls:

It is terrible to watch people concluding that a lesion in the unborn baby is too great to bear, then to witness them bonding with a corpse not nearly as disfigured as imagined and later to hear of repeated visits to the social workers. To one poor mother, the cleft lip turned out to be insignificant in the overall beauty of the now lifeless face. That baby was dressed and undressed almost daily (a little suit of blue, as I recall)… For months, the mother rang the hospital seeking reassurance.[2]

Grief can return to parents on birthdays and upon catching sight of a child living with the condition for which theirs was terminated.

How can we help those who find themselves confronted with a diagnosis of fetal abnormality? How can we help them avoid this aching regret?

I think there are two areas that need to be addressed: what are the biblical principles that help us think about disability, and what are the practical things that help? In this chapter, I will explore these questions and also look at our response as a society to the disabled who live among us.

Theology

How can it happen that an almighty and loving God allows an unborn baby to develop an abnormality? Is it an accident? Are the parents being punished? The Bible teaches us that God reigns in the universe and that his will is the final cause of all things. The chance that a pregnancy will end in miscarriage is 1 in 4; the chance of a baby being born with an abnormality of some kind is 1 in 30; and the chance of a baby being born with a serious physical or intellectual handicap is 1 in 50.[3] How can this be? Can God allow this to happen?

Yes, he can: “I form light and create darkness, I make well-being and create calamity, I am the Lord, who does all these things” (Isa 45:7). Furthermore, although we are still made in the image of God, this image has been corrupted through the Fall and now we all live in a broken world where bad things happen, people get sick, and ultimately, we all die. We groan along with the creation as we long for a new and liberated creation (Rom 8:22-23). Yet the Lord remains sovereign.

In our study of Psalm 139 (in chapter 3), we have seen how carefully God makes us. He doesn’t make mistakes. When Moses tried to get out of speaking to Pharaoh, and he told God he did not have the skill, God replied, “Who has made man’s mouth? Who makes him mute, or deaf, or seeing, or blind? Is it not I, the Lord?” (Exod 4:11). This is unexpected. You get the feeling that you may be looking at the issue of disability the wrong way.

Old Testament scholar Kirk Patston has had personal and professional experience of disability. He wrote an insightful passage about a Creator who allows the inexplicable to appear in this world:

When the Lord addressed Job he… spoke of his rights and powers as Creator, urging Job to think about the wild and wonderfully diverse world he created. The world includes creatures like ostriches, of whom the Lord says:

She lays her eggs on the ground

and lets them warm in the sand,

unmindful that a foot may crush them,

that some wild animal may trample them.

She treats her young harshly,

As if they were not hers;

She cares not that her labour was in vain,

For God did not endow her with wisdom

Or give her a share of good sense.

Yet when she spreads her feathers to run,

She laughs at horse and rider. (Job 39:14-18)

In this passage and the ones that surround it, God seems to be delighting in his own capacity to create diversity, even if it seems inefficient or puzzling from a human point of view. I find this liberating when I want to see disability as an unfair tragedy or to see my children or myself as victims in a random, cruel game. There is One who stands behind disability who knows what he is doing.[4]

He adds that when it comes to being wise, we are all disabled.

We can find this hard to accept because we are so conditioned by our society that it is difficult to truly believe disability is meant to be part of this world. We are used to having what we want, when we want it. No-one plans to have a disabled baby. How do we adjust to this unexpected news? How can we find the faith to hold on to our God?

Sarah Williams, who was told that her unborn child would probably die at birth, refused an abortion but then pondered with her husband how they could cope with the remainder of a difficult pregnancy and then watch their daughter die. Principles, however sound they might be, were simply not enough to give us the capacity to go on. They stopped short, leaving a great wide chasm of pain. She believes that God himself spoke to her in her distress: Here is a sick and dying child. Will you love it for me and care for it until it dies?[5] It is only through God’s grace that such sacrifice is possible.

It can help to go back to basics and consider the suffering Saviour hanging from a cross:

…a man of sorrows, and acquainted with grief…

he was pierced for our transgressions;

he was crushed for our iniquities;

upon him was the chastisement that brought us peace,

and with his wounds we are healed. (Isa 53:3, 5)

But remembering Jesus does not mean that we will not grieve our losses. Sometimes all we can say is, “I believe; help my unbelief!” (Mark 9:24).

In the Old Testament, deformed humans were not permitted to present sacrifices to God (Lev 21:17-23), and deformed animals were not to be sacrificed (Lev 22:18-25). Patston notes that, since the sacrificial system was concerned with sin and atonement, this practice set up an implicit connection between disability and sin.[6] Furthermore, when the prophets wished to condemn behaviour, they often used ‘disability rhetoric’, imagining the audience as blind and deaf (e.g. Isa 42:18-20, 43:8), thus further reinforcing the link between sin and disability.[7]

Of course, Jesus has replaced the sacrificial system with his own sinless death in our place. During his life on earth, he broke the Mosaic taboos regarding the treatment of the ‘other’, for example by touching lepers (Matt 8:3) and the dead (Matt 9:25). Furthermore, he denied the close link between sin and disability when he healed a man born blind (John 9:1-7) and, in fact, specifically included the disabled in his vision of the kingdom of God as a great banquet (Luke 14:21). It is interesting that he himself was depicted in prophecy as unattractive to men and carrying infirmity (Isa 53:2-4). God’s own divine power is made perfect in weakness (2 Cor 12:9).

This is the God who sacrificed himself on a cross to save us, who loved us and sent his Son as an atoning sacrifice for our sins. This is the God who loves us so much that he does not leave us as we are, but allows us to grow to maturity through suffering (Jas 1:2-4). How do you know you’ve had an encounter with God? Ask Jacob—you limp (Gen 32:24-31).

We have already discussed (in chapter 3) the doctrine of man made in the image of God (Gen 1:27). Man’s dignity is not based on his abilities or his characteristics, but is derived from the God in whose image he is made. In biblical thought, as each human life has unique dignity because of the divine image, so each life has an incalculable and incommensurable value. Each human being is an irreplaceable masterpiece of God’s creation. Each child is a gift of God to its parents. How can we say some are gifts while others should never be born? God does not make mistakes.

Furthermore, as the people of God, we are aware of a glorious future awaiting us after this life—so glorious that “the sufferings of this present time are not worth comparing with the glory that is to be revealed to us. For the creation waits with eager longing for the revealing of the sons of God” (Rom 8:18-19). In the new earth, there will be no more suffering (Rev 21:4).

Stanley Hauerwas questions why it is that we try so hard in this life to avoid suffering altogether. While not suggesting that every form of pain and suffering should be viewed as good, he considers what sort of people we should be:

…so that certain forms of suffering are not denied but accepted as part and parcel of our existence as moral agents. In viewing our life narrowly as a matter of purposes and accomplishments, we may miss our actual need for suffering, even apparently purposeless or actively destructive suffering. The issue is not whether retarded children can serve a human good, but whether we should be the kind of people, the kind of parents and community, that can receive, even welcome, them into our midst in a manner that allows them to flourish.[8]

He further suggests that “We rightly try to avoid unnecessary suffering, but it also seems that we are never quite what we should be until we recognize the necessity and inevitability of suffering in our lives”.[9] We live in a society where individuality and self-possession are valued. But are humans really like that? Hauerwas argues that the reason the disabled are so profoundly threatening to us is because not only do they seem to accept they are not self-sufficient, but also “they expose our own fear of weakness and dependence on others”.[10] In fact, the disabled offer us an opportunity to remember how dependent we really are on the suffering God of the cross.[11]

But this teaching may be too hard for parents at the time of diagnosis.

Support during a time of crisis

When parents learn that their child has a problem or is at risk of developmental impairment, they are thrown into turmoil. This is a paralyzing experience. During the period of indecision, those in the supporting role need to acknowledge that it’s really, really hard.

Jonathan Morris, a maternal-fetal medicine specialist who has counselled many parents in this situation, stresses that during this crisis, parents need time—time to talk, time to make decisions. Time is needed to adjust to the anxiety that every parent feels when their child is found to have something wrong with them. They need to deal with disappointed dreams—dreams each of us has as we (rightly) hope for the wellbeing of our children. Anger is not uncommon. Grief and waves of sadness can wash over them. Where there is a definite diagnosis, doctors can outline all the available options, but if the diagnosis is indefinite then it will be harder.

Parents also need information about their child’s situation. Wide consultation to get a variety of views is important. It works best if they can talk to someone with whom they already have a relationship. Annette says, I spoke to my doctors, but I wanted to talk about it to others too. I found it very difficult when people didn’t refer to it—it was the biggest single decision I had to make and as such I wanted interest and concern, whatever it was. I didn’t want it just to be ignored.

Parents need to spend time gathering information before making decisions. Medical input regarding the options is important. Often those who make the initial diagnosis have a limited understanding of the precise lifelong implications of that diagnosis. Parents need accurate information about what is known about the problem, what treatment options are available, and what can be expected throughout the pregnancy and after the birth. Such information can only be obtained from a wide range of medical and paramedical experts.

It is also important to put parents in touch with people who know what’s really involved in having a child with the same diagnosis—people who have had a similarly affected child and so have firsthand knowledge. This can be done through linkage with individuals or by contacting a patient support group. Talking it through with people who had experience of what was involved were the most valuable discussions, remembers Will.

Patient support groups can function face-to-face or online. Different resources will be available according to which disease is the focus, and where parents live. Parents may need assistance to know which disease organization is relevant to their child’s diagnosis; rarer diseases are generally under the umbrella of a more common but related disease. As well as giving social and emotional support, these organizations usually have information regarding what practical and financial resources are available in the community.[12]

It can be extremely liberating to talk to someone who has been in the same place and understands what it is like. Because of the prejudice against the disabled, some people just can’t even picture what life would look like with a disabled child in the family, and often are reassured by an opportunity to talk to a parent who is familiar with the lifestyle. Those who have had the experience often express their surprise at the joys involved. There’s no way I would ever want to change her, said Senator Sue Boyce of her daughter, who has Down syndrome. She regrets the increase in abortions for children with this genetic variation: It is my view that the world is a much poorer place without people with Down syndrome.[13]

A 2011 publication reported on 284 interviews with people affected by Down syndrome, conducted in order to collect information to pass on to expectant parents. The people with Down syndrome encouraged parents to love their babies with Down syndrome, mentioning that their own lives were good. They further encouraged healthcare professionals to value them, emphasizing that they share hopes and dreams similar to people without Down syndrome. Overall, the overwhelming majority of people with Down syndrome surveyed indicated they live happy and fulfilling lives.[14]

Even if life is hard for parents caring for a disabled child, it does not mean they regret the opportunity to have the experience. Susan Riggs’s son, Hugo, was born with Pelizaeus-Merzbacher disease, which left him severely physically and intellectually disabled. He was expected to die in early childhood. I believe these kids are sent to you for a reason, and a life’s a life whether it’s one trapped in a body like his or one that runs riot like his two sisters. Her husband, Ben, agrees: I don’t view Hugo as anything other than my first son and I’m very attached to him. Ben has spent many hours holding Hugo, preparing as best as he can for his son’s death.[15]

Research supports the benefits of making these links with those who have firsthand experience:

Surveys of women undergoing amniocentesis have shown that 62% say they would abort for sex-chromosome abnormalities, and 57% for blindness or paralysis of the legs. Yet only 20% of parents who have children with cystic fibrosis would consider abortion for CF. Clearly, having a personal relationship with an afflicted individual can summon up a host of nurturing instincts that do not come into play in a theoretical deliberation. It is interesting to note that these same parents of children with CF would be far more willing to abort for disorders they had no personal experience with. A similar pattern has been reported in parents of children with Down syndrome.[16]

Sometimes the parents need to be given the vocabulary to talk about what is happening. For example, what do you say to your other children? They will know something is wrong even if you say nothing. Be aware that they may feel responsible. Talk to them at their level of understanding, and listen to them to discover their questions. And again, how do you tell the mothers at school that your baby will die when it is born? How do you deal with all the well-wishers when you know your baby will not be normal? How do you cope with all the people who go quiet when they hear the news? Normally when a couple find they are having a baby, everyone is happy for them and congratulations pour in. When you have a disabled baby, no-one calls.

Support services are often attached to hospital units and may be able to provide support and counselling during this stage. It is very important that anyone involved with counselling does not put pressure on the couple either to keep or abort the baby. The parents are the ones who will have to live with this decision, and they have to know why they made the choice they did. Don and his partner found out that their baby had a problem that meant that she would die at birth. They were offered an abortion. It is undoubtedly the most difficult thing and decision I have ever made in my life, the reason being that I could not see any clear-cut right or wrong, and it was really only the two of us who could make the decision. Giving the parents time limits is a form of coercion that should be avoided. Even though many people aim to have an abortion before the point at which the baby’s birth and death needs to be recorded (often 20 weeks, though it depends on where you are), it is more important to make sure you make the right decision than try to meet any deadlines. This is an important decision and there is no rush. It’s a matter of life or death.

Choices

The options for the parents to consider are whether they will:

• abort the baby
• continue the pregnancy and prepare to take care of the baby
• look into palliative care if the baby is not expected to live long
• give the baby up for adoption.

If the parents decide to keep the baby then they will need ongoing physical, emotional and spiritual support. Caring for a disabled child is challenging. Nadia says, I kept asking myself why. I will never have an answer. But I feel that I learnt to rely on God more to get me through.[18]

You can pray for them, but don’t tell them that God would only let this happen to a strong Christian—it takes away their freedom to tell you how hard it is sometimes.

Abortion for fetal abnormality

Many couples make the decision to abort a baby after they find out that there is an abnormality. This suggests that regardless of whether the parents want a baby, they have decided they don’t want this baby.

Some liberal feminists reject the argument that antenatal screening expresses prejudice towards disability.[19] In particular, they argue that research into why women abort after a ‘positive’[20] prenatal diagnosis is complex, and that it is wrong to read desires and intent into the actions of individual women.[21] This is not to say there are no selfish or prejudiced women who abort simply because they do not like disabled people, or because they find it difficult to envisage fitting a disabled child into their lifestyle. However, these feminists argue that to deny the right to abortion because of fears of eugenics denies women the opportunity to abort because of inadequate governmental support systems.[22] Christians would not agree with this thinking, and even some feminists who are staunchly pro-choice oppose abortion for defect:

As Harvard University’s Ruth Hubbard has explained, “It is one thing to abort when we don’t want to be pregnant and quite another to want a baby, but to decide to abort this particular fetus we are carrying in hopes of coming up with a ‘better’ one next time”.[23]

We do well to hesitate in judging the motives of those who choose abortion. Aborting a previously desired child because of birth defects is rarely done easily or happily, and for many it is a difficult decision full of regret and pain.[24] However, as in all scenarios where abortion is considered, it is important that in this situation the parents are informed that they can choose to keep the baby.

Julie says, No-one actually said I had to end the pregnancy, but you know that’s what the experts think is best. Kay, on the other hand, was absolutely opposed to abortion and kept refusing to agree. It was so hard, everyone seemed to think I was crazy, and I had to keep saying it over and over. But once I was in the antenatal section, the doctors were much more supportive and they were much more encouraging about what would happen. Even the percentages changed. How many parents wish they could have kept their child, and how many didn’t realize it was a feasible option?

Alison Brookes discovered three factors that influence women’s decisions about whether to undertake prenatal diagnosis, as well as their use of the information made available by testing: the level of care a child will require, the level of care a woman feels confident to provide, and the level of care available for children with genetic conditions.[25]

In one way, the routine nature of antenatal testing can give parents a false sense of security. With all the tests offered, it is all too easy for prospective parents to forget that illness can befall a baby at any time during pregnancy and delivery, and after birth, and that the majority of birth defects are undetectable and unpreventable. It is well known that despite counselling, parents often take a negative prenatal screen test to mean there is nothing wrong with the child. Consequently, if the baby is found to have a problem late in pregnancy, or at birth, it may be all the more difficult for them to handle. Remember, there is no test that guarantees a healthy baby.

Deciding to terminate the pregnancy

There are different procedures in different places, and parents will need to ask questions, wherever they are, if they decide to end the pregnancy. They need to know the facts about the termination procedure itself, the inherent risks of having it (or not having it), their choices, the delivery method for the baby, time spent with the baby after delivery, legal requirements (postmortem, birth/death certificates, funeral arrangements), who can stay with them, and what they can expect afterwards.[26] They will need to know about the various options for collecting memories of the baby, and the emotional challenges that can be expected.[27]

Cases

I will look now at two hypothetical cases, in order to consider the options beyond abortion when a parent discovers in prenatal screening that their child has an abnormality. I will differentiate between lethal (incompatible with life) and non-lethal birth defects.

Case 1: A 31-year-old woman and her husband are told after her 18-week scan that the baby has anencephaly (congenital absence of the brain), a condition that is incompatible with life.

At first glance, it might appear that termination of pregnancy is the quickest and easiest way to help parents recover from the grief of finding that their child has a serious abnormality. However, research suggests this may not be the case. The decision to abort for genetic abnormality may have a more negative impact than abortion for non-medical reasons.[28] While abortion is sometimes presented as the only option when a fetus is diagnosed with a life-limiting condition, I would suggest that a perinatal hospice is a better option. In this scenario, the pregnancy is continued while plans are made for palliative care (comfort care) for the child at the time of birth. If one considers life in the context of eternity, 9 months instead of 90 years is of little significance. Continuing pregnancy is consistent with allowing life to be realized to its full—albeit only until birth in this case.

What will this look like?[29]

During the pregnancy

Sadly, I have had some experience supporting families in this situation. They need a lot of encouragement. From professionals they need accurate information and good communication. Specialist antenatal units are great if one is available. The family will need emotional support and the parents may want to record the pregnancy in some way, such as through a journal or through photographs.

It was weird, harrowing, to move through the months of the pregnancy knowing that the baby will die. I have heard of one couple who really enjoyed the pregnancy as the special time of their baby’s life—but we found it very challenging. At times, I wondered if abortion would have been a less protracted affair, even though we are glad we didn’t take that option.

At the time of delivery

The pregnancy is continued until labour begins and birth occurs normally, in a supportive and comfortable setting.[30] It is helpful to have detailed discussions in advance so that the time between the birth and death of the child is used well. In my experience, parents who pursue this option have had the consolation of knowing they did all they could for their child as long as they were able, and the subsequent funerals have been a powerful witness to the value of human life.

Case 2: A 42-year-old woman is told that it is highly possible her fourth child will be born with Down syndrome.

When a non-lethal birth defect is diagnosed, parents face the challenge of life with a disabled child.

First, as a mother who was advised on grounds of fetal abnormality to abort a daughter who was subsequently born healthy, my first response is to remember the false positive rate! Sometimes doctors can get it wrong.

Second, we know that some birth defects regarded as indications for abortion can be treated successfully in the womb or after birth. The confusion in our society about the value of unborn human life is highlighted by the fact that—hypothetically speaking—in one operating theatre a 22-week-old child can be treated for a birth defect (such as hypoplastic left heart) with intrauterine surgery (surgery in the womb), while in the next operating theatre a 22-week-old child can be aborted because of exactly the same problem. Some evidence suggests that surgery performed in the womb may give better results than surgery after birth,[31] however, what can be treated this way is limited because maternal outcomes are not as good.[32]

Third, we know that many families with a disabled child have indeed been able to manage, and they—and many disabled adults—would assert that these lives can be worthwhile and satisfying.

During the pregnancy

It can be helpful to spend time during the pregnancy understanding more about what will happen at and after the birth. If the child is expected to need medical care, it may be possible to meet those who will be involved beforehand. Will the hospital be able to provide the appropriate care, or will a transfer be necessary? When will the baby be able to come home? It’s difficult to prepare parents before the birth of any baby, but information will help. Non-judgemental support will be needed before and after the birth.

~

Education may be needed to help parents understand what the disability entails. For example, Down syndrome is often considered an indication for abortion, and without counselling, many parents would not be aware that these children can attend school and live semi-independent lives. They tend to have happy dispositions and I am sure they are much loved by their families. Sadly, it often happens that these families struggle to get the help they need in terms of community support, and Christians should be alert to the need to improve available services.

An interesting report from the United Kingdom indicates that the number of children born with Down syndrome rose by about 15% between 2000 and 2006. According to the Down Syndrome Association, more parents now feel that life and society have improved for the people affected. Religious or pro-life beliefs were a deciding factor for only about a third of parents surveyed. Others said they had been influenced by personal acquaintance with people who had Down syndrome.[33]

Some of the most passionate objections to the discarding of disabled unborn babies come from those who are disabled themselves. They find it highly offensive that society should judge their lives to be not worth living.[34]

It is interesting to consider why we think that disabled children suffer. Do we really think they suffer so much from being disabled that they would be better off dead? Do we think they will suffer living in a world where they don’t fit in? Or are we concerned that we will suffer because of them?

In fact, the disabled do not necessarily suffer the way we imagine we would suffer if we were them.[35] Those who are born disabled may be aware that they cannot do what others do, but for someone born blind, sight is not missed in the same way that we, who are so dependent on sight, would miss it. Harriet Johnson explains:

…disability shapes all we are. Those disabled later in life adapt. We take constraints that no-one would choose and build rich and satisfying lives within them. We enjoy pleasures other people enjoy, and pleasures peculiarly our own. We have something the world needs.[36]

Perhaps our concern for any suffering the disabled might experience would be better directed at changing things in us and our world, than at ensuring they are never born.

Kathy McReynolds, from the Christian Institute on Disability, suggests that if the disabled do suffer, it is partly due to the marginalization and discrimination they encounter. She encourages us to discover human dignity within the brokenness of disability by acknowledging the source of human dignity: God himself, who has stamped his image on us.[38]

Perhaps our attitude towards disability and abortion is too much influenced by the way the issue is framed in our world: the language of ‘personhood’, competing rights, a problem to be solved by individuals, the need to justify our decisions and find reasons for allowing the disabled to be born in spite of their disability. This is not how God views the situation. The Bible teaches us to be a people who practise hospitality and provide for the needs of others. Jesus said:

“Then the King will say to those on his right, ‘Come, you who are blessed by my Father, inherit the kingdom prepared for you from the foundation of the world. For I was hungry and you gave me food, I was thirsty and you gave me drink, I was a stranger and you welcomed me, I was naked and you clothed me, I was sick and you visited me, I was in prison and you came to me.’ Then the righteous will answer him, saying, ‘Lord, when did we see you hungry and feed you, or thirsty and give you drink? And when did we see you a stranger and welcome you, or naked and clothe you? And when did we see you sick or in prison and visit you?’ And the King will answer them, ‘Truly, I say to you, as you did it to one of the least of these my brothers, you did it to me’.” (Matt 25:34-40)

Who is more vulnerable than an unborn child?

We have been created for relationships, and God has given us Christian community. The Christian life is not intended to be one of isolation and self-containment. A problem that seems overwhelming for an individual can often be eased significantly by sharing it with a community of Christian brothers and sisters. I am encouraged when I hear of churches working together to help those caught in the dilemma of carrying an unwanted child, no matter why it is unwanted.

In this church, when a teenager has a baby that she cannot care for, the church baptizes the baby and gives him or her to an older couple in the church that has the time and wisdom to raise the child. That way, says the pastor, the couple can raise the teenage mother along with the baby. “That”, the pastor says, “is how we do it”.[39]

Our attitude to the disabled, or to any other ‘unwanted’ child, should be one of welcome; they give us an opportunity to express Christian hospitality. I am aware of many authors who assume that relieving suffering may necessitate the elimination of the sufferer.[40] How did we come to this?

As I write I am aware of how perverse my words will sound to some readers, but suffering is not the worst thing that can happen to you. In order to emulate our Lord Jesus, who gave himself for us, we will do what we can to ease the suffering of others, while also communicating the message, ‘It’s good that you are here’.

Longer-term support

If, as we have noted above, Jesus calls us to offer hospitality to the disabled, how can we support those who join our church communities? Because disability can last a lifetime, Christian communities will need to consciously and actively plan how to continue supporting disabled brothers and sisters; it is easy to grow lax when a need is ongoing. We are all members of the one body and we can be confident that we all have a part to play in the life of the church (1 Corinthians 12).

A list generated by those living with disability included the following practical tips that are worth considering if you want to help:

• Try to understand and provide a listening ear.
• Ask for prayer points and pray in an ongoing way.
• Give spiritual support (ministers have a key role in making contact with families, answering their questions as they seek to understand their position, and making sure the church does not forget their needs).
• Provide respite (offer to give the parents a break, or pay for a qualified carer if professional expertise is required).
• Provide home help (shopping, cooking and cleaning).
• Give financial support.
• Modify your church building so that no person with a disability is excluded (this may include building ramps, installing a hearing loop, providing special care for children so parents can attend a service).
• Reach out (invite the disabled to church and show your willingness to break down barriers, and make sure church functions are inclusive).
• Start a support group for those isolated by disability.
• Care for the siblings of the disabled.
• Take on an advocacy role to improve services for the disabled.[41]

Ruth and I have been Christians all of our married life and have found that our faith is the basis for coping with Alison day to day and for hoping for a life that is ultimately joyful and everlasting. We know that our resources are limited but that God’s are unlimited and we can always turn to him when life seems impossible. God doesn’t solve all of our problems and grant all our reasonable desires for Alison. She has not become ‘normal’ or shed her shocking behaviours. But there is help from our heavenly Father and there is eternal hope in the midst of all our joys, heartaches and suffering in the present life.[42]

~

Sometimes we feel dreadfully sad that we cannot have a conversation with William. This is something we truly long for. When we feel deep grief in our hearts that our son doesn’t relate to us in a way that we yearn for, we’re actually reminded of the grief that God feels for us, his children, to relate to him as we should. He, too, longs for us to talk to him.[43]

~

I have spent the last two or three months feeling sad, heavy and dismayed by the idea that my child is going to struggle in life with his understanding and communication. But stopping to analyse the fears I have for him, I can see that I’m most afraid of other people’s reactions to him. I’m worried that he’ll be bullied, excluded, laughed at, tormented or just plain ignored. How do I know he will suffer these things? Because I know the tendency of my own heart, and I know my own sinful reactions to others who are different from me. At times, I have bullied, excluded, laughed at, tormented and just plain ignored people who were ‘imperfect’. And in doing so, I have shown my own imperfections, which are far more serious, far more deadly and far more vile than any physical or mental disability could ever be. The real human imperfection is the sinful, unloving heart that each one of us carries inside.[44]

Three things are never satisfied;

four never say, “Enough”:

Sheol, the barren womb,

the land never satisfied with water,

and the fire that never says, “Enough”. (Prov 30:15b-160)

Infertility is painful, and often unexpected.

Married Christian couples usually just assume they will have children; they don’t anticipate any problems, because they have never tried to have a child before. If conception becomes difficult, they then realize they have no control over what happens. They don’t sleep well and sexual intimacy starts to suffer.

What makes it harder is that in many places infertility is a taboo subject, and many couples discover they can’t talk about it with anyone. It becomes a very lonely experience, especially in a church full of family programs. Meanwhile, life gets put on hold. It’s hard to plan ahead. The emotional pain gets worse every time menstruation recurs, confirming that there’s no pregnancy in place. One doctor said, “In the past three decades, researchers have made great strides in the treatment of infertility… Yet all of that is the relatively simple part. The more difficult part is mending the broken hearts.”[1]

It’s very difficult for those on the outside to understand an infertile couple’s level of suffering, but some sense of the pain and desperation can be gauged from the efforts they make to overcome their problem: the time and money spent, and the stress and pain of fertility treatment.

In some ways, the advent of assisted reproductive technology (ART), such as in vitro fertilization (IVF), has increased the anguish of infertile couples. The availability of these therapies forces them to decide if they want to take on the burden of treatment, and it can prolong the struggle for years. The Bible validates this emotional pain when it is compared to the insatiable natural phenomena listed at the start of this chapter.

In this chapter, I will look at infertility from both the pastoral and the medical perspectives, covering the following subjects:

• Definition of infertility
• Theology
• Infertility in a fallen world
• Options
• Biology of pregnancy
• Causes of infertility
• Medical assessment
• Treatment
• Living with infertility
• Coming to terms with infertility

Infertility: a definition

Infertility is a medical diagnosis that can be made when a couple has been having normal unprotected intercourse for a year or more without conceiving a child. It is a decrease in the ability to conceive, or ‘subfertility’. This should be distinguished from sterility, which implies an absolute inability to achieve pregnancy. Primary infertility describes those who have never conceived. Secondary infertility is a medical diagnosis for couples who have conceived successfully in the past but are then unable to conceive. It is also used to describe couples in whom conception has occurred but the pregnancy has not progressed past 20 weeks.[2]

It is difficult to know exactly how many couples infertility affects because not everyone presents for treatment, but it is thought to be a problem for around 1 in 6 couples of reproductive age.

There are many reasons people want to have children—for example, to continue the family name, to make sure they have someone to look after them when they’re old, or as a symbol of the marriage union. Some people respond to family expectations, some aim to help build the kingdom of God, while others don’t really think about it much at all. Whatever the motivation is, theologian Karl Barth suggests that:

In some degree they will all feel their childlessness to be a lack, a gap in the circle of what nature obviously intends for man, the absence of an important, desirable and hoped for good. And those who have children and know what they owe to them will not try to dissuade them. The more grateful they are for the gift of children, so much more intimately they will feel this lack with them. Parenthood is one of the most palpable illuminations and joys of life, and those to whom it is denied for different reasons have undoubtedly to bear the pain of loss.[3]

For me, the longing for a child was an overwhelming biological urge that is difficult to describe. I just can’t imagine what it would have felt like if that urge had never been fulfilled. Infertility from any cause is an enormous hardship for a couple to bear. How are Christians to understand it?

What the Bible says

Child-bearing is a good thing. It is not wrong to want to raise a family with your spouse.
Christians believe that children are a gift from God. Throughout the Bible, fertility is described as a blessing for the obedient (Deut 28:4-11) and a lifetime asset:

Behold, children are a heritage from the Lord,

the fruit of the womb a reward.

Like arrows in the hand of a warrior

are the children of one’s youth.

Blessed is the man

who fills his quiver with them! (Ps 127:3-5a)

By contrast, infertility is often seen as a curse from God. Deuteronomy 28 presents the opposite of fertility as not just barrenness, but also mayhem and exile. This passage anticipates the sacking of Jerusalem and the Babylonian exile in 587 BC, prophesying “cursed” offspring (v. 18) and exile with loss of children:

“Your sons and your daughters shall be given to another people, while your eyes look on and fail with longing for them all day long, but you shall be helpless.” (v. 32)

“You shall father sons and daughters, but they shall not be yours, for they shall go into captivity.” (v. 41)

Even the unimaginable cannibalism that eventuated as besieged Jerusalem starved is mentioned (vv. 53-57). Later in the chapter, the Lord again threatens to punish disobedience with barrenness:

“Whereas you were as numerous as the stars of heaven, you shall be left few in number, because you did not obey the voice of the Lord your God. And as the Lord took delight in doing you good and multiplying you, so the Lord will take delight in bringing ruin upon you and destroying you. And you shall be plucked off the land that you are entering to take possession of it.” (vv. 62-63)

We also see a connection between infertility and punishment from God when wives commit adultery (Num 5:11-28), and when adultery is committed between an aunt and nephew, or brother-in-law and sister-in-law (Lev 20:20-21).

Because of these and other passages, infertile men and women often search their hearts seeking reasons for God ‘punishing’ them—indeed, as do Christians who are suffering in other ways (through sickness, or the death of a child, etc.). There is an important balance to be maintained in dealing with these feelings.

At one level, we are right to realize that all the sickness, suffering and trouble of our world is a consequence of the Fall, of God’s judgement against human rebellion and sin. Every time we see or experience any kind of suffering, evil or injustice, it should remind us that this is a broken, sinful and judged world—a world in need of remaking. It should prompt us to remember that we ourselves are sinful and in need of forgiveness. And it should make us long for the new creation where there will be no “mourning nor crying nor pain any more, for the former things have passed away” (Rev 21:4). Infertility is one of these signs of the world’s brokenness, and the heartbreak and agony that it causes are real.

And yet on the other hand, we shouldn’t conclude that because we are suffering from infertility, it means God is punishing us, personally and specifically, for a particular sin that we have committed. Suffering and trouble in this world are not connected with our personal sins in a neat one-to-one correspondence like this. This is the message of Job, whose ‘comforters’ were convinced, quite wrongly, that Job’s terrible suffering must be God’s direct punishment against a particular sin or sins that Job had committed.

This is also the message of John 9 and the man born blind. The disciples asked Jesus, “Rabbi, who sinned, this man or his parents, that he was born blind?” (v. 2). But Jesus reminded his disciples that we can’t make a simple direct connection between suffering and sin: “It was not that this man sinned, or his parents, but that the works of God might be displayed in him” (v. 3). In the purposes of God, there was a reason for the man’s blindness, but it was not his sin or his parents’.

We also know by the example of Elizabeth, John the Baptist’s mother, that infertility is not necessarily due to sin. We are told that both she and her husband, Zechariah, were “righteous before God, walking blamelessly in all the commandments and statutes of the Lord. But they had no child, because Elizabeth was barren…” (Luke 1:6-7).

Indeed, Elizabeth’s story is one of many instances in the Bible where God ‘opens the womb’ of the barren woman and blesses her with a child. Sarah, the wife of Abraham, was blessed in her old age with the first child of the promise (Genesis 15-21). In the next generation, “Isaac prayed to the Lord for his wife, because she was barren. And the Lord granted his prayer, and Rebekah his wife conceived” (Gen 25:21). Then again in Jacob’s family: “When the Lord saw that Leah was hated, he opened her womb, but Rachel was barren” (Gen 29:31). Eventually God remembered Rachel and opened her womb as well (Gen 30:22-24). God was closely involved with the early generations of Abraham’s offspring.

The mother of Samson was also sterile until the angel of the Lord told her she would conceive a son who would bring the deliverance of Israel from the hands of the Philistines (Judg 13:2-24). Hannah wept and prayed for a child who she promised to commit to the Lord’s service, and her prayer was answered in the birth of Samuel, destined to be Israel’s prophet, anointing both Saul and David as kings over Israel (1 Sam 1:11-20).

However, just as we shouldn’t conclude that infertility is a particular punishment on us from God, nor should we conclude that God is bound to bless us with fertility if we are obedient, godly Christians. God worked in the lives of these particular women in the Bible for special purposes that apply to them alone. We cannot claim promises that were made to others in specific contexts that we do not share.

But there is no doubt that God is sovereign over fertility, just as he is over everything in our world. Eve acknowledged this at the birth of Cain, when she said, “I have gotten a man with the help of the Lord” (Gen 4:1). Sarah (or Sarai, at this point) acknowledged that it was God who had prevented her having children (Gen 16:2). As in all things, God is in charge.

I remember being particularly conscious of this when I was pregnant. We were not technically infertile ourselves, but as we started trying for a baby, we were in touch with a lot of couples who were. I knew I could not take becoming—or staying—pregnant for granted. I think this helped me a great deal.

When we start thinking about building a family our expectations about parenting are often very strong. We have such high hopes. But this means that for some of us there is a long way to fall.

Is this perhaps a problem in the way we teach young couples about marriage and family? Should we start teaching young people more clearly that children are a gift we should not take for granted? It’s important to strike a balance. Of course, we will continue to value marriage as the right place for the begetting and raising of children, but we also need to recognize with humility that God may have other purposes for our particular marriage.

Nowhere in the Bible does God promise that we will all have children. He hears all our prayers (Ps 65:2)—but sometimes he answers slowly, and sometimes the answer is “No”. The apostle Paul tells the story of how God gave him a thorn in his flesh (although we are not sure what the physical ailment was): “Three times I pleaded with the Lord about this, that it should leave me. But he said to me, ‘My grace is sufficient for you, for my power is made perfect in weakness’” (2 Cor 12:8-9a).

The Bible does not answer all the questions we have about infertility. But it does help us understand the character of our God. We live in a fallen world and our bodies are subject to decay. But that is not the end of the story.

I don’t want to minimize the pain of longing for a child who never arrives. But when we look at what God does promise, we realize that he will never leave us alone (Heb 13:5). He sent his Son to share our human life, with all its weakness and pain (Heb 2:17). We know that Jesus can sympathize with the deepest of our hurts.

God may choose to open a barren womb (as he did for the women above), but ultimately, whether or not we have children is in his hands. It can be difficult to think this way when you are in the midst of a storm. For those suffering with infertility, my prayer is:

…that according to the riches of his glory he may grant you to be strengthened with power through his Spirit in your inner being, so that Christ may dwell in your hearts through faith—that you, being rooted and grounded in love, may have strength to comprehend with all the saints what is the breadth and length and height and depth, and to know the love of Christ that surpasses knowledge, that you may be filled with all the fullness of God. Now to him who is able to do far more abundantly than all that we ask or think, according to the power at work within us, to him be glory in the church and in Christ Jesus throughout all generations, forever and ever. Amen. (Eph 3:16-21)

Infertility in a fallen world

The number of infertility clinic visits is increasing. Why is this?

It is partly because more women are leaving child-bearing until after 35 years of age. In the United States, according to data from the National Center for Health Statistics and the Census Bureau, in 1990, teenagers had a higher share of all births (13%) than women aged 35 years and older (9%). In 2008, the reverse was true—10% of births were to teenagers, compared with 14% to women aged 35 years and older.[4] In Australia, around 21% of women giving birth were aged 35 or over in 2006, up from 15% in 1997.[5] In the United Kingdom, the Office for National Statistics reports show that fertility rates for women aged 35-39 and 40-44 increased in 2009 by 1.0% and 2.4%, respectively. This continues the trend of the last two decades, during which the number of live births to mothers aged 40 and over has nearly trebled, from 9,336 in 1989 to 26,976 in 2009.[6]

In some cases, couples delay child-bearing until their careers are established and they are financially stable; easily available, reversible contraception has made this possible. The number of celebrities conceiving after the age of 35 years has perpetuated a myth that the biological clock can be ignored and child-bearing can safely be delayed. When we read about these celebrities, what is often not mentioned is that many have used eggs donated by younger women (which can be difficult and expensive to acquire). The number of older women who have tried, and failed, to conceive in their forties is usually not in the news at all. Some women find it difficult to find a partner who wants to have children. United States economist Sylvia Ann Hewlett surveyed more than 1,000 professional women and discovered that 42% were still childless after age 40, and only 14% had ever explicitly renounced motherhood as a goal.[7] While women generally know that their fertility reduces over time, many do not know when. Hewlett found that nearly 9 out of 10 young women were confident they could get pregnant in their forties.[8]

In fact, a woman’s fertility begins to decline at age 27. With regard to fertility there is only one message in the medical media: women are urged not to delay having children.

Other factors that account for increased fertility problems are the social phenomena of multiple sexual partners, and the consequent transmission of infectious disease and development of pelvic inflammatory disease and other problems that can damage the reproductive system.

The popular media sends contradictory messages to women about fertility. On the one hand, it’s considered liberating for women to not let a man get in the way of personal development; but more recently, celebrity babies in the media are reinforcing the ‘old-fashioned’ view that the role of women is to get married and have babies—like the 1950s, with edgier clothes.

This whole way of thinking seems to define a woman by her relationships—whereas the Bible legitimizes both singleness and motherhood for women, and our value does not depend on which we embrace. Furthermore, if we do invest too much significance in being a parent when considering our fundamental identity, the pain of infertility and childlessness is heightened even more. As Christians, we need to find our identity in Christ. The church should be the source of significant bonds of love and affection, providing opportunities to love and serve others. We should not regard it as a place that serves families, and thus a place to be avoided when we don’t fit the criteria for entry. As Christians, we need to be careful to avoid the insidious influence of public opinion (Rom 12:2).

Approximately 13% of women are diagnosed with infertility (7%-28% depending on age), and this has remained stable for the past 40 years. Ethnicity or race appears to have little effect, but primary infertility has increased while secondary infertility has decreased, probably due to the delayed child-bearing trend. Sterility affects 1%-2% of couples.[9] In normal fertile couples having frequent unprotected intercourse (i.e. making love every 2-3 days throughout your cycle), there is around an 85% chance of conceiving within one year.

Is there a right to have a child?

In community discussions about access to assisted reproductive technology (ART), we often hear talk about the ‘right’ to have a child. Does such a right exist? Many would say so—but it is difficult to see a basis for it. In legal terms, there are jurisdictions that make sure access to medical therapies like ART is available to everyone, but, as I have previously mentioned, ‘rights talk’ can confuse needs with wants.[10]

To establish a genuine ‘right to reproduce’ requires an argument to support the claim that having a child is a need rather than a want. The World Health Organization (WHO) has defined ‘health’ as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”.[11] With this in mind, proponents of this view therefore argue that:

• the strength of the desire to reproduce is biological in nature and requires the satisfaction of that desire if we are to live fulfilled lives
• infertility is a disease we are compelled to treat to allow for physical well-being
• it is not the role of governments to regulate private sexual relationships
• there are laws in many places that protect the right to marry and have a family (including the United Nations’ Universal Declaration of Human Rights).[12]

Response:

1. The physical impossibility for some people to bear a child (sterility) suggests that reproduction cannot be a ‘right’, because no-one has the power to make it possible for everyone.
2. While we can argue about whether infertility is the disease or the underlying problem is the disease, the question then is, “Who is responsible for providing treatment?” Is all healthcare a right, or just basic healthcare? What does this include? A universal right would mean it should be provided to people in every country.
3. It’s a fact that governments have long regulated private sexual relationships—by prohibiting incest and paedophilia, and by restricting polygamy and polyandry, for instance.
4. While there are laws allowing adults to marry and have families, these are considered to be negative rights that prevent interference by the state, rather than positive rights that oblige the state to assist the infertile with every treatment available.

I think it is difficult to argue that reproduction is a universal human right rather than a want. Regardless, ‘rights talk’ is not biblical. We have already seen that children are a gift from God—a privilege. But we are not all given the same gifts.

What are the options for a Christian couple who might be infertile?

Couples trying to come to terms with the idea that they may be infertile are incredibly vulnerable. They can easily commence a treatment that promises a child without stopping to think what it involves. Dr David Knight, a fertility doctor in Sydney, is well aware of the competing interests in an IVF clinic:

People are so desperate to have a child. I could get them to do almost anything. And that is a very scary and very powerful position to be in. And that’s why we have to work hard to ensure that the couple’s vulnerability is not exploited in pursuit of business objectives.[13]

This makes it particularly important that any couple in this situation seeks careful counselling in the early stages of their discussions, before anything is decided. It is ethically acceptable for Christians to seek medical help to restore the natural function of child-bearing,[14] but not all ‘standard’ medical therapy will be morally acceptable for those who want to protect life from its beginning.

Given that life starts at fertilization, what are the options for couples who find themselves in this position?

1. It’s okay to pursue no further treatment. Some couples may be happy to accept that child-bearing is not God’s current plan for them, and look to his guidance for the future. Christian ethicist Brent Waters describes marriage as not simply a means of reproductive self-fulfilment, or the parallel stories of a woman and a man, so much as a single story “whose bond shapes who they become in their life together”.[15]
2. It’s possible to wait. Even though infertility is diagnosed after one year of trying to become pregnant, only 85% of couples are expected to conceive in the first year. Sometimes ‘infertility’ is really just impatience. For those considering taking things further, however, some doctors would advise that they not wait longer than 6 months if any of the following apply:

• the woman is over 35 years of age
• there is a history of amenorrhoea (no periods), oligomenorrhoea (infrequent periods) or pelvic inflammatory disease
• either partner has had treatment for cancer or a serious illness, such as diabetes or hypertension.[16]

3. The couple can seek a diagnosis to determine the cause of infertility. This can be helpful even if no further treatment is pursued, just to know what is going on. Sometimes the problem underlying the infertility can be corrected easily. However, couples need to be careful that they continue to regard infertility as a joint problem within their marriage—rather than one partner’s problem—so that blame is not focused on one person. This helps marital unity.
4. Subsequent to diagnosis, couples may be offered correction of a medical problem or a recommendation to go straight to ART treatment. It is at this point that I would particularly urge Christian couples to stop, pray, collect information, think carefully and not just agree to anything that will help them achieve their desire for a baby. Gerry remembers, We were given a 100% impossibility of falling pregnant naturally, so the process of thinking through IVF as our only solution for having our own children was a hard journey for us. Couples should take it slowly; problems are avoided by looking ahead.[17]
5. Couples may consider adoption at any point of their journey. It helps if they have come to terms with the loss of the potential for biological offspring before exploring this option. It is possible to have a healthy, loving family without any genetic link.[18] Embryo adoption is a new option to consider.[19]

There are many known causes of infertility. The problems for secondary infertility are almost identical to those of primary infertility. To understand the problem, we need to understand the normal biology of pregnancy.

Biology of pregnancy

The first step of pregnancy is fertilization. This requires the egg and sperm, at the correct stage of maturity, to be brought together. Next, the resulting embryo needs to be transported to the uterus at a time when the endometrium (uterus lining) is ready to support implantation and further development of the embryo. For all these events to occur in sequence requires intact reproductive systems in the man and the woman, with intercourse occurring sufficiently frequently for the sperm to arrive at the fallopian tube when an egg happens to be there (there is only a 12-24 hour window of opportunity). Even when fertilization occurs, it is estimated that over 70% of the resulting embryos are abnormal and fail to develop or implant.[20] When you think about it, it is not surprising that some people are unable to conceive. What’s surprising is that anyone manages to have children at all!

Female reproduction

At puberty, a woman has around 400,000 immature eggs stored in her ovaries. When she starts menstruating in her early teens, she releases an egg every month when she ovulates. The female ovulatory cycle is explained in detail in chapter 2, but basically, in the first half of the menstrual cycle, the egg develops in the follicles of the ovaries in response to hormones. About halfway through the cycle there is a surge of oestrogen when the egg is released into the fallopian tube (ovulation), which thickens the endometrium (uterine lining).

If the egg is joined with a sperm in the fallopian tube following sexual intercourse, fertilization takes place and an embryo is formed. The embryo grows as it moves down the fallopian tube towards the uterus, and at the end of the first week it attaches to the endometrium in a process called implantation.[21] Hormones produced first by the woman’s body, and then by the placenta, sustain the pregnancy until the child is born. It is not necessary for a woman to orgasm for fertilization to take place.

If the egg is not fertilized, hormone production stops and the endometrial lining (with the egg) is shed from the body in menstruation (the woman’s period). This occurs monthly until a woman reaches menopause around 50 years of age.

Male reproduction

The male is born with two testes. Each testicle has to make and store sperm on a regular basis. Beginning at puberty, a new stock is made every 74 days in response to a surge of the hormones testosterone, gonadotropin-releasing hormone (GnRH), luteinizing hormone (LH) and follicle-stimulating hormone (FSH). The epididymis (the coiled tubes that store and carry sperm from the testes) aids in the development of the sperm and helps it to travel through the vas deferens tubes and the ejaculatory duct. As it travels, the sperm combines with secretions from the epididymis, vas deferens, seminal vesicles and the prostate (the secretions are collectively known as seminal plasma) to make semen. The seminal plasma provides nutrients for the sperm and protects them during their journey through the female reproductive tract (which is usually hostile to sperm). When the man has an orgasm during sexual intercourse, the semen travels through the urethra, out of the penis and into the woman’s vagina in ejaculation. The sperm must make its way through the cervix to the uterus and into the fallopian tube. If an egg is travelling through the fallopian tube at this time, the sperm can enter the egg, resulting in fertilization. Approximately 200-500 million sperm are normally released per ejaculation.

Causes of infertility

Infertility can result from problems in either spouse, or both. There are some geographical variations, but overall, a cause for the infertility can be found in 80% of cases with an even distribution of male and female factors. Male factors account for about a third, female factors for about the same number, and about 40% of cases are due to multiple factors. Estimates vary, but for 5%-30% of couples no cause is found. (The wide range is due to varying ways of defining ‘no cause’ in research.)

Age

A couple aged 30 with no infertility problems has an 80% chance of conceiving within 12 months; at 40, a 50% chance; at 45, a 10% chance.

Female

By the time she is 40, a woman has only a few thousand eggs left. As the eggs age, they are harder to fertilize and less likely to produce healthy embryos. There is a drop in fertility, an increase in miscarriage rate, an increase in perinatal death rate and an increase in fetal abnormality. Also, intercourse tends to decrease in frequency with age. The biological clock is real, and no advances in reproductive technology have been able to slow it down.

Male

Men are also putting off having children, but some of them do have that luxury. Pablo Picasso fathered a child when he was 66, and I once had a patient who had a child in his eighties. “Life doesn’t stop at thirty”, he told me after I finally accepted he didn’t mean he’d had a grandchild. The effect of age on male fertility is less clear but some evidence suggests the decline parallels that in women.[22] The pregnancy rate goes down, the miscarriage rate goes up, and for those over 40 years of age, male infertility is a definite risk, with more chromosomal (genetic) abnormalities detected.[23] Slightly reduced testosterone may lead to reduced libido (sex drive), the testes become smaller and softer, there is more erectile dysfunction, and there is a reduction in normal sperm; thus the ability to conceive is reduced. Worldwide, male fertility rates are declining, and it is possible that environmental as well as genetic factors are contributing.

Lifestyle factors

You may be stuck with your age, but there are some things that you can modify that may affect fertility as well as the health of the baby.[24]

Anne Clark, a fertility specialist in Sydney, screened the blood of men in her reproductive clinic and found that more than a third of them had vitamin D deficiency. These men were also deficient in folate and had high levels of homocysteine (a protein associated with cell toxicity). In the couples where the man had his nutritional deficiency corrected, just over half conceived naturally or with minimal treatment.[25]

Pre-conception health

Given that several lifestyle factors are known to contribute to infertility, some doctors suggest couples spend at least three months ‘cleaning up their act’ before they try to get pregnant. Even though one single problem may not cause infertility, a combination of factors can be enough to push you over the line. Men should be encouraged by the fact that though women have the eggs they were born with, men have a new batch of sperm every three months, so there is an opportunity to improve the quality. Even if IVF is planned, making lifestyle changes (for both husband and wife) can reduce the risk of miscarriage, without any ethical problems. Couples who hope to become pregnant should address these issues:

• Diet: A well-balanced diet is important, as it can improve fertility, reduce the risk of fetal abnormality, and increase the likelihood of a live birth. Women should take folate supplements—usually 0.4mg daily from two months prior to conception—and check with their doctor in case more is needed.[26] Women at risk should be screened for vitamin D deficiency prior to pregnancy and given vitamin D supplements if necessary; if you live somewhere with nice weather, 10-15 minutes of sun per day without sunscreen should be effective. In Australia and New Zealand, iodine (250mcg daily) for women is also recommended. Women should avoid taking vitamin A supplements and eating crustacea and liver products, before and during pregnancy, as too much can cause problems.
• Exercise: Undertake exercise in moderation.

• Weight: Abnormal weight can be associated with hormonal dysfunction. Obese women are almost three times as likely as non-obese women to have difficulty conceiving, either naturally or with ART. Weight should be lost before pregnancy, not during. Current evidence advises against conception within the first year after bariatric surgery (gastric banding etc.) due to risks of miscarriage, prematurity and fetal growth restriction.[27] There is some evidence that paternal obesity may contribute to reduced fertility.[28] Underweight women also have difficulty conceiving. People trying to conceive should aim to have a body mass index (BMI) between 20 and 25 kg/m².
• Smoking: Smoking cigarettes reduces fertility—and because passive smoking causes problems as well, both man and woman should stop smoking when trying to conceive.[29] Regular marijuana use also increases the risk of infertility.[30]
• Alcohol: It is unclear how much alcohol is needed to affect fertility, so it is advisable for men to reduce their intake; women should consider avoiding alcohol completely.
• Caffeine: The association between infertility and caffeine is unclear but it is recommended that women not drink more than two cups of coffee per day while trying to conceive and during pregnancy.

• Other factors: There is some evidence that stress and environmental pollution may cause infertility problems. While couples are getting healthy, they should ask their GPs which tests and vaccinations are recommended before conceiving.[31]

Female factors

Ovulatory factors

Dysfunction of the ovaries (not producing eggs normally) accounts for around 40% of female factor infertility. Dysfunction can include ovarian cysts, polycystic ovarian syndrome, and other hormonal problems such as early menopause. Advanced age leads to a natural reduction in ovarian reserves.

Cervical factors

When a woman is ovulating ‘fertile mucus’ is usually produced, which helps the sperm to swim up through the cervix and the uterus to meet the egg in the fallopian tube. Infertility can result from problems with the mucus, such as it being too scant, too thick or hostile to the man’s sperm.

Pelvic factors

Uterine factors are not commonly a cause of infertility, but they include tumours, polyps or abnormal anatomy. The role of fibroids in infertility is unclear.

Tubal abnormalities

These are more common, usually in the form of a blockage caused by endometriosis, infection, or damage from a previous ectopic pregnancy or surgery. Endometriosis in the pelvis (having normal endometrial tissue in abnormal places) can distort the anatomy of the reproductive system, and interfere with egg quality and the subsequent development and implantation of the embryo. It appears that the extent to which fertility decreases roughly correlates with the severity of the disease.[32]

Immunological problems

While antibodies are usually protective cells that protect the body against foreign substances like bacteria, some women produce antibodies that can attack sperm, the embryo or even their own cells. This can cause infertility or recurrent pregnancy loss.

Male factors

The cause of up to 40% of male infertility is unknown.

Sperm abnormality

If sperm can’t swim in a straight line it makes it hard for them to get anywhere near the egg. A low sperm count or impaired sperm function make it difficult for a sperm to fertilize an egg under normal conditions. Max didn’t believe the result when he got his sperm count back. I’ve been healthy all my life! he said. He had it rechecked. Twice.

Poor sperm quality, low sperm motility (movement), semen deficiency or insufficient (or no) sperm can all cause problems. Some men have a problem where their own immune system attacks their sperm.

Other problems

Some men have ejaculatory problems. Others can have a blockage either in the epididymis or the vas deferens. Testicular cancer, infections, an extra X (female) chromosome, undescended testes, low testosterone levels and steroid use can all cause problems.

No cause found

This can be very frustrating. I found it very hard to accept that no-one could tell us what was wrong. I still do, said Brett. Up to two thirds of couples in this category will conceive within three years, if they keep trying.

The menstrual cycle

As explained above, in order to conceive it is necessary for sperm to arrive at the fallopian tube just after ovulation (when an egg is released). It can be helpful for couples to learn about the phases of the menstrual cycle in order to time intercourse to coincide with peak fertility (aim for every two days just before and during the ovulatory phase). Ovulation usually occurs 14 days before the next period is due (irregular periods can make the timing more difficult). Natural family planning centres can teach couples to recognize the ovulatory phase using body temperature and cervical mucus changes. Some clinics offer ‘ovulation tracking’—a more accurate way of working out when ovulation occurs by measuring hormone levels in the blood.

Medical assessment

When first visiting the doctor, couples will need to talk about their past health and any factors that may be affecting their fertility. The range of causes is large and the doctor will want to narrow things down so that you do not have unnecessary tests. Both partners will need to be examined carefully. If the couple has any questions about things they have been told or have read on the internet, this is a good time to ask.

Women may be asked about their menstrual history, contraceptive measures, any prior pregnancies, surgery, infections, pap smears (and treatment if test results were abnormal), medications or exposure to toxins.

Men may be asked about any children they have fathered previously, exposure to toxins, previous surgery, infections and treatment, any medications, and whether they have had to shave less often (this can reflect hormone problems).

The doctor will also be interested in the couple’s general health, family history (looking for disorders that may affect fertility), and the regularity and timing of intercourse.

Depending on what the doctor finds, the couple will probably be asked to undergo some tests at this time. These may include the following:

• Semen analysis: The man will be asked to provide a sample of semen for examination.[33] He will be asked to abstain from sex for several days before collecting the sample (to allow it to build up), and it will need to be at the lab within an hour of collection (so it is fresh). Semen examination includes looking carefully at the sperm to see how many are there, how they move (motility), and whether they look normal (morphology). If there are abnormalities in the first test, it is usually repeated three months later to allow the production cycle to complete. One abnormal test does not confirm a problem.

• Blood tests: Hormone levels in the man and the woman may be checked to ensure that normal production of hormones is occurring so that sperm and egg production is supported.

Further tests may be done to check for blockages or damage to the woman’s reproductive system, and also to check for infection. These include:

• Hysterosalpingogram (HSG) or hysterosalpingo-contrast-sonography (HyCoSy): HSG is an x-ray that shows the inside of the womb and fallopian tubes to check for blockages. It involves the injection of fluid into the womb. HyCoSy is a similar test but it uses transvaginal ultrasound instead of x-ray. Ultrasound can also be used to detect anatomical abnormalities in the reproductive tract.

• Laparoscopy: This is explorative surgery to see if the fallopian tubes are damaged. It is likely to be recommended if there is a history of pelvic infection, ectopic pregnancy or endometriosis, or if infertility continues at 24 months.

• Endometrial biopsy: The lining of the uterus can be examined by taking a small sample of uterine tissue via a small catheter inserted through the cervix. It may be done with a transvaginal ultrasound to examine the endometrial thickness.

There are no ethical problems for Christians seeking a diagnosis for their infertility in this way.[34]

The first assessment can be quite overwhelming. Deciding to present for investigation can be a very emotional time as it is an acknowledgment, even if just between the couple themselves, that they have a problem. They will often receive a large amount of information and it may be hard to take it all in. They should ask if the doctor has any written information they can take away, and if they find they have questions afterward, they should be encouraged to write them down so they can remember to ask at their next appointment.

Treatment of infertility

If any general medical problems are found—such as malfunctioning of the thyroid—these will be treated in the standard way. These days, many causes of infertility are effectively bypassed rather than treated. Some doctors may think it will be cheaper and easier to go directly to IVF rather than to spend time treating the underlying disease itself. Conditions such as endometriosis can be treated with medication or surgery, but sometimes IVF is recommended instead. Couples need to be aware of their options whenever IVF is recommended, especially if they have concerns about its use. They may need to make a point of asking about alternative treatments, because IVF is so routinely used nowadays that it may not occur to the doctor to mention other options.

This book is not a replacement for medical advice, and each doctor has a couple’s personal information to guide them in a way I cannot; but here are some things to keep in mind for those who want to explore all possibilities with their doctor.[35]

In the treatment of infertility, the usual practice is to go from the least to the most invasive treatment in a stepwise manner. The treatments involved will obviously depend on the cause of infertility being addressed. The doctor involved will advise regarding the appropriate steps for each particular couple. The treatments listed here aim to correct the underlying problems causing infertility, and raise no ethical problems for Christians.[36]

Where ART is part of the recommended therapy, it is marked with an asterisk (*). Where this is the case, please go to chapter 12 to read the discussion about whether there are ethical issues for that particular procedure.

Male factor infertility

Poor semen quality

Medical or surgical treatment to normalize or at least improve poor semen quality is always the first and most appropriate option, when necessary and possible. A wide range of treatments is available depending on the cause.

Intrauterine insemination (IUI)*

Mild to moderate abnormality of the sperm can be managed by preparing the semen in order to concentrate the sperm, then injecting it through the cervix into the uterus. Fertility drugs may boost sperm production.

Intracytoplasmic sperm injection (ICSI)*

ICSI involves injecting a single sperm into each egg, and is used in combination with IVF*. If necessary, the sperm can be retrieved from the testes by microsurgical epididymal sperm aspiration (MESA)* or testicular sperm aspiration (TESA)*. A minimum number of sperm are necessary. ICSI is used when there are severe abnormalities in the sperm (low numbers, low motility, poor appearance), and fertilization through standard IVF fails.

Obstructive problems

These obstructions block the passage of the sperm. They can be addressed directly through surgery, or bypassed by using MESA* or TESA* with ICSI*.

Retrograde ejaculation

This condition can be treated with medication, or urine can be treated in order to collect sperm for IUI*.

Hormone abnormalities

These abnormalities can result from genetic problems such as Klinefelter’s syndrome, or they can be caused by a lesion in the pituitary or hypothalamus gland in the brain. Most of these problems can be treated with medication.

Varicocoele

This is a dilatation of scrotal veins, which is thought to impair fertility by raising the scrotal temperature. It is present in 15% of men. Treatment is controversial.

Donor sperm*

When male infertility cannot be treated, donor sperm* for insemination* or IVF* is available. This is a common practice. Donor sperm is usually frozen before injection to reduce the risk of transmission of infection to the woman.

Female factor infertility

Ovulatory problems

Ovulation can be induced in 90%-95% of patients so long as they have eggs and no serious hormonal disturbances.

The usual medication used is clomiphene citrate* (Clomid, Milophene, Serophe). Once ovulation is achieved, timed intercourse is recommended. Side effects are common with treatment and include hot flushes, swinging emotions, bloating and visual changes. There is a slight increase in the likelihood of twins with this treatment, and an even smaller increase in triplets. If this treatment doesn’t work, or clomiphene was not indicated, ovulation may be induced using gonadotropins*, often used in conjunction with IUI*. These are given by injection and have an increased risk of side effects such as multiple pregnancy and ovarian hyperstimulation syndrome. Even though these medications can be given outside of an ART context, they are commonly used with it and so are examined from an ethical perspective in chapter 12.

Menopause or reduced number/quality of eggs

The recommended treatment in women over 42 years of age or those with inadequate eggs is to use donor eggs* from a younger woman, using IVF*.

Uterine abnormality

Some uterine abnormalities can be surgically corrected. Other women with normal ovaries, but who are unable to use their own uteruses due to abnormal shape, disease, surgical removal, or another illness which makes it unsafe for them to become pregnant, can still have genetically-related children by using IVF* with a gestational surrogate*.

Tubal factor infertility

Depending on which part of the tube is blocked, reconstructive surgery is an option; in fact, in some instances it can improve the success rate for IVF*. However, in other instances the success rate for surgery will be extremely poor. IVF* will be offered if the obstruction cannot be repaired.

Endometriosis

While IVF* is likely to help with an anatomical problem, it is less likely to help with the other aspects of infertility in endometriosis. Depending on the severity of disease, treatment options include surgery, medication and ART*.[37]

Unexplained infertility

Treatment options range from ‘expectant management’ (i.e. waiting), to IUI*, hormone treatment, IVF* or a combination of these. In 2008, a British study found that in couples with unexplained infertility, existing treatments such as clomifene and unstimulated intrauterine insemination are unlikely to offer superior live birth rates compared with expectant management.[38] One study suggested that early treatment with IVF (after one year) does not improve outcomes, with 60% of births after early IVF possibly resulting from natural conception that would have occurred anyway in the following two years.[39]

Some specialist clinics use preimplantation genetic diagnosis (PGD)* to screen for aneuploidy (chromosome abnormalities) in older women, recurrent miscarriage or unexplained IVF failure.[40] The abnormal embryos are discarded and only those that appear normal are transferred to the uterus. This is not an ethical choice for Christians.

The last resort

In the treatment of infertility, whether you are dealing with female or male factors, the last resort offered with standard treatment will be IVF* and embryo transfer* (although some doctors refer earlier).

Can Christians use alternative therapies?

Infertile couples need to be careful that their vulnerability and intense desire for a child do not make them susceptible to fraud. Alternative therapies like acupuncture and traditional Chinese medicine have helped some couples. But as with any medical treatment, Christians need to be good stewards with regard to their money, time and acceptance of God’s sovereign will. Therapies relying on ‘life-energy’ or spiritual forces other than Christianity should be avoided. Remember that even the beast, as recorded in Revelation, could do great and miraculous signs (Rev 13:13). With any alternative medicine we should check with our doctor that it won’t do any harm, but in this situation it is important to establish that there is no risk either to the woman or to the baby if a pregnancy occurs.[41]

Living with infertility

Infertility challenges self-image, sexuality and relationships. The diagnosis begins a roller-coaster ride that can continue month after month for years. Professional counselling may be needed to cope with the stresses associated with infertility. Subtle pressure may be felt from well-meaning friends and relatives. This can develop into judgemental attitudes towards couples that are assumed to be childfree by selfish choice.

Amy, who with her husband suffered from secondary infertility and had tried for more than 10 years to have a second child, was criticized for allowing her daughter to grow up without siblings. Carmel said:

We’ve been pretty open about our infertility. But we’ve struggled to know how much to tell family while we’re going through IUI cycles. The first cycle, we let family and close friends know. It was good to have people know and pray for us. But at the same time we didn’t want to be talking about it heaps because conceiving is a private matter normally, so it does feel strange telling people about it. And then there is the disappointment of no pregnancy and needing to tell people who are disappointed for us. I felt bad as they had their own grief about it. So we’ve not told people much about subsequent cycles. We’ve talked to a few people and it’s really nice. However, family does like to know and a few have expressed disappointment that they didn’t know. I’m not sure what the answer is.

Failed expectations can mean couples put pressure on themselves, which may increase stress levels further.

Stresses of infertility

With infertility comes a loss of control—loss of control over one’s body, one’s life. As yet another monthly period comes, the sense of failure and frustration can increase. Stress can be experienced in a number of areas.

Marital stress

Authors Sandra Glahn and William Cutrer have good advice for couples struggling with infertility; the relevant chapter in their book is subtitled, ‘She wants a baby; he wants his wife back’. It reminds me of Hannah’s husband, Elkanah, who said to his distressed, infertile wife, “Hannah, why do you weep? And why do you not eat? And why is your heart sad? Am I not more to you than ten sons?” (1 Sam 1:8). Some things never change.

After explaining how infertility affects men and women differently, the authors give some advice to limit the stress. Given that women often complain their husbands don’t listen, the authors have found that it can be helpful for couples to agree ahead of time to limit their talk about infertility to 20-30 minutes a day. This motivates the woman to focus on the most important things she wants to communicate, and lets the man know there are limits to the amount of energy she expects him to spend focusing on infertility for that day. Most couples don’t spend enough time talking to build a healthy relationship anyway, so it is good for the marriage if both of them can discuss other things (that includes you, husband!). As they communicate and the husband begins to recognize the grief triggers for the wife (pregnant women, babies) and responds, her needs are met, and he gets what he wants—a happier spouse.[42]

Most couples report having less sex after a diagnosis of infertility. What was once pleasurable intimacy becomes ‘love by the calendar’. It is important to take time for physical intimacy. Glahn and Cutrer suggest that by separating ‘lovemaking sex’ (where you take the time to be close) and ‘baby-making sex’ (where you just get the job done), couples can maintain marital intimacy despite the pressures of treatment.[43] It’s worth a try. Afterwards, it took a long time to get it back to normal, said Lara.

Women and men usually grieve differently. Although infertility hits both men and women with self-image challenges, these are expressed in different ways. For her, it attacks her womanhood; for him, it challenges his virility. Linda felt that her body had let her down: Part of being a woman is being able to be a mother. I can’t do what I was made to do. I wonder if this is partly influenced by the habit we have of saying it is the wife who can’t have children, even when we know it takes two. If men can perform the act, they are thought to be fertile. Consider the Bible: sure, Elizabeth was past menopause when she became pregnant, but she had been married for a long time before menopause occurred. Is it possible that Zechariah had a low sperm count (Luke 1:5-25)?

Yet it is just as difficult for men. I felt emasculated, humiliated, one man said of his medical assessment where he discovered he was ‘undersized’. IVF nearly wrecked our marriage. He felt very guilty knowing that, even though his was the abnormality, most of the IVF treatment was going to be his wife’s burden. The treatment options were deeply unfair and inequitable. We’ve worked out that my wife had 200 injections over the course of the treatment. I had two. She suffered the hormone treatment, the scanning, the surgical collection of eggs, the psychological hell of embryo transfer and the two-week wait for a result. So that was tough, knowing that I was the reason for her pain. He felt that during their infertility his masculinity hung in the balance. In my head, I know infertility just happens. It does not reflect who you are as a man. But when you can’t give your wife what she wants more than anything else in the world, and you know that any other man could, it’s impossible not to take it personally.[44] This is a problem that men just don’t talk about—having their manhood on the line. Some research has indicated that infertile men report a 42% decrease in their level of sexual satisfaction after diagnosis.[45]

Even though some research suggests there is a higher rate of marital breakdown during infertility treatment, some couples find that they come through stronger and closer than ever, with the sentiment, ‘If we can survive that, we can survive anything’.

Emotional stress

It is normal for men and women to feel emotional when they fear infertility. We have a reassuring example in Hannah, who wept and wouldn’t eat and was so disturbed in her prayers that Eli the priest thought she was drunk (1 Sam 1:1-14). The Lord did not reprimand her for her behaviour, but “remembered her” (v. 19). By looking at the psalms, we know that God wants us to be honest with him.

One of the hardest aspects of infertility is the death of all the dreams the couple shared. It is difficult for them to see their friends having children, then yet more children, while they are struggling with daily injections. Then the teenage girl down the road gets pregnant without even trying. The process of fertility treatment can take a long time, and it may take years for the couple to finally recover from the grief. It waxes and wanes with each cycle. While everyone grieves differently, many people will find they go through some, or all, of the classic stages of grief described by Elisabeth Kübler-Ross (not necessarily in this order): denial and isolation (“this is not happening to me”), anger (“how dare God do this to me”), bargaining (“if you will just let me”), depression (“what is the point?”) and acceptance (“I’m going to be okay”).[46] People come to terms with their situation in their own way. Those stuck in this process may benefit from counselling to help work through it.

Spiritual stress

A common experience for those suffering from infertility is the long journey to a place where they can believe God is good and know that they still trust him. A woman familiar with the problem wrote:

It’s easy to say you trust God, but it takes a lot longer to actually mean it—and mean it to the point where you can honestly say that whatever God’s will is, you are content to accept it. And while this end point is the Lord’s work, you also have to work hard to get there. There is no way to circumvent or hasten the learning process.[47]

Well-meaning advice

I remember once, years ago, a friend tearfully telling me that she and her husband had just been told they would never be able to have children. I reached for her hand and said earnestly, “God must have something better in mind for you”. She pulled her hand away and said, “What could be better than having your own child?” I thought about our two little girls asleep in their beds, and at that moment I couldn’t think of anything to say.

There seems to be no end to the variations of saying the wrong thing when it comes to infertility. There are whole websites dedicated to listing the insensitive comments and uninvited advice that infertile patients suffer. It is hard to know where to start listing them:

• You’ve been married for years now—when are you going to have a baby?
• Just relax! (This is a big favourite.)
• You really need to pray about it.
• Maybe you’re not doing it properly!
• What kind of underpants does your husband wear?
• I know just how you feel…
• I know someone who… then fell pregnant.
• At least you can have fun trying!
• Want kids? You can have mine!
• Don’t worry—just keep trusting God.
• At least you have…
• You can always adopt.
• You think you’ve got problems? Well…

The problem with these sorts of comments is that, while they may be said casually or even seriously, they can be very hurtful to those on the receiving end. There are several types of comments that are common: the ‘personal’ comment, which is just plain rude; the ‘cheer up’ comment, which is inappropriate; the ‘don’t worry it will be fine’ comment, which may not be true; the ‘fix-it’ comment, which won’t work; the ‘spiritual pep talk’ comment, which is just plain irritating because they don’t need reminding that God is involved. Finally, the ‘trite’ comment attempts to deal with the situation by minimizing the grief of the infertile. That will only make them feel worse.

Within the Christian community there will be many people with good intentions and no idea what to do or say (I can attest to that). For those wanting to help, here are some tips to consider:[48]

1. Be there for them. For me, one of the most powerful biblical examples of empathy is found in Job 2, where Job’s friends decide to go and comfort him:
   

   And when they saw him from a distance, they did not recognize him. And they raised their voices and wept, and they tore their robes and sprinkled dust on their heads toward heaven. And they sat with him on the ground seven days and seven nights, and no-one spoke a word to him, for they saw that his suffering was very great. (Job 2:12-13)

   Never underestimate the power of just being with someone who is suffering. It’s okay to say nothing. At these times we are comforted by human presence.

2. If you do want to say something, keep it simple. “I’m sorry” can be enough. You’re not being asked to fix the problem.
3. Be sensitive in the way in which you give spiritual encouragement. It is natural for Christians to want to help their brothers and sisters with biblical exhortations of the goodness of God. But this is not the time for intellectual answers. As theologian Don Carson suggests, “Doubtless it is true… that ‘in all things God works for the good of those who love him’” (Rom 8:28), but it is less obvious that it should be quoted to a suffering couple:
   

   If they know the Lord well, then perhaps, with time, they themselves will cite the verse with renewed faith and understanding; but it should not be thrust at them in the wrong way, or at the wrong time, or without tears, lest it seem like a bit of cheap ritual, miserable comfort, heartless proof texting.[49]

4. The warmth of touch—a handshake, a pat on the back, a hug, whatever is appropriate for your relationship—can go a long way.
5. Let your infertile friends express their honest feelings without you judging them. The Bible is full of examples of people who became angry and frustrated and expressed their grief to God, who comforted them. Look at the psalms. I wonder if one of the reasons no-one talks about their infertility is the hurtful things people say to them when they try. This creates barriers and makes it difficult to offer them support; it would be good to see this change. Think carefully about the questions you could ask a childless couple, such as “Have you thought about having children?” There are ways of asking questions that are gentle, especially in the context of an ongoing relationship. Consider how to ask questions that convey interest, concern and love, that are sensitive, and that provide them with an opportunity to say as much or as little as they feel they can. The couples I have spoken with would love to be asked, but it is often the way they are asked that makes the difference. If they share, try to stay on the topic with them. Listen and don’t change the topic just because you find it too hard. Listen and ask them what it is like for them, and this will help. Pastoral care worker Jill McGilvray suggests:
   

   When we listen to someone who is hurting we help to carry their burdens. If we rush in with so many words, we risk adding to it instead. Your aim is to create a comfortable space for someone, where they will feel safe to talk.[50]

6. Acknowledge their mourning. We are told to “Rejoice with those who rejoice, weep with those who weep” (Rom 12:15). This is not a time for being cheerful. Statements such as, “It must be so hard” are better than, “It’s not so bad”.
7. Pray for them and with them. Ask them what they want prayer for. Don’t just pray for them to fall pregnant; pray they will be content, whatever the circumstances, and that they will grow in their trust in God.[51]
8. Initiate acts of kindness and don’t wait to be asked. Sometimes coping with pain takes all your energy and you don’t know what others can do for you, even when they ask. Take the initiative and either make a specific offer (“Can I mow your lawn?”) or just go ahead and help, if you know them well enough. Drop off a meal—everyone needs to eat.
9. Be patient. Mari said, I remember going to Bible Study for years and the only prayer point I ever had was that I wanted to have a baby. Even if it takes a long time, hanging in there with them will make a big difference to the couple.
10. Be aware of childless couples in your congregation or Bible study group and don’t make assumptions about why they are childless. Ask sensitive questions of them, draw them into fellowship, and don’t let their childlessness be a barrier. When mothers are together they naturally chat about their children, but what if there is a woman in their midst who has no children? What is it like for her? At church the couples with children join together and the childless couple can feel excluded. Work out how to include them and share your family—your children—with them. Break that barrier. Some couples experiencing infertility have ‘church-shopped’ because they have felt so excluded and odd, but when a couple is so fragile and so vulnerable, this is how they will feel. Be especially sensitive at times like Mother’s Day and Father’s Day. These are not happy times for everyone.If you want to be sensitive but you’re not sure how, it can help to just ask infertile friends directly what you should do. For example, it is difficult to predict how they will feel when they’re around other people’s children. Hayley and Andrew were asked if they wanted to come to a first birthday party, or whether they’d prefer not to come. Hayley responded, We’d love to come—it does hurt to see our friends’ families, but it hurts more to be excluded from their lives. Judy, on the other hand, decided it was just too painful to be around children, so she stopped going to the women’s Bible study and socialized with her friends who didn’t have kids.

How to handle the comments if you’re on the receiving end

It does help to think ahead about how you would handle some situations. You can’t explain everything to everyone, so sometimes it’s best to smile and move on. Try to forgive the tactless as Jesus requires, even “seventy-seven times” (Matt 18:21-22).

Online chat rooms and networking sites like Facebook have made the issue of difficult comments much harder for many people; news of a new baby travels quickly on these sites and this can be confronting for those struggling with their own fertility. Polly, undergoing fertility treatment for 4 years now, described how she felt when she read a girlfriend’s post: “Your daughter will hold your hand for a little while, but will hold your heart forever.” I know she wasn’t trying to hurt anyone, but it felt like she was kicking me in the gut. She feels bombarded by pictures of pregnant abdomens and baby ultrasounds. In these situations, when it becomes too hard, it may be necessary to block your friend for a while. Polly noted, If I was smart I just wouldn’t go on Facebook any more, but then I’d lose touch with all my family and friends. It is an ongoing dilemma.

In other ways, however, the internet can connect infertile couples to online support groups with many other people who are going through the same problems they are. It can help to ease the journey when it’s shared with someone who understands. And if couples can manage to share their grief with their friends, they might be amazed by how many others have had the same experience. It’s like a club, Amy said. You don’t realize how many members there are until you become one of them.

Coming to terms with infertility

When I spoke to couples who had struggled with infertility, I always asked them to tell me the most important thing they would say to others in their position. Many times, the answer was, It’s okay to stop trying.

I have seen couples go to extraordinary lengths to find the money and the energy to keep trying with IVF. The injections, the blood tests, the medical appointments, the roller-coaster each month as they wait for the pregnancy test result to see if the embryo ‘stuck’. Those who opt for no treatment are also ‘trying’ in their own way. They may still have the monthly held breath of hope as they wonder, “Maybe this time…”

How do you know when to stop trying? Glahn and Cutrer suggest, “When it hurts more to go on than it does to quit, it’s time to quit”.[52] This works for some people, but not everyone would agree. At one point in Australia, ART received the government subsidy for only six cycles. When it became available for an unlimited number of cycles, while there was gratitude for the government’s generosity, it also meant that many couples lost a logical ‘cut-off’ point that allowed them to pull out gracefully. My wife was so obsessed she just couldn’t stop, said Paul. How could I tell her she had to stop? But that was our marriage for 12 years. In the end, it was only when she turned 40 that we were able to talk about doing something else with our lives. Stopping treatment can be made even harder because of the way it is described as ‘giving up’ or ‘failing’, with the implicit suggestion that such couples just aren’t committed enough, rather than using terms that affirm them for making a positive choice.[53] However, infertile couples really can’t win, because those who don’t stop are just as pitied, often being described as ‘desperate’. Kay told me, slowly, I wish I had been secure enough in my faith that I could look at not having children and know I could survive it.

Couples may find it easier if they think about the stopping point before starting treatment. It is not necessarily a negative approach; it simply means taking a realistic look at success rates. How far are you prepared to go to get a baby? Are there some treatments you definitely won’t try? Is there a limit to how much money you are going to spend? Is there a limit to how much of your married life you are prepared to dedicate to the quest for a biological child? Questions of Christian stewardship regarding use of time and energy should also be considered. How long should life be on hold regarding the work of the kingdom? These are significant questions. There is nothing wrong with wanting a baby, but once you want one at any cost, you have a problem. Be careful (1 Cor 10:14). When starting on the quest for a child, consider writing down your guidelines and the reasoning behind them. It may help later on.

When a couple decides to stop trying for a child—and only they can do that—it’s time for them to make decisions. Although there are many paths their lives could take, the essential question for them at this point is whether they want to try building a family by other means (e.g. adoption, foster parenting). In some places there are age restrictions on who is eligible, but spiritual parenting will still be an option.

Deciding to accept one’s infertility, to walk on and not look back, can be very hard and very sad. The anguish can take some couples by surprise. Grief at ending infertility treatment can last for years. You’re not just giving up IVF, said Patsy, You’re giving up hope. At the same time there may be some relief in knowing you can move on. There is no ‘right’ way to feel. You don’t stop feeling sad, said Tina, but it doesn’t keep hurting so much. There are many accounts of the rewarding lives Christians can lead as they seek first the kingdom of God, and childless couples will still have many joys in life—but it will not be the same.

It may seem like more than they can bear, but we all have this promise from God: “I will never leave you nor forsake you” (Heb 13:5). God does not minimize the loss. Let him help you.

What could be worse than losing a child? The death of the firstborn was the last and worst of the plagues in ancient Egypt, and the Lord knew it would bring “a great cry throughout all the land of Egypt, such as there has never been, nor ever will be again” (Exod 11:6).

King David and Job expressed their grief at the loss of their children in other physical ways—David fasted, lay on the ground and wept (2 Sam 12:15-23), and Job tore his robe, shaved his head, fell on the ground and worshipped (1:13-20). Jeremiah prophesies King Herod’s ‘slaughter of the innocents’ (Matt 2:16-18) by describing Jacob’s wife, Rachel, grieving inconsolably over the lost children of Israel at the site of her tomb:

“A voice is heard in Ramah,

lamentation and bitter weeping.

Rachel is weeping for her children;

she refuses to be comforted for her children,

because they are no more.” (Jer 31:15)

It is only in the new heaven and the new earth that God will wipe every tear from our eyes (Rev 7:17, 21:4).

Any type of pregnancy loss is a devastating experience for the parents. Yet it is a strange grief, because you are mourning for someone you have never met. It often goes unnoticed by others, and can become a lonely journey for those who experience it: isolated, alone, confused, and gut-wrenchingly sad. Some aspects are experienced in common but every story is unique. It is thought that one in four known pregnancies ends in loss.

Different types of pregnancy loss

Pregnancy loss can be confusing because there seem to be so many names for the same thing. There is no internationally agreed list of terms to describe many of the events in pregnancy, and some terms have persisted that were developed before ultrasound was available for accurate diagnosis. Changes in terminology have been recommended to clarify these events, which would be helpful in improving data collection and research in this important area.[1] Unexplained stillbirth in late pregnancy is the single largest cause of death in perinatal life in the Western world. The lack of understanding about what causes pregnancy loss is a problem that must be addressed.

Below, I list different types of pregnancy loss and the various names that can be used to describe them. Categories marked with an asterisk (*) are not technically the kind of pregnancy loss that would be investigated as outlined below under ‘recurrent miscarriage/recurrent abortion’, but as parents may have a similar response regardless of the cause of the loss, they are included here. 

Miscarriage/spontaneous miscarriage/spontaneous abortion*

These terms refer to the ending of a pregnancy before 20 weeks gestation, a time when the baby is unable to survive independently. It involves the spontaneous expulsion of the baby from the womb. The loss may occur anywhere. There will usually be heavy bleeding, possibly blood clots and abdominal cramping like period pain. Sometimes there is a sudden release of fluid out of the vagina if the waters break. The cervix opens and the developing baby comes out with the blood. Sadly, there is little that can be done to prevent a miscarriage once it is underway.

It can be distressing for women who have the medical term for this—’spontaneous abortion’—written in their medical records, as non-medical people can confuse it with ‘elective abortion’. This is one reason it has been suggested that the term no longer be used.

Many women miscarry without even realizing, especially in early pregnancy. They may mistake a miscarriage for a late period. The miscarriage may be complete, which means the uterus is emptied, or incomplete, which means some tissue is left in the uterus and the mother will need a dilation and curettage (D&C) of the uterus under general anaesthetic to remove it. There is a risk of infection if this is not done.

Stillbirth

This term refers to a baby who dies before or during birth. The WHO definition of stillbirth is a birth weight of at least 1000g or a gestational age of at least 28 weeks (third-trimester stillbirth). However, there is still no international standard to define when a baby is considered stillborn. In Sweden, babies are considered stillborn at 28 weeks. In the United Kingdom it is 24 weeks. In the United States and Australia, a baby who has passed the 20-week mark is considered stillborn, while in Norway it is at 16 weeks.[2] Most stillborn babies are delivered naturally after the mother has gone through labour, even if it is known that the baby is dead before labour starts. In many places, stillborn children need to be legally registered as a birth and a death. Approximately half of stillbirths occur prior to 28 weeks of gestation and about 20% are at, or near, term.[3]

I just felt numb when I was told [that my baby had died]. And terrified that I had to give birth, remembers Rhea.

Blighted ovum/anembryonic pregnancy/early fetal demise/empty sac*

These terms describe a pregnancy where the egg is fertilized and implantation occurs in the uterus, but an embryo does not develop. There will be symptoms of pregnancy and there may even be an empty gestational sac in the womb on the ultrasound. 

Threatened miscarriage/threatened abortion

These terms refer to any vaginal bleeding before 20 weeks. There may or may not be cramping. The cervix is closed. Spotting (losing very small amounts of blood) in early pregnancy is common. Women experiencing spotting or bleeding during pregnancy should check with their doctor or midwife to see whether there is a problem. Up to half of these women will go on to have a miscarriage, but the rest of the pregnancies will continue normally. Tests may be done to check what is happening. Even when I went for the ultrasound, it was so surreal. I couldn’t believe this was happening to me. This was something that would only happen to someone else, said Jan.

Missed miscarriage/delayed miscarriage/missed abortion/intrauterine death

This occurs when the embryo or fetus has died but a miscarriage has not yet occurred. Women who experience this may not know there is a problem until they have a routine check-up.

Wendy didn’t know she had miscarried the first time until she saw her doctor. He couldn’t find the heartbeat. An ultrasound was done to check on the baby, but the baby had died and was still inside her. This was extremely upsetting. How could I not know there was something wrong with my baby?

The mother may be allowed to choose whether to have a D&C (also called an ERPC—evacuation of retained products of conception) or to wait until labour starts so she can deliver the dead baby naturally.

Recurrent miscarriage/recurrent abortion

This refers to three or more consecutive miscarriages by the same woman. It is at this point that most women would start to have tests to discover the cause.

Ectopic pregnancy*

This term denotes a pregnancy where the embryo implants outside the uterus (usually in the fallopian tube), where the baby will not survive. It is a serious situation that is potentially fatal for the mother and requires urgent treatment. An ectopic pregnancy can be especially hard to cope with when the emergency situation may prevent a woman from fully comprehending that not only is she losing the baby but also her chances of having another baby in the future may be reduced.

How common is recurrent pregnancy loss?

A 1988 study found that the total rate of early pregnancy loss after implantation, including clinically recognized spontaneous abortions, was 31%. Most of the 40 women in this study with unrecognized early pregnancy losses had normal fertility, since 95% of them subsequently became clinically pregnant within two years.[4]

Across the globe, around 3 million babies are stillborn every year—more than 8200 babies a day.[5] Although 98% of these deaths take place in low-income and middle-income countries, stillbirths also continue to affect wealthier nations, with around one in every 300 babies stillborn in high-income countries.[6] This translates to around 6500 per year in the United Kingdom and around 2000 in Australia.[7] While no accurate data is collected in the United States, it is thought to be around 26,000 every year.

An Australian study found that, on average, for every 10 women aged between 28 and 33 years who had ever been pregnant, 5 would have had a birth only, 2 would have had a loss only, and 3 would have had a birth and a loss.[8]

Causes

After a pregnancy loss, there can be an overwhelming need to find out why it happened. Many people will spend time searching the internet for answers, but there is a lot of inaccurate information out there. Check with your doctor if you have questions about information you have found.

Although there are still many unknowns, some causes for pregnancy loss have been recognized. Miscarriage and stillbirth occur along a time continuum of nine months, so the conditions that can cause them do overlap.

Miscarriage

It is still not known what causes many miscarriages, but it usually seems to be because a pregnancy is not developing normally. Most miscarriages occur in the first trimester (first 3 months of pregnancy). The most common known cause (over 50%) is genetic abnormality (abnormal chromosomes).[9] Many non-chromosomal problems have also been associated with miscarriage—these include hormonal abnormalities, physical abnormalities (e.g. an abnormally shaped womb or a weak cervix), platelet problems, environmental exposure to toxins, infections and immunological factors.[10]

Stillbirth

There is still a lot of research that needs to be done to discover the causes of stillbirth. Researchers talk more about ‘associations’ than ‘causes’. In 2011, the top 5 known causes of stillbirths assessed worldwide were:

1. childbirth complications (such as pressure on the umbilical cord, which cuts off the baby’s blood supply, or a problem with the placenta such as it tearing away from the uterus wall)
2. maternal infections in pregnancy
3. maternal disorders, especially hypertension (high blood pressure) and diabetes
4. fetal growth restriction (small babies)
5. congenital abnormalities (such as lethal chromosome disorders and malformations in the baby).[11]

In high-income countries, placental problems and infection associated with preterm birth are linked to a substantial proportion of stillbirths.[12] Good antenatal care reduces the risks.

Is there anything that can be done to reduce the risk of miscarriage or stillbirth?

Stillbirth rates in high-income countries declined dramatically from about 1940, but this decline has stalled in recent years. The present variation in stillbirth rates across, and within, high-income countries indicates that further reduction in stillbirth is possible.[13] Since we don’t know what causes many miscarriages and stillbirths, much interest centres on what puts a couple at increased risk of pregnancy loss.

Research into risk factors hopes to find ways to reduce the frequency of pregnancy loss. The identification of risk factors is intended to help parents, and not to make anyone feel guilty. Remember that risk factors can influence the outcome, but they have not been proven as a definite cause. They are certainly not grounds for blame. Obviously, the risk factors we most want to know about are those we can do something about. Potentially, as many as 40% of stillbirths could be due to the three combined risk factors of maternal age over 35, history of smoking, and being overweight or obese (Body Mass Index [BMI] over 25). These factors also carry an increased risk of miscarriage.[14] It is not unethical to try and reduce risk factors, so long as we are mindful of the need to be wise stewards of our time and our money, and we do not allow it to interfere with relationships.

Advanced age

The majority of early miscarriages are thought to result from chromosomal defects, and the only known risk factor for that is advanced maternal age (greater than 35 years).[15] One study found that while younger women (20-25 years) had chromosomal abnormalities in 17% of their eggs, by 40-45 years this figure had risen to 79%.[16] There is some evidence that increased paternal age (greater than 40 years) may also contribute.[17]

Smoking

If a mother continues to smoke cigarettes, the risk of the baby dying during pregnancy increases by about 30%.[18] It is important to give up smoking before getting pregnant, even though this may be very difficult. Try to avoid second-hand smoke as well, because even if the smoke comes from someone else’s cigarette, it can still cause problems if you breathe it in.

Obesity

Apart from increasing health risks to the mother, obesity also increases the risks of miscarrying a normal baby and recurrent miscarriage. Some studies also show an increase in stillbirths.[19] (There may also be a risk if the mother is underweight before she gets pregnant,[20] so aim for a normal BMI of 20-25.) I know it’s not politically correct to say someone should lose weight, but you only need to see the tragedy associated with this reversible problem before you say it anyway.

Illegal drugs

Cocaine use increases the risk of miscarriage in the first trimester, and heroin use increases the risk of the baby dying in pregnancy or soon after.[21]

Previous miscarriage or termination of pregnancy

There does seem to be some association between pregnancy loss and past history of pregnancy loss, but research results are mixed.[22]

Caffeine

Some research has indicated a link between miscarriage and the consumption of drinks containing caffeine. A much-publicized study in 2008 suggested that pregnant women who have 2 or more cups of caffeinated drinks a day have twice the risk of having a miscarriage than those who avoid caffeine.[23] By 2 drinks they mean 200mg of caffeine, which is equivalent to 2 mugs of instant coffee, or 4 cups of medium-strength tea or hot chocolate, or 6 cups (5 cans) of cola per day. If you get your coffee from a café you may be getting more than 200mg of caffeine in one cup, depending on the beans and how it is made. For example, Robusta beans generally contain more caffeine than Arabica beans. (200mg is less than a ‘tall’ Starbucks coffee.)

The study’s authors suggested that women who want to become pregnant should stop drinking coffee for 3 months prior to conception and throughout the pregnancy.

Maternal health

If the mother has health issues such as hormone problems, diabetes or immune disorders, there can be an increase in the incidence of pregnancy loss. However, good control of these conditions before and during pregnancy will reduce the risk.

Regular or high alcohol consumption

This link is not definitely proven, but there is increased risk of stillbirth with heavy drinking, binge drinking (5 or more drinks in a row) and having more than 3 drinks a week in the first trimester.[24] It’s safest to avoid alcohol altogether.

Exposure to toxins

High mercury levels can lead to miscarriage. To be safe, pregnant women should avoid sushi, limit their consumption of fish high in mercury levels (such as tinned tuna), and eat fresh cooked fish no more than 2-3 times per week. It’s also good to try to reduce exposure to household pesticides and any toxic chemicals in the workplace.

Experiencing stress

Feeling stressed or anxious—whether from recent emotional trauma, major life events during pregnancy or stressful employment—has been linked to an increased risk of miscarriage, but study results are mixed. Feeling happy and relaxed, or well enough to have sex, may reduce risk[25] (vaginal intercourse can’t harm the baby during pregnancy and doesn’t cause miscarriages[26]). This is a difficult issue for those couples who have already experienced a pregnancy loss, because it is hard to relax completely when you worry about whether it will happen again.

Antenatal infection

If the mother contracts an infection such as rubella, listeria, chlamydia or toxoplasmosis in early pregnancy, the risk of miscarriage or stillbirth later in pregnancy is increased. Other infections such as cytomegalovirus, parvovirus and Group B streptococcus can also cause problems. Women should check with their doctor or midwife if they are concerned.[27]

Rubella infection (German measles) is best avoided by vaccination against the disease; women of child-bearing age should consult their doctors.[28] Other ways to reduce the risk of rubella infection include staying away from those who are known to be suffering from rubella and those who have been exposed to the disease.

Listeria infections are reduced by not eating contaminated foods. In order to do this, it is best to avoid unwashed vegetables, uncooked meats and fish, unpasteurized milk products (watch out for soft cheeses like brie), cooked delicatessen meats, refrigerated smoked seafood, chilled pâtés and spreads, and ready-prepared meals. Listeria bacteria are destroyed by cooking and pasteurization, but not by refrigeration. Although some foods—such as cold cuts of meat and ready-prepared meals—are already cooked, they can become contaminated with listeria when they are chilled.

Chlamydia infection is a sexually transmitted disease. There is a risk of infection from unprotected anal, vaginal or oral sex with someone who is infected. To avoid infection, a condom should always be used during sex; this is especially important if either partner has had multiple partners.

Toxoplasmosis is an increased risk when cleaning the litter box of an outdoor cat, which might have eaten an infected bird or mouse; so too is eating undercooked meat.

Antenatal screening tests

Two tests that are used in normal pregnancy to screen the baby for disease can cause miscarriage. These are amniocentesis (1% risk) and chorionic villus sampling (CVS; 1%-2% risk). Note that these tests do not need to be performed.[29] Therefore, this risk can be completely eliminated.

Fetal reduction

This procedure involves the abortion of all but one or two fetuses in a multiple pregnancy so that the remaining ones have a better chance of developing normally. The risk of miscarriage is 5%-10%.[30] Note that this procedure is unethical for those who wish to protect life from its beginning.[31]

Post-term (over 40 weeks) gestation

While most miscarriages occur in the first trimester, there is also an increased risk of pregnancy loss after 40 weeks gestation (this is thought to contribute to about 1% of stillbirths).[32] This has raised the question of whether labour should sometimes be induced rather than waiting for it to happen naturally. It is important to get regular antenatal care so the progress of your pregnancy can be monitored.

Growth restriction

A significant number of stillbirths are associated with restricted growth in the baby.[33] This is known to be associated with a reduction in fetal movements. The mother’s perception of whether she has experienced a decrease in movements for 24 hours is thought to be a reliable guide. The way to find out if fetal kicking is reduced is to count, once a day: in the third trimester, some practitioners will recommend that the mother spends some time each day counting the baby’s kicks. There are lots of different ways to do these ‘kick counts’, so she should ask for specific instructions.

Here’s one common approach: choose a time of day when the baby tends to be active (it’s preferable to do this around the same time each day). The mother should sit quietly or lie on her side to avoid distractions and then she should time how long it takes to feel ten distinct movements—kicks, punches and whole body movements all count. If she doesn’t feel ten movements in two hours, she should stop counting and call the midwife or doctor.[34] It is advisable to avoid comparing notes with other mothers, as every baby has their own routine.

While there is some debate as to the value of fetal movement monitoring (because of the variation in what is ‘normal’ and the risk of increasing anxiety unnecessarily), a trial which is currently underway in Australia has not only demonstrated that there is an association between a decrease in the mother’s perception of fetal movements and stillbirth, but also that 59% of women were not given any specific information regarding fetal movements during their pregnancy.[35]

Diet

A British study found an association between a reduced risk of miscarriage and eating fresh fruits and vegetables daily and using vitamin supplementation before and during pregnancy (in particular, folic acid, iron, iodine and multivitamins).[36] Plus—some good news, at last—eating chocolate daily was also associated with a reduced risk of miscarriage in the first trimester.

Of all these risk factors, the most important to address in high-income countries are obesity, smoking and advanced maternal age.[37]

Investigations

In most places, one miscarriage in the first trimester does not warrant having any tests because it is so common. If a woman has a miscarriage in the second trimester, or two or three first-trimester miscarriages, her doctor may suggest some tests to try to work out what is causing the miscarriage, in case there is something that can be done to prevent it. All stillbirths should be investigated.

These tests may include:

• blood tests to check for chromosome abnormalities (both parents), hormone or immune problems (mother only)
• tests on the baby’s body looking for chromosome abnormalities
• ultrasound or x-ray of the uterus
• endometrial biopsy (suctioning a small piece of the tissue from the uterus lining to check that the hormonal changes are normal).

Genetic screening

Sometimes when a woman has recurrent pregnancy loss, she will be advised to become pregnant using assisted reproductive technology (ART)—in particular, in vitro fertilization (IVF) with preimplantation genetic diagnosis (PGD) screening of the embryos. The idea is that if the miscarriage is due to chromosomal defects, you can check the genetic profile of the embryos created before they are implanted, so that only the normal ones are transferred (one at a time). The rest are discarded. This is not an ethical option for those who value human life from the time of conception.[38]

Living through a loss

There are several things that make the loss of a pregnancy at any stage difficult to cope with. One can be the lack of public acknowledgement, particularly if the loss is early in the pregnancy. Another is that the loss is rarely expected; one moment the parents are full of dreams about the coming baby, decorating the nursery and welcoming this little one into their lives, and the next moment it’s gone. Sandra said, I thought it was getting pregnant that was difficult. No-one told me that staying pregnant is just as hard. Ruth said, I can’t get excited about anyone’s pregnancy now. I always wonder if something will go wrong. These losses are so frequent, yet as a society we really aren’t very good at dealing with them.

In the delivery room—stillbirth

It may or may not be known beforehand whether the baby has already died or will die soon after delivery. If there is advance warning, plans can be made for the delivery ahead of time so that the parents can make the most of the short time they will have with the baby. Even if the stillbirth is unexpected, many of the suggestions in the box below can be followed.

One thing that parents of a stillborn baby often mention is how quiet the room is when a stillborn baby is delivered. No cry of a newborn baby, no calls of congratulation. Nothing.

They talk about a baby who was born sleeping, and then going home with empty arms. I do not think I can do justice to those parents who have suffered such a loss with my words alone. I recommend reading the texts listed at the end of this book,[39] to hear from those who have experienced the loss of a child in their own words.[40]

Other children in the family

If there are already other children in the family, thought should be given to how they will be told of what has happened or will happen. An open and honest approach is recommended; children can often cope better with loss than their parents. Don’t try to pretend it hasn’t happened, as it will affect them whether you tell them or not. Thought should also be given to whether they will be given the opportunity to see the baby. Ask them what their questions are, as you might not be aware of what they are thinking.

At the funeral for a stillborn sister, a little girl was listening to the sermon. Afterwards she asked her parents why the minister had said there would be no mourning in heaven. Before they could respond, she continued, If there is no morning in heaven, when will (my sister) wake up?[41]

Afterwards

Saying goodbye is hard. For Maisie, the most difficult time was leaving the hospital: I wasn’t prepared for it. It just hit me as we were driving out of the parking lot and I cried and cried. Grief may well up when it is least expected, and that’s okay.

Despite the difficulties of coping with a child’s death, parents still have to deal with the formalities, such as a funeral. This may be a time when the husband can contribute in a meaningful way while the mother recovers physically. The parents may find it helpful to mark the passing of their baby with some sort of ceremony, even if there is no body. It is a pity that our Western society has lost its traditions around death and that there is no recognized way to mark the passing of a baby through miscarriage or stillbirth. The Japanese have Mizuko kuyō, or ‘fetus memorial service’, which is a ceremony for those who have had a miscarriage, stillbirth or abortion. Temples usually sell statues for display near the temple, which, in some places, the parents dress up with little clothes. Parents say they have found the ritual comforting.

I think the closest thing we have in the West is a church funeral. What I felt was so important was the funeral. It enabled us both to plan and be active during that incredibly difficult week after her birth. It also enabled me to recognize her as a real person, who deserved a real goodbye. So it marked a very clear full stop to that terribly sad chapter of my life, and therefore enabled us to move on. Some hospitals provide memorial services to remember the babies who have died at that hospital. I have attended funerals for stillborn children that, although incredibly sad, were a wonderful testament to the value of every human life.

Parents may choose to make the funeral private or public, and they should be aware that there is no need to rush. Services can help extended family and friends acknowledge their loss too. Once again, it may be difficult. Roxanne and her husband decided to bury their child. She said, I was okay until they put him into the ground. Then I lost it.

If parents have had to register the birth, they will have given thought to naming their child. Even if the baby was too young for this requirement, it is still helpful to name the child in order to validate the birth and make verbalizing memories easier.

Some parents bury the child’s remains in their back yard and mark it with a cross or a tree. Some parents scatter the ashes in a special place. Some families have a formal burial. Close family and friends may have made clothes for the baby, which can be worn by the child at this special time. Jenny and Chris invited their children to put toys in the tiny coffin.

It may take a long time before the parents recover from their grief, and life for them will never be quite the same again.

Many families find ways to remember their baby as life goes on, perhaps with a piece of jewellery, or a memento displayed at home, or maybe each time they see a particular flower. Some families will celebrate the child’s birthday each year, or just keep remembering how old their child would have been had they lived. Each family finds its own way to remember the child who isn’t there.

Post-mortem examination/autopsy

While it can be distressing to think about having a baby’s body examined, it can sometimes provide an explanation as to why the death occurred, and it can contribute to medical understanding of stillbirth in general. It is hard for parents to think this issue through at such a difficult time (immediately after the birth), but only they can make the decision they feel happy with. It is possible to do some tests (such as swabs for infection, x-rays or genetic examination) without a complete autopsy. Results can take up to weeks and months to be completed; parents should discuss the findings with their doctor, as they are usually explained in technical terms, and they will want to know what should be considered for future pregnancies.

Psychological trauma and grief

In many places, there is no routine follow-up for patients who have suffered miscarriage, and so they do not receive the care they need at an emotional level. Miscarriage is known to lead to depression and anxiety, as well as grief. A 2009 survey by the Stillbirth and Neonatal Death Charity (SANDS) in the United Kingdom found that 81% of parents said they suffered depression after the death of their baby; 39% said it affected their physical health; and, 25% said they lost earnings because they had to change jobs or career.[45] The bereavement experienced by these parents may seem protracted and intense compared to other types of grief.

Some researchers have likened it to post-traumatic stress disorder, similar to that suffered by trauma victims.[46] High levels of guilt are common, as well as a sense of having lost part of oneself. There is no standard pattern of grief but talking about it is usually helpful, and although parents won’t forget, the grief does ease with time.[47]

One problem is that many people don’t realize it is grief they are experiencing. It may be the first time the parents have lost a loved one. They may need to be told that grief is a normal reaction to bereavement. The lack of acknowledgement of the miscarriage or stillbirth may mean that not even the parents consciously register that the death of a real person has occurred. Legitimizing the grief process can help parents move through it.

It is not uncommon for grief to be associated with a sense of physical fatigue. It can be difficult to sleep, concentrate or even communicate with others. Those who are grieving may seem withdrawn and depressed and it may be hard for them to get out of bed some days. It is important that they do not feel they are to blame for what has happened. They should not rush back to work. They should let themselves feel what they feel, because they have had a significant loss.

It is not unusual for mothers and fathers to grieve in different ways.[48] Mothers may have a more intense reaction and be more likely than fathers to cry with others. They are more likely to seek support, desire to talk endlessly about their baby, and be preoccupied by their loss. But this does not mean that fathers care less. It is difficult for grieving men in our society, where displays of male emotion are frowned upon. However, these fathers often have a preference for solitude, and may be unwilling to discuss the baby in social and work situations. They may feel a responsibility to be ‘strong’ for their wives and not share their tears, even with them; this can lead to couples feeling even more distant from each other.

Generally, the condolences—if there are any—are directed to the wife. That can leave husbands with very little support. Some may have had to go home from the hospital to an empty house with an empty cot in the nursery, although some will be allowed to stay at the hospital. One of the saddest stories I heard was of a new father cuddling his stillborn daughter with tears in his eyes, saying he just wanted to try and warm her up.[49] Fathers feel protective of their children as well as their wives, and it is a terrible hardship when there is nothing they can do.

A woman is more likely to feel a stronger sense of responsibility for the miscarriage, and guilt that her body has ‘let down’ both the child and her husband. She may feel she has failed as a woman. Self-blame is increased in those who have missed miscarriages, and in those where no cause for the miscarriage is identified.[50]

Even when they think they have recovered, a wave of sadness may hit these parents when they least expect it. There are ‘grief and loss’ websites for parents that can be helpful. Sometimes, when everyone around the parents is telling them to count their blessings, it helps for them to connect with other parents who are feeling the same way and not wanting their loved ones to be forgotten. You can count your blessings and still grieve your losses. Parenting after a loss can be complicated by the memory of the one(s) who didn’t come home. Counselling may be needed to sort through the confusing thoughts and emotions experienced.

Taboos

Susie turned to me at work and said, Why don’t we ever talk about it? I’ve been listening to stories about every baby that’s born, and I’ve never heard of one miscarriage. Miscarriage is still a taboo subject, which makes the grieving harder. Paul said, I wonder why? Is it because they are worried it might happen to them, or because they’ve been hurt by it themselves?[52]

It often helps to talk. It helps make the baby more real and helps people feel better. Words from bereaved parents may help others when it happens to them. So many people don’t know how common pregnancy loss still is. Even that term can be unhelpful; it wasn’t just a pregnancy that was lost—it was a baby.

Apparently some things have improved over the last few decades; there was a time when the parents would not get to see their baby. I once met an older woman who hadn’t been told whether her stillborn child was a boy or a girl. Her husband wasn’t even allowed into the delivery room.

It is hard to talk about a child who has died prematurely; we often do not know what to say. But it helps those who are grieving when others resist the desire to avoid the topic altogether. Sarah Williams, who found out that her child would die at birth, was grateful when a pregnant friend reached out to her across the gulf separating them. She remembered a verse of Scripture that instructs us to “rejoice with those who rejoice, weep with those who weep” (Rom 12:15). She writes: Both grieving and rejoicing are choices we must make actively out of love for one another within the resilience of community. Her friend chose to mourn with her as she learnt her baby would die. Later, Sarah would choose to rejoice with her friend when her baby was born. Both choices were costly.[53]

When should another pregnancy be attempted?

Everyone is different, but it is recommended that parents wait until the woman is physically and emotionally ready, and has had any tests recommended by the doctor, before attempting another pregnancy. Medically, it is safe after one normal menstrual cycle. Most women will have a period 4-6 weeks after a miscarriage. However, it may take much longer for parents to feel ready to try again due to the challenge of coming to terms with the loss.

Talking about the baby

Tammy says, At our church, on Mother’s Day they handed around chocolates to all the mothers. I didn’t get one, but I felt like saying, “I had a baby but she died”. Bereaved parents won’t want to explain things to everyone, but it may be that sometimes they will want to acknowledge the child that is not sitting beside them. If they think beforehand about how to say what they want to say, it might make it easier. And at church on Mother’s Day, give all the women a chocolate. No-one needs a reminder of those they have lost; even if they don’t have children, they do all have a mother. Williams notes: The thing about losing a child is that you do not just lose them once, but you go on experiencing the loss of what they would have been.[54]

Some parents call their little ones ‘angels’. Christians are aware that an angel is another type of being entirely. I think this usage just reflects the difficulties for secular parents attempting to find the vocabulary to talk about these things.

Theology

Where is God in all of this? These are challenging things to comprehend, so thinking about them before tragedy strikes can make things easier.

However, it does not always work out that way. If your sense of loss is still fresh, it may be better for you to look at the psalms, especially Psalm 23 and Psalm 90. Otherwise, read on.

One of the things I love about the Bible is the way it helps us understand why the world is the way it is. Reading the book of Genesis helps us understand how we should respond to bereavement; sickness, death and grief are now unavoidable realities in our world because of human sin and God’s judgement.

We all know the story. God said to Adam, “You may surely eat of every tree of the garden, but of the tree of the knowledge of good and evil you shall not eat, for in the day that you eat of it you shall surely die” (Gen 2:16-17). But Adam and Eve, persuaded by the serpent, ate of the prohibited fruit. As a result, God told Adam that he would return to the ground from which he was taken: “for you are dust, and to dust you shall return” (Gen 3:19b). And they were banished from the garden so they could not eat from the tree of life and live forever (Gen 3:22-24).

Death came into the world with the Fall, rendering this life “vanity and a striving after wind” (Eccl 1:14). Death is the last enemy to be destroyed (1 Cor 15:26). It is not what God originally planned for us, and we are right to find it an outrage.

Ecclesiastes is one book of the Bible that clearly talks about the transience of life on earth:

If a man fathers a hundred children and lives many years, so that the days of his years are many, but his soul is not satisfied with life’s good things, and he also has no burial, I say that a stillborn child is better off than he. For it comes in vanity and goes in darkness, and in darkness its name is covered. Moreover, it has not seen the sun or known anything, yet it finds rest rather than he. Even though he should live a thousand years twice over, yet enjoy no good—do not all go to the one place? (Eccl 6:3-6)

The life of the stillborn child is compared to that of a rich man. The child has no identity and no opportunity to develop character or personality. It has no experience of life. And yet the Preacher thinks the child is better off for being spared the prolonged misery of the dissatisfied rich man who, like each one of us, will also die.

As Job protests against his suffering and curses the day of his birth, he cries to God:

“Let the day perish on which I was born,

and the night that said,

‘A man is conceived’…

because it did not shut the doors of my mother’s womb,

nor hide trouble from my eyes.

Why did I not die at birth,

come out from the womb and expire?

Why did the knees receive me?

Or why the breasts, that I should nurse?

For then I would have lain down and been quiet;

I would have slept; then I would have been at rest…

Or why was I not as a hidden stillborn child

as infants who never see the light?” (Job 3:3-16)

In this passage, Job—out of desperate grief and sorrow—proclaims the life of a stillborn child to be a blessing compared to the intolerable suffering he has just experienced.

Experiencing the harsh realities of our existence, becoming acquainted with grief as the unthinkable happens, and realizing, as we protest helplessly, that sometimes parents must bury their children, we “groan inwardly as we wait eagerly for adoption as sons, the redemption of our bodies” (Rom 8:23). God knows how much we suffer. “Likewise the Spirit helps us in our weakness. For we do not know what to pray for as we ought, but the Spirit himself intercedes for us with groanings too deep for words” (Rom 8:26). And we are not left alone: “for you have been my help, and in the shadow of your wings I will sing for joy. My soul clings to you; your right hand upholds me” (Ps 63:7-8).

There may be times when we doubt the goodness and sovereignty of a God who allows children to die before they are even born. But God knows how many days he has ordained for each baby before one of them comes to be (Ps 139:16). He reserves the right to take human life. Job recognized this when he said “Naked I came from my mother’s womb, and naked shall I return. The Lord gave, and the Lord has taken away; blessed be the name of the Lord” (Job 1:21).

It might be difficult to say that God is both good and sovereign, if the death of an unborn child was the only thing we could look at. But it isn’t the only thing; we can also look at a dearly loved only Son, who suffered and died for us on a cross while we were still sinners. God is also a parent, whose only begotten Son died before his time. And that tells us how much he loves all his children. “Behold, God does all these things, twice, three times, with a man, to bring back his soul from the pit, that he may be lighted with the light of life” (Job 33:29-30). In the words of Don Carson, sometimes God speaks to us in the language of pain.[55]

In Romans 5, we are told that even as death entered the world through one man, Adam, because of sin (v. 12), all men can now have eternal life because the Lord Jesus Christ died for us (vv. 8, 21) if only we will trust in him: “For the wages of sin is death, but the free gift of God is eternal life in Christ Jesus our Lord” (Rom 6:23). We will still mourn, but we know death is not the end.

If life is eternal, where are they now—these children who have died in infancy or in the womb? The Bible does not speak clearly to us on this matter. When King David was told that his son by Bathsheba would die, he fasted for 7 days while pleading with God for mercy. When his servants told him the child had died, they were amazed at his subsequent composure—getting up and washing, going to the tabernacle to worship, and asking the cook for some food. What was David trying to achieve by his praying and fasting? David tells us himself:

“While the child was still alive, I fasted and wept, for I said, ‘Who knows whether the Lord will be gracious to me, that the child may live?’ But now he is dead. Why should I fast? Can I bring him back again? I shall go to him, but he will not return to me.” (2 Sam 12:22-23)

He knew his God. He knew that his was a God of grace.

We know that David believed in a life after death (see Pss 16:10-11, 17:15). Some commentators have understood his reply, “I shall go to him, but he will not return to me” (2 Sam 12:23) as indicating that children who die young go to heaven. This may be reading too much into the text. It is more likely to reflect the fact that although David did not have the full light of the revelation we have received through Christ, he was aware that there is a life after death, that the child still lived, and that he would join him when he also died.[56] Yet it shows David had the confidence to trust God and leave the child’s destiny in his hands.

In the Bible, death does not equal annihilation.[57] Jesus referred to relationships after death while engaging in a debate about the resurrection, in Matthew 22:23-32. He quotes Exodus 3:6 where Yahweh spoke to Moses from the burning bush: “I am the God of Abraham, and the God of Isaac, and the God of Jacob”. Jesus reminded the crowd that the use of the present tense in this Exodus passage reflects the unbreakable relationship that God’s people have with him beyond the grave, in a living union that continues to honour the covenant he had made with Abraham (Genesis 15). “He is not God of the dead, but of the living” (Matt 22:32).

Furthermore, God’s covenant is upheld even when we can’t see how it can possibly prevail. After the miraculous birth of Isaac, Sarah’s only child, we struggle to understand why God would ask Abraham to sacrifice his son (Gen 22:1-3). Why does God threaten the child of the promise? We see from the rest of the chapter that God was testing Abraham, and that he reaffirmed his promise after Isaac’s last-minute reprieve. Dale Ralph Davis observes that God is very kind in allowing us to see these events in the Bible, showing us that it can be a part of the normal Christian experience to think God is contradicting his own character: after blessing Abraham with a son, God appeared to be sabotaging his own plan. Abraham was praised for obeying God (Gen 22:18) even though he was walking in the darkness, unable to see the light. In Daniel 2:22 we read: “[God] knows what is in the darkness, and the light dwells with him”. I do not know what happens to those little ones who die before they are born, but I do know something of the character of our God. In Genesis 18, Abraham asked God for grace and mercy, on behalf of the people of Sodom and Gomorrah. He approached the Lord and said:

“Will you indeed sweep away the righteous with the wicked? Suppose there are fifty righteous within the city. Will you then sweep away the place and not spare it for the fifty righteous who are in it? Far be it from you to do such a thing, to put the righteous to death with the wicked, so that the righteous fare as the wicked! Far be that from you! Shall not the Judge of all the earth do what is just?” (Gen 18:23-25)

We do not know with certainty what happens to those infants whose passing we mourn. What we do know is this: the Lord and Judge of the universe can be trusted to do what is right. Even though we may be walking through the darkness, God knows what is there and the light dwells with him. He will keep his covenant with us.

Often we live in the here and now, at times forgetting that “the sufferings of this present time are not worth comparing with the glory that is to be revealed to us” (Rom 8:18). We will still weep—knowing that a little one is not going to suffer a lifetime in this fallen world will not make us miss them any less. But in the dark times we must try to look ahead to the resurrection (1 Cor 15:20-26), because “Death is swallowed up in victory… thanks be to God, who gives us the victory through our Lord Jesus Christ” (1 Cor 15:54, 57).

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.

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.

Most couples, when they are undergoing ART treatment, do not think about making decisions about leftover embryos. Once treatment is complete, the realization that there are frozen embryos excess to their needs often comes as an unwelcome surprise and an unforeseen ethical dilemma. It is the most common problem I find raised in counselling sessions with Christians.

A 2009 study from the University of California in San Francisco found that 72% of couples were undecided about the fate of their stored embryos. In 2008, it was reported to the House of Lords that 1.2 million human embryos had been destroyed in the United Kingdom over the previous 14 years, 82,955 of which were used in destructive research.[1]

Sally, pregnant with twins, said, I never thought there would be leftovers. I was only thinking about having a baby. Jodie said, I think someone may have mentioned it at the beginning, but my thoughts were completely consumed by the children I wanted. There wasn’t room to think of anything else.

Anne Drapkin Lyerly, a professor of obstetrics and gynaecology at Duke University Medical Center, agrees: ‘When you’re pouring your money, your heart, and your soul into creating an embryo and creating a life, the last thing you want to think about is how you’re going to dispose of it”.[2]

A couple may arrive at this point for several reasons. Their treatment may have been successful and they have as many children as they want. They may be finding treatment so stressful that they feel they cannot undergo any more cycles. Don said, We were planning to use all our embryos, but after having a scary emergency delivery and a baby in intensive care, we decided we’d been through enough. Sometimes the couple would like more children but cannot transfer the embryos for medical reasons. Sadly, couples may divorce during treatment. Whatever the reason, the embryos are there in the freezer, and their destiny is in the hands of their parents. Several studies testify to the difficulty of this decision.[3]

Research aimed at understanding how clinic patients manage this situation is in its early stages, and there is still much ambiguity in the results. But by looking at what has been done, we can start to get an idea of the extent of this problem and the challenges it holds for those involved.

One problem identified is that parents often have difficulty talking about their frozen embryos because they have no language to describe them. They have no words available to express their experience of having their potential child outside of the body and in cryostorage (frozen).[4] (I don’t think the parents are the only ones who struggle with this.)

Research suggests that many patients not only know very little about the technical side of freezing embryos but also do not demonstrate a need to know, their confidence in the medical team being enough. However, it has also been noted that patients tended to make comparisons between frozen embryos and food storage, possibly because we use the same words—‘fresh’ and ‘frozen’—for both. The idea that an embryo can reach its expiry date (as can frozen food) may reinforce the idea for some patients that the embryos are just ‘ingredients’ for their fertility treatment. This can be reflected at times in less concern for the embryo’s destiny (see below). Some patients did not realize they had any say in whether embryos would be frozen, but secretly felt that those embryos would be of poorer quality. At times they would create new embryos even though frozen ones remained. This indicates a need for further discussion at the outset of treatment about frozen embryos and their fate.[5] In fact, storage time has no effect on the success of a pregnancy.[6]

Most parents report that something happens to make them begin to start thinking about the leftover embryos—for example, the time limit for storage approaches, or the bill arrives for the clinic storage fees. Anne and David didn’t know what to think, so they paid the bill. The next year when the bill arrived, they paid it again. Adele asked, What do people do? Keep on paying, like me? A 2008 study in the United States of 1000 patients found that 20% of couples who wanted no more children said they planned to keep their embryos frozen indefinitely.[7]

According to a 2010 journal article, while there is no single statistic on the number of ‘surplus’ embryos in storage worldwide, it is estimated that there are roughly 400,000 frozen embryos in the United States, approximately 12% of which will not be used by the couples that are storing them.[8] Australia has up to 120,000 frozen embryos, up from 70,000 a decade ago[9]—although according to the clinics, some of these embryos may still be transferred. The United Kingdom has about 52,000. The number of such embryos is thought to be increasing due to the significant improvement in the technology of cryopreservation (freezing), and the increasing regulation that restricts the number of embryos that may be transferred during a single treatment cycle. At present there is no mechanism in place to minimize the number of embryos made for each couple. In Australia, the ethical guidelines for use in ART recommend that “Clinics must limit the number of embryos created to those that are likely to be needed to achieve a pregnancy”,[10] but as long as there is no correlation between the number of embryos created and the number of live births, it will be impossible to enforce such a recommendation. The maximum number will continue to be encouraged by the clinics (which won’t hurt success statistics, either). One hopes that there is no correlation between the increase in the number of embryos made and the number of embryos used for research.

Some countries, such as Italy and Germany, do not allow cryopreservation of embryos. Others, such as Australia, have statutory limits on the duration of storage; these vary from state to state. The United States also has state-based guidelines, but embryos may be stored indefinitely. In the United Kingdom, embryos may be stored for up to 10 years, with possible extension to 55 years. In Belgium, patients have to decide what they are going to do with possible leftover embryos (embryo disposition decision—EDD) before their first treatment.[11] The cost of storage varies between clinics, averaging between $300-$600 per year.

Professor Jenni Millbank, an Australian health law specialist, is aware of how difficult it is: “It’s a very, very painful decision and it’s one that many couples never consider they’ll have to make when they start down the IVF path”.[12] She notes that at the time of this decision, parents are no longer involved directly with the clinic for support and are not usually offered counselling. She agrees that it might help for clinics to forewarn patients at the outset of treatment about the possibility of surplus embryos. Certainly, I would suggest it is far better to think ahead and try to avoid this situation altogether by limiting the number of embryos created.

Some parents become conscious of the potential problem during their treatment. It can get complicated. Sandy found the prospect of having excess embryos one of the most challenging aspects of ART:

[Becoming concerned about the fate of excess embryos] was difficult, as I became consumed with the ethical dilemma of thinking what to do if something happened to me. What would happen to our children that had been created? And also what if my husband died—would I still have the embryos implanted? We thought through issues like me being pregnant with no husband; or having my sister carrying our children if I were to die; or adopting our embryos to another Christian couple if we both died. These were issues we hadn’t thought through before we began treatment, and if we had, we might not have frozen the embryos. We felt such an urgency to have our other embryos implanted after our first son was born. I remember feeling such relief after our last embryo was implanted that God in his goodness had allowed our embryos to have a chance in the womb.

Basically, there are 6 alternative disposition options for excess frozen embryos following completion of ART treatment:

1. Avoid the decision (thus discarding the embryo by allowing it to ‘expire’)
2. Continue storage
3. Thaw and discard
4. Use the embryos
5. Relinquish the embryos to another couple for reproduction
6. Donate to research

Not all of these options are always available, but we will look at each one in turn.

1. Avoid the decision

A substantial number of parents find it all just too hard, and walk away from their embryos. When the storage term is up for the embryos, if the parents are lost to follow-up and there is no-one to pay the storage costs, the embryos are usually removed from the freezer and allowed to thaw out and perish. Sometimes the parents will pay the storage costs but delay making a decision so that the embryos ‘expire’ legally and can no longer be used for further treatment, research or donation to others. But no decision is itself a decision when such arrangements are in place.

This phenomenon has not been closely studied, but may be associated with the idea some patients have that cryopreserved embryos are a bit like frozen food, which deteriorates over time. It may also be based on the idea of letting “‘nature’ take its course”, and thus seeking to avoid responsibility for the decision.[13] Similarly, a non-decision accompanied by prayer to allow God’s sovereign will to prevail is essentially a decision to abandon the embryo.

Whatever the motivation behind this decision, it is not consistent with the biblical responsibilities parents have for their offspring. The parent’s obligation goes beyond procreation, and continues during the child’s upbringing.[14]

2. Continue storage

This is basically the same decision as (1), except that the storage fees are paid and the decision is put off indefinitely. This is obviously not possible in those jurisdictions where storage time limits are enforced. This is one of the reasons time limits were introduced—because of the number of orphan embryos that were accumulating in clinic freezers.

In 2009, the United Kingdom’s Human Fertilisation and Embryology Authority debated whether frozen embryos could be stored to serve as spare parts; a body repair kit, as it were. The idea was that you would store the embryo(s) until a problem occurred, then thaw it and develop it into stem cells. This was said to be “an attractive commercial possibility”.[15] Pro-life campaigner Josephine Quintavalle commented, “It is sadly almost inevitable that bespoke embryonic stem cells created from frozen surplus will become the latest must-have healthcare accessory”.[16] This would not be an ethical option for Christians.

One problem with postponing the decision is that if you wait too long, you just shift the decision to someone else—whether to a clinic staff member after you have moved without telling them, or to a family member after you die. A famous case in Australia involved the question of whether frozen embryos could inherit from the estate after their wealthy parents were both killed in a plane crash.[17] (Apparently they can’t.) Some decisions are enforced when marriages end. There have been several cases where divorced couples have fought legal battles over the custody of frozen embryos, where one partner wants them transferred and the other doesn’t. It would be wonderful if courts tended to err on the side of life, but more often they seem to be reluctant.

Once again, a non-decision represents an abandonment of the embryo that is not consistent with biblical directives for parents to provide ongoing care for their children (Eph 6:4; 1 Tim 5:8).

3. Thaw and discard

This option involves taking the embryos out of the freezer and leaving them on the laboratory bench. Without a supportive culture medium (nutrient fluid), the embryos expire as they thaw.

It has been reported that “about 90% of IVF couples choose to discard surplus frozen embryos rather than give them to infertile couples, or donate them for scientific research”.[18] IVF Clinic director Gab Kovacs describes this as “a shameful waste”, saying that clinics need to provide patients with better information about their options: “It breaks my heart to discard embryos. They’re such a valuable asset. People go to so much trouble and expense to produce them.”[19]

While some would see this option as an abandoning of the embryo, often it is done as a sign of respect. Some Christians distinguish between ‘letting die’ and ‘killing by destructive research’, and would consider the first option to retain the embryo’s dignity and be morally permissible. I must say that I have struggled with this area. The literature supports my own findings that some parents who think of their embryos as children would rather have these ‘children’ discarded than give them a chance at life (through transfer to a uterus).[20] I find this irrational. But I have never been in this position myself.

My own view is that if these embryos were created with the goal of transferring them to a uterus, they should at least be given that chance at life.

Some religious denominations rule out the option of embryo donation, based on the belief that the generative capacity of a woman belongs to the marital union, and so may not be given outside the marriage. In this argument, embryo donation is seen as equivalent to adultery. Once an embryo is created from the parents’ own gametes, it is argued that it is sinful to place it in the reproductive tract of a third party. Similarly, it would be sinful to receive a donated embryo, as the wife becomes ‘with child’ from outside the marital relationship. On this view, withdrawing the embryo from storage and placing it in a more natural environment to allow it to complete its short life is the most respectful way to treat it.[21] Some parents perform a ceremony to mark the demise of the embryo with reverence.

Some doctors provide the service of ‘compassionate transfer’. This procedure involves transferring the embryo(s) into the woman’s uterus at a time in her cycle when embryo implantation is unlikely/impossible. I have heard people describe this as a way to ease their consciences about letting the embryos die, because they can pretend they tried to give them a chance at life. While the action of uterine transfer is ethical, the intention to do so at a time when pregnancy is nigh impossible is definitely not. (Remember, you need good intentions as well as good actions.) Therefore this would not be a morally acceptable option for Christians.

4. Use the embryos

Some parents find they just can’t make the decision to let their embryos go. I don’t think anybody knows what their opinion is until they’re in this situation, said Betty. She had one embryo left after giving birth to her sons, 8 and 6 years old at the time. After two more years of deliberating about their options, she and her husband finally decided to have a third child. One excess embryo changed my whole life, she says. She is thankful for her daughter, but also thankful that she had only one excess embryo.

Katie and her husband, on the other hand, had 5 embryos plus twins aged 6 years. Every time a bill came in the mail I thought about it, but I couldn’t let them go. Now, at 48 years of age, she has decided to have more children, through a surrogate if necessary, until all the embryos have been transferred. She is very emotional, but also very determined.

Judy and her husband had 6 frozen embryos, plus 3 children, two of whom were born through IVF. I can’t have nine children, Judy said. But neither could she bring herself to consider any other option. Finally she and her husband decided to have one embryo transferred. Now they have 5 frozen embryos, but they only have to decide about one at a time.

The option of using excess embryos yourselves may not be available to all couples, as sometimes a complication of pregnancy or another illness may make a further pregnancy highly dangerous or impossible. This is one of the few cases where I think it would be ethical to consider a surrogate if you wanted more children, or else consider another of the ethical options listed here.[22]

Embryos created by assisted reproductive technology are intended for uterine transfer. Giving them a chance at life in this way is entirely consistent with biblical value for all human life made in the image of God (Gen 1:27, 9:6).

5. Relinquish the embryos to another couple for reproduction

Once they have their own families, it is not uncommon for parents to consider helping other infertile couples. Having known the pain of infertility themselves, they immediately think of others in the same position. A 2009 study examined the way parents make a decision about whether to donate their embryos to another couple. Initially, most would consider donating to another couple, and it was found that the way the parents thought about their embryos was important in whether they decided to go ahead. Parents who thought about their embryos in terms of a “genetic link” or a “symbol of the [marriage] relationship” were less likely to go ahead with relinquishing the embryo to another couple than those who thought of the embryo more as something useful.[23] The “genetic link” and “symbolic meaning” views both involved seeing the embryo as a union of the two parents, the ‘one flesh’ idea, “something of the two of us”.[24] This was associated with positive feelings towards the embryos, but a reluctance to relinquish them to other couples because it would be too difficult to know that their child was ‘out there’ and be unable to protect them. I’d always be thinking whether that child in the street looked like my other children, said Jane. Sandra said: Now suppose that you did that and when that child is 18 years old, in it walks and it has had a very bad childhood. Then that would be painful. This in part helps me understand the conundrum of parents who prefer that their ‘children’ perish rather than be transferred to another family.

By contrast, those who saw the embryos as ‘something that is useful’ saw them more as objects that were valuable because of the effort involved in their creation—and thus their value to the potential beneficiaries of their donation. This was associated with a conscious effort to create emotional distance between themselves and the embryos (to protect themselves), and the parents’ reluctance to destroy the embryos because it would be a waste of their value. However, the main motive in donating to others was to help them.

While interest in relinquishing to another couple has been reported for 5%-39% of participants in research, it appears to be more often contemplated than actually performed.[25] Indeed, the transferring of frozen embryos to another couple raises so many complex psycho-social dilemmas that some countries have prohibited the practice. At the time of writing, relinquishing embryos for transfer by others was not allowed under law in Austria, Denmark, Germany, Israel, Italy, Latvia, Norway, Slovenia, Sweden, Switzerland, Taiwan, Tunisia and Turkey.[26] Check with your clinic—sometimes it is possible in your country but not at your clinic, in which case you may need to have your embryos moved to a clinic that does offer the service. Countries that permit relinquishment of embryos to others for reproduction have procedures in place to regulate the practice. This may include making decisions about who will receive the embryos, intended contact between the genetic parents and the recipients, and arrangements for the child to learn the identity of their genetic parents. Sometimes clinics impose their own rules, such as how many embryos you need to have before they will arrange the relinquishment. This is an area that needs further development. Current legislation is inadequate. Most problematic for legislators is whether you treat the transaction as an adoption (with full screening of the prospective parents) or as a donation (which tends towards anonymity). Lessons have been learnt about the damage done in the past by anonymous adoption of babies, and laws are now in place encouraging contact between birth mothers and children. These issues remain unaddressed with embryos in many jurisdictions.[27]

In 1997, the Nightlight Christian Adoptions organization in the United States began the Snowflakes Frozen Embryo Adoption Program, which helps frozen embryos realize their ultimate purpose—life—while helping infertile couples. They named the program ‘Snowflakes’ because every embryo, like every snowflake, is frozen and unique.[28] The first snowflake baby was born in 1998, and the term ‘Snowflake babies’ has continued to be used to describe babies born in this manner. Last I heard, over 200 babies had been born through this program, which uses the language of adoption even though the actual legal process is different.[29] An Australian study reported many more couples willing to adopt than there were embryos available.[30]

It is interesting to note the response of one United States specialist in reproductive law to the sudden popularity of embryo adoption: “The problem with this label [adoption] is it elevates embryos to the status of a child in many people’s minds, and then you end up on a slippery slope. If you can adopt embryos, how can you do stem-cell research on them or discard them?”[31] How indeed?

One study reported on a small sample of mainly Christian parents who had to make EDDs[32] and who decided to relinquish their surplus embryos to infertile couples (this sample reflecting the population of those most likely to do so). The study found that the reasons for their decision included a sense of responsibility toward their unused embryos, and the thought that it would be wrong not to donate them:

• NOT donating the unused embryos to another couple would have weighed on my conscience…
• …we wanted them to go to something or someone who would do something life sustaining with them…
• …we had created these lives and were responsible for finding them good homes if we could not be that home.[33]

These thoughts were often based on Christian beliefs. All the same, not everyone found it an easy choice:

• …it was the lesser of all evils [compared to destroying the embryos].[34]
• The initial decision was difficult because I felt like I was giving away my children.[35]

In the end, the child’s best interests were what swayed all people in the study.

Once the decision had been made, all participants found the process of relinquishment easier: The biggest feeling was relief. We had given them [the embryos] a shot at life and the rest was in the hands of God.[36] There was a varying amount of contact desired with the adopting families. Some expressed satisfaction in having ongoing contact as ‘aunts’ and ‘uncles’, while others decided to keep their distance. Feelings often changed once a child was born.

The shipment date for the embryos going to another clinic was significant for many, bringing with it a sense of loss:

• There was just a sense of finality about knowing that they were leaving “home” and starting their journey to become someone else’s children.
• I knew one hundred percent that we didn’t want any more children but it was bittersweet.[37]

It can be difficult to know that you no longer have a say in what happens to your embryos. You may feel responsible if the transfer fails, and it could be distressing if there is prenatal screening and the adopting couple decides to abort. You can avoid some problems by careful choice of who will adopt the embryos (e.g. choice of a Christian family), but there are no guarantees. Wes and Gina chose a family they knew and were in regular contact with, but in the end it left them feeling they could have raised the little boy better. I think we now regret our choice. We realize what we missed, said Wes. One mother found it challenging when she heard the adopted baby was a girl, having had only boys herself. Many continued to feel that ‘their’ child was living with another family, but for some this was a positive thing—to know, having been infertile themselves, that they had been able to give the joys (and trials!) of parenting to another couple. Many couples saw relinquishment as a lifelong process. It would be good to see the development of appropriate support services for those involved.

While I am aware there are some Christians who oppose embryo adoption because they believe that procreation should always be the result of normal sexual relations using the gametes of husband and wife, I consider that relinquishment of excess frozen embryos to another couple for the purpose of reproduction is an ethical option for Christians. It rescues embryos that would otherwise be destined for destruction. It gives the embryos a chance at life, which was why they were created. And it is consistent with being as responsible a parent as possible in the situation where one cannot nurture the embryos personally.

‘Snowflake babies’ are the most powerful visual illustration we have of the continuity of life from embryo to live birth.

6. Donate to research

While embryo research has always been associated with the development of IVF, legislation around the world allowing destructive research on human embryos was closely connected to interest in embryonic stem cells (ES cells). This was certainly the case in Australia, where destructive research has been legal since 2002. Soon after taking office in 2008, President Obama lifted a ban on federal funding of ES cell research that had been in place in the United States for 8 years.

I liked the idea of donating to scientific research because without research we would never have been able to have our babies through IVF, said Rhoda. We thought about donating to another couple, said Joe, but I couldn’t live with the idea of my child growing up without me. He and his wife decided to donate to science because without science we wouldn’t be parents. Mary decided to donate to science to give life to other people: I know it’s not life for our embryos, but we’re still giving life.

One study found that the decision of whether or not to donate to science depended more on the parents’ perception of science and scientists, rather than their perception of the embryo.[38] They found that feelings of not having control over what would happen to their embryos, and vivid fears that scientists would allow their embryos to develop into children, were the main arguments against donation to research. One participant thought that “letting an embryo grow” was the only thing you could do with an embryo, obviously ignorant of the destructive nature of most research.[39] This also reflected a poor understanding of the 14-day rule for keeping embryos alive, as well as ignorance of research methods in general and embryonic stem-cell research in particular. A few participants thought research was inappropriate for an embryo: It is really like ‘do some tests on it’ and then into the rubbish bin with it. That’s science all right.[40] But most doubts were directed at the science itself: It may be a strange thought but they might very well transfer it into an animal, you know… Of course, this is a stupid example, but you never know, right?[41]

In terms of medical ethics, there is general consensus that parents must give informed consent before embryos can be donated for destructive research—that is, they must be given adequate information that is comprehended by a mentally competent person in a voluntary manner. However, there is no agreement on what ‘adequate information’ entails. It will vary with the parents concerned.

Donation of excess embryos for use in destructive research will be an unethical choice for Christians. This is because all human beings are made in the image of God and should be treated with respect (Gen 1:27, 9:6). It is wrong to kill innocent people (Exod 20:13). In view of the confusion surrounding stem-cell research, we will look at it more closely in the next chapter to discover the unique ethical challenges it involves.

Conclusion

One thing the research shows is that when there are leftover frozen embryos, parents need to be told about all their options, and these options need to be fully explored before a decision is made. In the end we account for all our own decisions to God and, we need to be at peace with that. This includes taking responsibility for having allowed the embryos to be created in the first place. In some places, the decision as to whether your embryos really are ‘surplus’ to your needs is made separately from the decision regarding what you will do with them. I think this can be a helpful distinction.

Finally, knowing that there may be options for leftover embryos should not make you more cavalier regarding how many embryos you request at the beginning of treatment. It is because of the accumulation of frozen embryos in the first place that these options are necessary. Apart from using all your own embryos, I see even the ‘ethical’ options as a compromise in a fallen world.[42]

Open your mouth for the mute,

for the rights of all who are destitute.

Open your mouth, judge righteously,

defend the rights of the poor and needy. (Prov 31:8-9)

One of the options that may be available to parents who find themselves with excess frozen human embryos at the end of ART treatment is to donate the embryos for use in research.

This may sound like a reasonable thing to do. Many people think that although the destruction of human embryos in research is regrettable, at least some good may come as a result—for example, possible medical cures that the research may produce. The widely reported potential of human embryonic stem cells (ES cells) has been influential in building community support for human embryo research. It is seen as a compassionate response to those disabled people who might benefit from such research. But is it consistent with a Christian world view? Must Christians ‘heartlessly’ oppose scientific progress—or is there an ethically acceptable way to support new medical technologies like stem cells?

The global discussions concerning human embryo research have been as passionate as they have been misinformed. In this chapter, I will explain how we arrived at the current situation regarding stem-cell and destructive-embryo research, present a summary of the arguments that are commonly used in community debates on this issue, and also reflect on the biblical view.

I do this in the hope that as social discussion of this matter becomes more sophisticated, ethical choices will be better informed. I recognize that there are a range of opinions on this topic, even amongst Christians, so I will give you my views and explain my reasoning.

We have discussed the humanity of the embryo in previous chapters. This chapter will not revisit those issues but instead will consider whether, given that the embryos are indeed human, it is right to use them in destructive scientific research.

Human embryos in the laboratory

Human embryos were first created and grown in the laboratory as part of the research that led to the development of assisted reproductive technologies (ART).

The British scientist Robert Edwards, who was controversially awarded the Nobel Prize for Medicine in 2010, began his basic research on the biology of fertilization in the 1950s. He proposed that fertilization outside the body could represent a possible treatment for infertility. Other scientists had shown that egg cells from rabbits could be fertilized in ‘test tubes’ (usually petri dishes) when sperm was added, giving rise to offspring. Edwards decided to investigate whether similar methods could be used to fertilize human egg cells.

It turned out that human eggs have an entirely different life cycle to those of rabbits. But Edward’s team discovered how human eggs mature, how different hormones regulate their maturation, and at which point the eggs could be fertilized. In 1969, his efforts met with success when a human egg was fertilized in a test tube for the first time.

However, that first embryo did not develop. Edwards suspected he would have more success by working with eggs that had matured in the ovaries before they were removed for in vitro (‘in glass’) fertilization (IVF). He started looking for possible ways to obtain such eggs in a safe way.

Edwards contacted the gynaecologist Patrick Steptoe. Steptoe became the clinician who, together with Edwards, developed IVF from the experimental stage to applied medicine. Steptoe was a pioneer in laparoscopy, a technique that allows the doctor to see the inside of the abdomen and pelvis. Steptoe used the laparoscope to see the ovaries and remove eggs. Edwards put the eggs in culture medium (a fluid containing water, salts and nutrients in which cells can be grown) and added sperm. This time the embryos grew to the 8-cell stage. (Interestingly, this first zygote was formed by Edwards collecting his own semen one night in the lab and adding it to a ripe human egg in a dish. The next morning he observed the embryo’s typical cell division).[1]

Despite these scientifically ‘promising’ early studies, the Medical Research Council decided not to fund an extension of the project. However, a private donation allowed the work to continue.

It has been suggested that Edwards performed this research in an “ethical desert”, carrying out IVF on 1200 women before any studies were reported on primates.[2] There may be some truth in this, although Edwards himself initiated some ethical debate in a paper published in 1971. It is interesting that he saw ethics as involving issues of safety for patients and children but not issues based on “vague religious or political reasons”.[3] He claimed it was up to scientists to set ethical standards, not politicians or religious leaders.[4] While Professor Christer Höög, a Nobel official, felt that the ethical controversies in IVF had been resolved at the time of the award, Edwards himself always saw it as morally divisive. In 2003, he said that “It was a fantastic achievement, but it was about more than infertility. It was also about issues like stem cells and the ethics of human conception. I wanted to find out exactly who was in charge, whether it was God himself or whether it was scientists in the laboratory.” [5] And he discovered that “it was us”. Note that this whole argument depends on the assumption that a human embryo is not a child under his care.

Edwards and Steptoe established the Bourn Hall Clinic in Cambridge in 1974—the world’s first centre for IVF therapy. In 1978, Lesley and John Brown came to the clinic after 9 years of failed attempts to have a child (Mrs Brown’s fallopian tubes had been damaged by ectopic pregnancies some years earlier). IVF treatment was carried out, and when the fertilized egg had developed into an embryo with 8 cells, it was returned to Mrs Brown’s uterus. These first ‘experiments’ at IVF and embryo transfer had been repeated 101 times on other patients before the first successful delivery was achieved. A healthy baby, Louise Joy Brown, was born through caesarean section after a full-term pregnancy on 25 July 1978—the world’s first IVF baby. She weighed 5 pounds, 12 ounces, and was completely normal.[6]

Gynaecologists and cell biologists from all around the world trained at Bourn Hall, where the methods of IVF were continuously refined, inevitably causing the destruction of more unwanted human embryos. IVF is now an international practice, and has led to the birth of 5 million babies since then.[7]

It is worth observing that destructive human embryo research (of the kind required for IVF therapy to be successfully developed) marked the first time pure science researchers had come up against the ethical restrictions on human experimentation that had been in place since the end of World War II. It was at the Nuremberg Trials following the end of World War II that the medical atrocities of the Nazis came to light, and statutes were created to protect human subjects of medical research so that such abuse would never happen again.[8]

The Nuremberg Code (1947) was one significant articulation of research ethics principles for human experimentation, and many similar declarations have followed. These principles include the need to ensure that human experiments will only ever be performed on subjects who have given voluntary consent, and that subjects should never be exposed to research that is expected to cause death or disabling injury. A version of The Nuremberg Code developed by the World Medical Association, the Declaration of Helsinki (1964), is widely regarded as the cornerstone document of human research ethics, and has influenced national human research guidelines in many countries. It must be followed by doctors who wish to publish medical research in peer-reviewed journals.

Medical researchers have grown up with these guidelines and have until recently seen them as a challenge to lateral thinking rather than as a barrier to progress. Medical advances have continued despite the existence of what some regard as ‘limitations of freedom’. We have not allowed people to be experimented on if they do not freely consent. We have not allowed researchers to bribe research subjects to participate in dangerous trials.

However, pure science researchers such as Edwards had never previously wanted to conduct human experiments that were dangerous for the subject—traditionally, they have used animal experimentation. When it was first proposed that experiments on human embryos should not be permitted on moral grounds, they were taken aback. The mantra of science has been, ‘If you can do it, you should do it’. Like Edwards, many researchers think the scientists should be in charge of the research agenda, not the ‘establishment’ (whether that means politicians or religious figures).

Yet an ethical approach needs to consider the rightness of the proposed research, not merely whether or not it is technically possible. If we think we can do it, we need to consider whether we should do it, without an automatic assumption that all technological progress is good for us. In particular, we need to consider whether it has been good for the hundreds of thousands (possibly millions) of embryos that have been destroyed in the course of IVF being developed and then practised around the world.

It is clear that IVF was originally intended as a medical treatment for couples that were unable to conceive naturally. However, for many years, Edwards noted that “implantation rates remained stubbornly low”, as if embryo quality had been decided long before transfer.[9] Those running IVF clinics obviously wanted to do everything they could to help infertile patients, and several practices developed in order to improve success rates.

For example, clinics began to encourage couples to give them permission to create as many embryos as possible after egg collection from the woman’s body. Egg collection is an invasive and expensive procedure with the potential for serious side effects. You don’t want to do it more often than you have to. And obviously, the more times you place an embryo in the womb, the better the chance of a pregnancy developing. There is no formula to predict accurately how many embryos are needed to produce one live birth—hence many clinics today continue to suggest ‘the more embryos the better’.

Infertile couples tend to be extremely vulnerable emotionally at the beginning of treatment, and are understandably amenable to any suggestion that may improve their chances of success. This can mean that the number of embryos created is much greater than the number of children the couple would ever want—perhaps more than 20 embryos for one couple. But the expectation is that not all embryos will end up as live births. Any embryos left over from the first treatment will be frozen for future use (although if there are a large number, often only the ‘best’ ones will be frozen). Some embryos won’t survive defrosting, and others may not develop once in the woman’s womb.

This ethical dilemma is too difficult for some parents to resolve, and so they walk away from their embryos rather than making a decision regarding their fate. As a result, there are now hundreds of thousands (it is thought) of frozen excess human embryos around the world.[10]

So consider the situation that was developing: scientists could see that the number of surplus embryos was adding up. At the same time, many questions concerning early human development remained unanswered. Why not, they thought, utilize these surplus embyros to advance our knowledge?

Following a long consultation in the United Kingdom, the destruction of excess frozen human embryos in research was approved by parliament in 1990. I was living in London at the time and remember it well. It was a difficult question in a secular, pluralist society. Some believed that all tampering with the human embryo from the time of fertilization onwards was wrong, but doubted that it should be subject of criminal sanctions. Others wanted such tampering to be treated by the law as murder. Still others were happy for the research to go ahead unchecked, and ended up embroiling their opponents in arguments over time limits, which were reluctantly accepted as the lesser of two evils.

In the end, a 14-day rule was instituted, whereby research resulting in the destruction of human embryos was permitted up until the time the embryo reached 14 days old. Until the 14-day rule, there had been no law at all, and researchers had been legally able to undertake any research they wished. At least the 14-day rule brought some regulatory constraints to embryo research. It is fair to say that most people at the time seemed to think that some legal regulation was necessary. An editorial in The Times responded to the Warnock committee’s case for the 14-day limit on research[11] by saying that it was “as convincing a statement of where sanity should rest as can be hoped for”, but also, more ominously, “It would be idle to pretend that such a limit is for all time, but for now the public would appear to accept it”.[12]

Initially, much of the resulting experimentation was aimed at improving ART techniques and training technicians, and this type of research continues to this day. Then, in 1998, human embryonic stem cells were isolated and cultured for the first time.

Two independent teams of researchers in the United States were involved in this scientific milestone. One team, from the University of Wisconsin-Madison and led by Dr James Thomson, derived stem cells from surplus embryos donated to fertility clinics, and established the first embryonic stem cell lines.[13] At approximately the same time scientists from Johns Hopkins University, led by Dr John Gearhart, derived germ cells from cells in fetal gonadal tissue, using aborted fetal tissue as their source.[14] Pluripotent (i.e. capable of differentiating in various ways) stem cell lines were developed from both sources.

Stem cells

There are two things that make stem cells special. Firstly, they have not yet committed to any particular cell type, and can turn into any one of the body’s several hundred tissue types (e.g. bone, muscle, nerve or skin). Secondly, unlike other cells in the body, they can keep replicating indefinitely.

Scientists are excited about the potential use of stem cells in combating diseases for which we currently have no cure, diseases that involve the death of tissue the body cannot regrow—diseases like spinal cord problems, heart attacks, different types of blood disorders, brain disorders like Parkinson’s Disease, diabetes, and many others. This is a very promising area of medical research, often called ‘regenerative medicine’, to which no sensible person objects.

Now, many people are confused about stem cells because they don’t realize there are several types, classified according to where you collect them from. Firstly, there are embryonic stem (ES) cells, collected from the inner cell mass of a 6-day-old blastocyst[15]—a process that kills the embryo. Secondly, there are adult stem cells, which is a slightly confusing term as they are collected not just from adults but also from children, the placenta and the umbilical cord blood—in fact, from any source other than embryos.[16] The harvest of these stem cells does not cause any lasting damage to the person from whom they were collected. (I will discuss other types of stem cells below.)

Those who value human life from the time of fertilization immediately recognize an ethical difference between these two types of stem cells, as one involves death of the developing human from which it is harvested, while the other causes no lasting damage.

The idea for using stem cells (of both main types) in therapy goes like this: once the cells are grown in the laboratory, if they could be turned into the type of cell needed for a particular patient, the cells could be injected at the site of tissue damage, and thus repair the patient’s problem—heart cells for a damaged heart after a heart attack, nerve cells for a damaged spinal cord after a neck injury, insulin-producing (islet) cells for a diabetic, and so on. So far, research has been very encouraging for adult stem cells in many areas, with progress being made in the treatment of more than 70 diseases.[17] You may have heard of a bone marrow transplant for someone with diseases of the blood or cancer. This is an example of adult stem-cell treatment that has been standard treatment for years. Currently more than 200 trials are under way around the world using adult stem cells that have been extracted from bone marrow.[18]

There are difficulties with embryonic stem cells, as they can turn into cancers (teratomas)[19] when injected into animals for experiments. Obviously this is a major concern, and human research has been slow in winning approval. Despite this cancer problem, some scientists want to persist with the research because ES cells are easier to harvest than adult stem cells and may be more flexible—in fact, they were once thought to be the only pluripotent cells available for treatments. There have been emotional debates in many countries over the past decade regarding whether this research should be permitted. Early on in these discussions, the public was promised that research on ES cells would mean quadriplegics would be able to walk within the decade, cancers would be cured, and Alzheimer’s disease would be conquered. These cures have not eventuated.

It is now more than 10 years since the first human embryonic stem cells were isolated, and the promise of miraculous cures remains hollow. ES cell research has provided no therapies to date, and continues to drain limited medical research dollars away from other more promising areas of science.

Those opposed to ES cell research have no ethical objection to regenerative medicine that uses adult stem cells. The main reason they object to ES cell research is that it involves the destruction of embryonic humans. But there is another ethical problem involved in ES cell therapy: cloning.

Stem cells and cloning

Obviously, the aim of research on ES cells is a worthy one: the development of therapies to help sick patients. We can understand the motivation. However, imagine this scenario: suppose I sustain an injury to my spinal cord so that I can no longer walk. In the future, doctors may decide to treat me with ES cell therapy if such a therapy has been developed. However, if they took a frozen embryo from an IVF laboratory, grew it up into a blastocyst, harvested the ES cells (killing the blastocyst in the process), turned them into nerve cells, and injected them into my neck, my body would reject them. This is because my body would recognize that those cells have different DNA (genetic material) from my cells.

To overcome this rejection problem it has been suggested that instead of using a frozen excess embryo, we make an embryo clone of me. (A clone is another human with the same DNA.) It is expected that this would be done with a procedure called somatic cell nuclear transfer (SCNT), where the genetic material from one of the patient’s cells replaces that in a donated human egg, which is then stimulated to grow.[25] We then grow that embryo into a blastocyst, harvest the stem cells, turn them into nerve cells and inject them. In this case my body would accept the cells, because they have the same DNA as my other cells. This type of cloning is usually called ‘therapeutic cloning’, as it is hoped that therapies will be developed from it. It is also called ‘cloning for research’. (Note that this procedure is not yet possible—and it is certainly not ‘therapeutic’ for the embryo involved.) Therapeutic cloning was always, therefore, implicit in the development of ES cell therapies.

But there’s another problem. Remember Dolly the cloned sheep?[26] Dolly was cloned using ‘reproductive cloning’, which is cloning to create a live birth rather than an embryo to be used in research. But the technology used to create her is exactly the same as that used in therapeutic cloning. If doctors decided not to use the cloned blastocyst of me to get ES cells, but instead transferred it (or ‘her’ or ‘me’) to a woman’s womb, it could technically come to birth as my clone. The initial technique is the same; it is just pursued with different goals. (Note that cloning is not necessary for therapies involving adult stem cells, since we can harvest the stem cells from the patient being treated, meaning that the DNA matches and there is no immune rejection problem.)

Philosophical objections to reproductive cloning are widespread in our community. There is concern about issues of confused identity, difficult family relationships and unrealistic expectations (e.g. to become like the one cloned).[27]

Some countries have responded to this problem by legislating a partial ban on cloning—where therapeutic cloning is permitted but reproductive cloning is prohibited. They think these rules will keep scientists from using the technology to bring a human clone to birth. But the technology is the same for each, and it will be impossible to prevent scientists from progressing to reproductive cloning once the technology is better understood. Given that a fertilized embryo and a cloned embryo look the same under a microscope, it would be impossible to police a partial ban, because the permitted activity (fertilized embryo transfer in a clinic) and the prohibited activity (cloned embryo transfer in a clinic) look identical. The law would be unenforceable.

We know there are doctors who claim to have already attempted reproductive cloning, such as those in Clonaid, a group associated with the Raelian sect. Raelians believe the human race was started by aliens who cloned the first human. They believe that reproductive cloning is the pathway to eternal life, and claim to have achieved cloning (in Canada and Australia, where it is illegal). Raelian reports of successful clone births have yet to be substantiated.[28]

Perhaps the most prominent supporters of reproductive cloning have been Panos Zavos, a reproductive physiologist from Kentucky who claims to have implanted clones that did not develop,[29] and his colleague, Italian fertility doctor Severino Antinori. These two doctors are responding to a large group of people who see cloning as a way to replace a lost loved one (Severino claimed that more than 1,500 couples had volunteered as candidates for his research program).[30] It has also been suggested that cloning is one way a single or homosexual person could have genetically-related offspring.

Up to this point, these doctors have not obeyed the law prohibiting reproductive cloning. So it is hard to imagine what will cause them to obey it once the technology is better developed.

Human embryos were multiplied for the first time in 1993, when Dr Jerry Hall and Dr Robert Stillman successfully split one human embryo in two.[31] However, they could not prove that the genetic profiles were identical, in which case they were not technically clones.

In 2001, scientists at Advanced Cell Technology in Massachusetts claimed to have cloned human embryos by the process of SCNT, but as only one embryo got to the 6-cell stage, it was not regarded as a true clone.

The idea of using clones for spare parts was the basic plot of the movies The Island (2005) and Never Let Me Go (2010). It seems inconceivable that any government would allow the killing of live infants for such a purpose. However, the ideal gestation of a fetus for tissue transplant has already been investigated in animal models in serious academic investigation.[32] And we already allow the selection and gestation of saviour sibling embryos to provide regenerative tissue transplants.

In recent times, the most notable event in human embryonic stem-cell research was the exposure of fraud on the part of South Korea’s Woo Suk Hwang and the retraction of his papers from the journal Science.[33] This brings the total of successful, non-fraudulent reports of cloning of human beings to zero. While early human embryos have been created by SCNT, human ES cells have not been derived from them (which is considered the test of a successful experiment by leaders of the field). Therefore despite over two decades of effort, this research has still not succeeded.

Ethical issues for reproductive cloning

Debates about human cloning have fascinated Hollywood for years. Here I will list just a few prominent arguments. Further detail can be derived from the references. It is worth noting that while I am addressing the common view of cloning (i.e. that a human clone will be identical to the one who was cloned), the reality is less straightforward. How our genes are expressed depends on their environment, so a clone would probably resemble the original person less than twins would resemble each other, who are conceived and nurtured in the same environment.

(a) Arguments against reproductive cloning

Philosopher Leon Kass is concerned about the pervading belief that all children should be wanted children.[34] He recognizes that the logical result of such thinking will be that in the end, only those children who fulfil our wants will be fully acceptable.

Kass is also concerned that modern bioethics seems to believe all evils can be avoided by compassion, regulation and a respect for autonomy. While these developments have done some good to protect personal freedoms, sadly they have also devalued the big questions of human existence. He questions the problem of confused family relationships—for example, if a woman gave birth to a clone, genetically it is not her child but her twin (identical twins are naturally-occurring clones). It is also possible that a clone may have to live with unrealistic expectations that they would be identical to the person who was copied—after all, why would you want to clone someone unless you wanted to replace them exactly? This could make it harder for cloned children to believe they are loved unconditionally. In each scenario, cloning represents reproduction for the benefit of the parents, rather than embracing the child as a gift from God. It also raises difficult issues of identity and individuality for the clone.

But Kass is concerned most of all about the instinctive ‘repugnance’ we feel when we think about cloning human beings. He believes this repugnance reflects an intuitive recognition that the procedures involved are dehumanizing, even if we cannot articulate exactly how we know this. He believes this should not be ignored.

The United Nations condemned all human cloning as being incompatible with human dignity and the protection of human life, passing a declaration to that effect in 2005.[35]

(b) Arguments for reproductive cloning

Philosopher John Harris is not impressed by the appeal to human dignity. He points to identical twins as an example of clones we regard as non-problematic.[36] If they are acceptable, he reasons, then why not clones—particularly since the phenotype (genetic expression) is expected to be different? He also points to situations where human embryos are destroyed or endangered by widely accepted ART practices, and suggests that we need a strong moral objection to prevent a woman from having a child this way. He disregards the argument that clones would have only one social parent, because that happens in real life all the time. Furthermore, he denies that it makes the clone a commodity, suggesting that if you create an individual capable of autonomy, then their existence (i.e. being created) is in their best interests, and motives for their creation are either morally irrelevant or subordinate to other considerations.

Harris’s arguments depend on giving the human embryo no moral significance, and believing that doing some good is better than doing no good. He therefore goes so far as to say it would be violating human dignity to prohibit reproductive cloning, since we would be limiting the so-called ‘right to reproductive freedom’. Harris’s argument is very similar to the one advanced by Joshua Lederberg 30 years earlier.[37]

Egg donation

Introduction of therapeutic cloning would demand a large supply of human eggs. At current rates, it would not be unusual to use 100 eggs to achieve one cloned embryo.

Up until now, United Kingdom law has prohibited the payment of egg donors for IVF, but it allows them to be compensated for expenses and for the inconvenience of donation (to £250 maximum). It also allows payment for eggs donated to research (also to £250 maximum). At the time of writing, the Human Fertilisation and Embryology Authority in the United Kingdom is reviewing the guidelines for compensation for donation of eggs and sperm for reproduction, and it is anticipated that compensation will be increased. Private organizations in the United States pay thousands of dollars for donated eggs to use in IVF. Many advertisements on the internet promise $8,000-$10,000 per cycle, and there are reports of Ivy League college students receiving as much as $50,000 per cycle.[38] In April 2011, thousands of women across the United States joined a class-action suit demanding better compensation for egg donors.[39] The selling of human tissue is prohibited in Australia.

A rare side effect of the drugs given to allow the harvesting of more than one egg is ovarian hyperstimulation syndrome (OHSS). There are now reports of significant illness and even death in egg donors from OHSS, due to complications such as twisting or rupturing of the ovaries and kidney problems. There have also been reports of cancers in women who have donated eggs, possibly associated with the drugs injected into them. The long-term effects of undergoing egg donation are not fully known.[40]

To protect the vulnerable and financially needy women who might be susceptible to financial exploitation, I would suggest we need to pressure our governments to limit the use of human eggs to the creation of an embryo only for the purpose of achieving pregnancy, and that payment for eggs should be banned. Even though many of the advertisements for donors focus on the benevolent aspects of donating eggs so that those donating can “answer prayers”, “make dreams come true” or give “new hope, new life”, many women have testified to the fact that it is the money that tempts them to become egg donors.[41] Women considering the donation of their eggs need to be fully informed of the risks involved. The United Nations’ cloning resolution refers explicitly to the need to prevent the exploitation of women.

We should note in conclusion that human eggs themselves are not ethically significant (in the way that a human embryo is). It is the coercion of the donor women that causes an ethical problem here.

Safety aspects

Reproductive cloning in animals is still extremely inefficient—it took over 275 attempts before Dolly the sheep was born—and of the 5% of cloned animals who survive, a disproportionate number suffer from deformities, early death, heart, kidney and liver disorders, and other health problems.[42] All cloned animals appear to have genetic abnormalities.[43]

In February 2011, a New Zealand state research organization, AgResearch, abandoned trials of cloned animals due to unacceptable death rates of laboratory animals:

Applied biotechnologies general manager Jimmy Suttie said that after 13 years of studying how to prevent abnormalities forming in cloned animals, AgResearch had ended its cloning research. “The decision was made, enough is enough.”

Only about 10% of cloned animals survived through the trials, with the main problems being spontaneous abortions [miscarriage] and hydrops—where a cow’s uterus filled up with water, leading to the mother being euthanised as well.[44]

In addition, scientists do not know how cloning affects mental development. While factors such as intellect and mood may not be so important for a cow, they are crucial for the development of healthy humans. With so many unknowns concerning reproductive cloning, it is generally accepted that applying this technology to humans would be negligent on the part of those involved. Even the creator of Dolly, Sir Ian Wilmut, says it would be “utterly irresponsible” to clone humans.[45] These problems would no doubt be resolved if we ‘practised’ enough, but how many lives would be lost in the meantime?

Ethical alternatives

Opposition to embryo destruction in research prompted some creative thinking that has led to the discovery of ethical alternatives. The Yamanaka Lab in Kyoto, Japan, found that ES cells were not the only source of pluripotent cells. They discovered that 4 transcription factors in ES cells could induce pluripotency in skin (read somatic) cells. The reprogrammed skin cells were called ‘induced pluripotent stem cells’ (iPS cells). They were isolated first in mice (in 2006)[46] then in humans (in 2007).[47] These iPS cells look the same as ES cells, proliferate like ES cells, and even have the same ability as ES cells to produce teratomas. While iPS cells are not problem free, they are ethically preferable to ES cells because they do not require the destruction of human embryos or the use of human eggs. They have the added advantage that the somatic (body) cell involved can be harvested from the patient needing treatment, thus eliminating the problem of immune rejection.

In early 2010, scientists at Stanford University succeeded in transforming mouse skin cells directly into functional nerve cells with just 3 added genes, bypassing the step of becoming a pluripotent stem cell completely.[48] This method was an improvement over iPS cells, with increased speed and efficiency of transformation. Then in October 2011, scientists at Harvard Medical School developed a way of producing ES cell alternatives without requiring genetic modification at all, making the reprogramming process easier and safer. Synthetic modified RNA molecules encode the proteins without integrating into the cell’s DNA. Dr Derrick Rossi and his team were able to turn RNA-induced pluripotent stem cells (RiPSCs) into muscle cells.[49] These cells function like ES cells without the problems of ES cells.

Worldwide, many scientists previously investigating ES cells have turned to reprogramming of somatic cells as a more reliable and less controversial option. Meanwhile, adult stem-cell research has continued quietly. No laws had to be changed to allow it to progress because it does not involve the ethical problems of ES cells. References to papers showing advances in adult stem cell-research are too numerous to list. Therapies are being developed in clinical trials for many medical conditions including diabetes mellitus, multiple sclerosis, many malignancies, and cardiac problems.[50]

According to the opponents of destructive embryo research, none of it is necessary. It is possible to develop stem-cell therapies with no ethical problems by using adult stem cells, or perhaps iPS cells, or cells reprogrammed in one of the newer ways. Neither adult stem cells nor the other more recent alternatives require cloning or egg donation, because you can harvest the cells required from the patient being treated, with no DNA incompatibility. No embryos need be destroyed. The original grounds given to justify embryonic stem-cell research—that it offered cures available by no other method—are no longer valid.

Quite frankly, I think therapeutic cloning was never going to take off as a standard treatment. Eminent stem-cell scientists were ruling out the possibility of using therapeutic cloning in clinical scenarios as early as 2001. At that time Australia’s Dr Alan Trounson commented, “They’re never going to have enough women’s eggs to do it”, while Dr Alan Colman, then research director of the company that helped clone Dolly the sheep, explained, “It’s too laborious and costly to employ as a routine therapeutic procedure”.[51]

All the same, the first person to clone a human being is going to be famous, and many people are still trying.

The debate

Having outlined some of the facts and the history that has unfolded, we are in a position to assess the progress of the public debate on human embryo research.

So far, more than 30 countries have introduced laws prohibiting human cloning, including therapeutic cloning. Given that those with comprehensive bans include Canada, Germany and Switzerland, it does not seem to be a reaction of conservative morality that is driving these laws, but a concern for human dignity and safety.

The arguments

Opponents of human ES cell research reason that if a human being exists from the time of fertilization, and the harvesting of the stem cells destroys that human being, then the research is unethical.

In making this argument, opponents of destructive research on human embryos do not think they are risking the loss of any medical therapies. They regard the success of adult stem-cell research, and the discovery of other ethically sound alternatives, as evidence that regenerative medicine can develop without using ES cells. Generally, they suggest that excess embryos in IVF clinics be adopted by infertile couples or allowed to die undisturbed. Opponents of ES cell research would also like to see a tightening of safeguards to prevent further accumulation of excess human embryos. Use of ‘spare’ embryos has resulted in the development of a market for human embryos, which in turn has led to legislation allowing the creation of more embryos for destructive research.

As previously argued, supporters of destructive embryo research have suggested that legal protection is due only to human persons, and that personhood is not achieved merely on biological grounds but also requires the development of characteristics that are not found in a human embryo in the first two weeks.

Supporters of ES cell research point to other social policies that imply the same notion (that the nascent human does not deserve protection), such as access to elective abortion, the use of post-conception contraceptives, and the research already occurring in IVF clinics. The high rate of natural embryo implantation failure is also used in support of this position.

It is also argued that since the surplus frozen embryos are going to die anyway, we might as well gain some benefit from them before that happens. This position relies on the philosophical theory of consequentialism—that it is only the consequences of our actions, not the actions themselves, that determine right from wrong. By suggesting that the moral interests of the surplus embryos are trumped by the needs of the sick who would benefit from the possible therapies developed, some have even argued that it is unethical not to use the embryos for research.

In fact, destructive embryo research was first championed using a variation of this argument—namely, that ES cell research is ethical so long as only surplus embryos are used, and so long as informed consent is obtained from those for whom the embryos were created. While the loss of the embryos is seen as regrettable, the benefits of the research justify their use.

Note that there are several unspoken assumptions in this argument. The first is that the ends can justify the means, especially if the ends are great health benefits. The second is that there are no ethical problems in destroying embryos on purpose rather than just letting them die. And there is even a suggestion that those who raise ethical questions lack compassion in denying potential cures to many people who are suffering debilitating or life-threatening illnesses.

Of course, all these arguments in support of human embryo research depend on the assumption that the human embryo is not a human person deserving of protection.

Before I finish this section, I would also like to point out that those in the community who support destructive embryo research are not necessarily heartless monsters. Most proponents of embryo destruction that I have met are driven by the desire to find new treatments for disabling disease. They honestly do not believe that a human being exists at this stage of development. And the reason they think that is because it is what they were taught at university.[52]

The way the debate has been conducted

As in many of our public bioethical debates, community discussion regarding the benefits or dangers of ES cell research has been superficial and inaccurate. Exaggerated claims from scientists and the media regarding the state of ES cell research have led to unrealistic expectations on the part of many citizens. While this is a perennial problem in medicine, where any breakthrough in a lab becomes a headline for a cure, even some stem-cell scientists have admitted that in their enthusiasm they might have overestimated what could be done. Liberal bioethicist Arthur Caplan has complained:

Embryonic stem-cell research was completely overhyped, in terms of its promise. And people knew it at the time. I tried to say so myself at different times myself, even though I support embryonic stem-cell research. But this notion that people would be out of their wheelchairs within a year if we could just get embryonic stem-cell research funded was just ludicrous…

Here’s an assertion that you hear all the time: “Stem-cell research will help Alzheimer’s”. But stem-cell research has no possibility of helping Alzheimer’s. Alzheimer’s is a gunk-up-the-brain disease, where every cell is affected. You can’t fix it by any sort of stem-cell research. Model it? Maybe. Cure it? Never.[53]

‘Dumbing down’ of the debate by newspapers, so that it was presented as a simple choice between benefits for the disabled versus unwanted embryos, meant that the distinction between adult and embryonic stem cells was completely lost for many citizens. Take a look at the newspapers; if it is a report about advances in stem-cell treatments it is labeled simply ‘stem cells’ (although it involves adult stem cells). If it’s about the way conservatives are slowing down progress due to their anti-science dogma, it’s labeled ‘embryonic stem cells’. Ask your friends—you will find that most people think that there is only one type of ‘stem cell’: the kind that requires human embryos.

In Australia, at least, there was also the persistent reminder that if we did not let our top scientists do what they wanted, they would go overseas and we would be worse off medically, academically and financially. Financial incentives for allowing ES cell research is a regular feature of the debate.

At best, the quest for ES cell treatments has been misguided. At worst, it has been manipulative hype. Given that we now know embryonic stem-cell research is never likely to yield therapies, bioethicist Anthony Fisher has questioned the real agenda:

In the first place, I think it is an example of the so-called salami technique. People are unwilling to concede all of A to Z, but if you slice thinly enough, A, then B, then C, one at a time, eventually you will have the whole salami. Sell people on using just a few excess embryos from IVF programmes that would be disposed of anyway, while promising them miracle cures for high-profile individuals. Then it will be much easier down the track to sell them on allowing you to manufacture new, better designer embryos to use for cells, tissues and other things you want. Take cloning off the agenda for a while, then introduce it under the title of ‘therapeutic cloning’ while pretending to be appalled by any suggestion that cloned children would be allowed. Then find a sad case of someone whose only chance of having a genetically related healthy child is by embryo cloning and before you know it, cloning will be fine too. Next introduce animal-human hybrids, again promising responsible limits and endless cures. All along there is really nothing you presently want to do that is excluded or unfunded, but you can make it look as if you are reluctantly submitting to severe constraints… and so it goes.

The really big markets for embryos may well be not in therapies but in gaining research grants, kudos and rewards for embryologists and their associates. Large stocks of embryos may also have been used for technician training, drug testing, toxicology and research on new contragestives and abortifacients. This was expected to yield sufficient new markets for the near future. But the general public remained queasy, and so was repeatedly fed scientifically implausible promises of cures for Ronald Reagan, Christopher Reeve, Michael J Fox or their successors.[54]

In public debates, it is always a challenge for us to get to the facts and the truth, especially when we are dependent on the media for information. It is a challenge for our churches to find knowledgeable Christians who can help us understand the issues, to the point where we can make informed choices that reflect our values.

The Christian approach

For all ethical dilemmas, Christians have a moral compass derived from the Bible.[55]

In summary, the Bible recognizes that all human beings bear the image of God, and therefore have unique value and deserve to be treated with respect. At the very least, the concept of being made in God’s image has profound implications for the value to be placed on human life, the protection and care it deserves, and the gravity of interfering with it. This might do nothing to convince those who don’t believe in God, but it should help them to understand where Christians are coming from in this debate.

The Bible also teaches that the end does not justify the means. It refutes the notion that we should do evil that good may result (Rom 3:8).

Community consensus?

Destructive human embryo research will, I expect, continue. It will be opposed by most Christians. I would like to see, at the very least, stipulations that the proposed research must always demonstrate proof of concept in an animal model before embryonic humans are destroyed. But given that there will be support for it to continue, as well as opposition, how do we find consensus as a community?

I would suggest it is not possible. In the end, the moral status of the embryo is not a fact, but a value. Whether or not we choose to value and protect the embryo will depend largely on our world view and our ethical framework. Those who would pursue destructive embryo research are considering consequences only—the possible benefits. Those opposed to it are concerned with the act itself—there are some things you should just never do. The two parties are passing like ships in the night. They will never meet because they are talking about different things.

These are important moral issues. In a pluralistic society like ours, we cannot just ignore the people we disagree with; we need to consider all the different views in our community when we are making decisions. Where there is no consensus, in democratic countries we take a vote. And those whose views have not prevailed need to obey the law. Personally I am happy with this, on two conditions—that those who vote are informed regarding all the facts, not just some of them, and that tolerance and respect remain for those whose moral convictions leave them deeply disturbed.

So far we have discussed the morality of different types of medical treatments, but we have not paused to consider whether it is ethically acceptable to use modern medical technology at all to manipulate our child-bearing. Are we playing God when we try to control when and how we have children?

There has always been a wide range of opinion and practice among Christians on this matter. Soon after his conversion, my physician husband was taken aback when a woman in his congregation explained she was not going to visit a doctor to treat a thigh abscess, but was instead going to pray according to the instructions of James:

Is anyone among you suffering? Let him pray. Is anyone cheerful? Let him sing praise. Is anyone among you sick? Let him call for the elders of the church, and let them pray over him, anointing him with oil in the name of the Lord. And the prayer of faith will save the one who is sick, and the Lord will raise him up. And if he has committed sins, he will be forgiven. (Jas 5:13-15)

She was waiting for God to heal her. Likewise, a friend of mine was devastated when a well-intentioned group of parishioners visited her to pray for her chronic back pain, and then accused her of having inadequate faith when she did not immediately improve.

There has always been a level of suspicion or unease among some Christians about medical technology. And it is not getting any easier. Healthcare is changing rapidly. The escalation in the number of ways we can manipulate the unborn human is regularly creating ethical dilemmas that we have never had to confront before. The developing scientific environment will demand a constant shift of focus and approach to the moral challenges, and new situations will require us to keep re-examining the subject. Rote answers won’t be enough.

What are Christians to do as we try to determine God’s will for us in this area of our lives? Is it legitimate for Christians to use medical treatments at all, or should we always depend on prayer? Are we trying to usurp God’s sovereignty when we visit a doctor, or does he work through the treatment? What is the relationship between divine healing and the practice of medicine? Is it okay to restore health so long as we don’t try to improve on nature? How should we respond to suffering as followers of a suffering God?

In order to address these challenging questions, I want to start by thinking more broadly about technology, for that is what medicine is—a particular form of human technology.

God and biotechnology

Good afternoon, ladies and gentlemen. This is your pilot speaking. We are flying at an altitude of 35,000 feet and a speed of 700 miles an hour. I have two pieces of news to report, one good and one bad. The bad news is that we are lost. The good news is that we are making very good time.

This anonymous quote is often used to introduce discussions of bioethics, expressing the common feeling that we humans often seem better at devising technology than knowing how to use it.

The word ‘technology’ is derived from the Greek techne, meaning art and craft, and logos, meaning discursive reason or rational discussion. Technology is the making or crafting of things using our reason. While the term itself was not used by the Greeks, the idea of technology was recognized by Aristotle when he described a productive state (as opposed to an action) involving true reason.[1]

The appropriate use of technology is an aspect of our stewardship of the earth, in obedience to God’s cultural mandate in Genesis 1:28, to “fill the earth and subdue it” (cf. Ps 8:4-8; Heb 2:5-8). Hebrews 2:8 clarifies the scope of our stewardship: “…in putting everything in subjection to [man], he left nothing outside his control”. We understand this to mean that the creation is subject to mankind’s benevolent rule under God.

The Bible gives us many examples of the high value given to man’s technological skill. Early technologists in the Bible are introduced in Genesis 4, with Jubal developing musical instruments (v. 21) and Tubal-Cain forging tools out of iron and bronze (v. 22). Taking the specifications God had given him, Noah built an impressive three-decker ark to ride out the flood (Gen 6:13-22). In the construction of the tabernacle, God chose Bezalel and “filled him with the Spirit of God, with ability and intelligence, with knowledge and all craftsmanship, to devise artistic designs, to work in gold, silver, and bronze, in cutting stones for setting, and in carving wood, to work in every craft” (Exod 31:3-5). The exquisite detail of Solomon’s temple displays the intricate beauty wrought with skill by the craftsman Hiram, thus making the temple fit for the Lord of hosts (1 Kgs 7:13-51). Christ himself was a carpenter’s son and presumably continued the family trade (Matt 13:55), and the apostle Paul made tents (Acts 18:3).

But from the earliest times, it was not only the godly who were given these gifts from God. After all, Cain (who murdered his brother, Abel) built the first city (Gen 4:17). And it is disappointing, if not surprising, that the description of Tubal-Cain’s ability to forge iron tools is immediately followed by his father Lamech boasting of killing a young man (vv. 23-24). Did the ‘tools’ quickly become weapons?

At a basic level, then, the skill and ability to use the materials of the created order to make things is one of God’s good gifts to us—whether the ability to make a chair, or to make music on the guitar, or to make a house that is beautiful and functional in its design. We do not somehow cease to trust God when we work or use our skills in this way—as if God’s provision for us can only operate when we are doing nothing! We work for our food, and at the same time we give thanks to God and pray for him to bless our labours. Medical technology is just another example of the skill, knowledge and ability that mankind has been able to develop because of how God has made us.

However, the Bible contains many warnings of what can go wrong when our God-given technological creativity is abused. The builders of the tower of Babel in Genesis 11 were skillful but fundamentally opposed to God. The technology the Israelites used to decorate the tabernacle was the same technology they had used to make the golden calf centuries before. Technology can be utilized for good or evil.

The same is true today. The technology we use to identify the genetic code for the purpose of curing disease is also being used to screen unborn children so they can be aborted. We should not be naïve about the risks that technology holds.

Since the Renaissance, technology and science have steadily assumed a more and more important place in Western society. Francis Bacon (1561-1626) mapped out a specifically Christian vision of using science for the welfare of human kind. In his New Atlantis (1627), he describes a society governed by the use of modern science and technology that could conquer nature for human benefit. Robert Boyle (1627-1692) and Isaac Newton (1642-1727) also saw the possibility of bringing glory to God through discovering the nature of his creation.

But it is not always a simple matter of man using technology. Technology also shapes and changes us. The Industrial Revolution (1750-1850) saw a drastic change in the profile of society—from a rural economy with families involved in cottage industries, to an urban economy built on manufacturing and commerce, in which women stayed home with the children while men went out to work. This changed social and family life enormously. The transformations of the past 50 years—many of them driven by technology—have brought yet more changes. With the rise of the service economy and the knowledge economy, there are now many more clean and safe jobs that women want. With the simultaneous development of reliable birth control, women now have an unprecedented level of biological and economic independence.[2] This has had a massive impact on the institution of the family, and not always in a way that nurtures the children involved.

The dangers inherent in technological progress have been voiced by Christians (e.g. CS Lewis) and non-Christians (e.g. Aldous Huxley). Huxley’s Brave New World (1932), a satirical portrayal of a scientific utopia, has been influential in the debate over the morality of technology in modern society. The novel warns of the power of technology to dehumanize mankind; it portrays a world where suffering has been eliminated, but at the expense of our real humanity and individuality. Lewis, on the other hand, in his The Abolition of Man (1943), acutely sees technology not so much as “Man’s power over Nature” but as “a power exercised by some men over other men with Nature as its instrument”.[3]

Theologian Oliver O’Donovan suggests that what makes ours in particular a technological culture is not so much what we can do, but how we think about it. He insightfully suggests that our culture is not technological because of the sophistication of our “instruments of making” so much as because we think of everything we do as a form of instrumental making: “Politics… is talked of as ‘making a better world’; love is ‘building a successful relationship’. There is no place for simply doing.”[4] O’Donovan continues:

The fate of a society which sees, wherever it looks, nothing but the products of the human will, is that it fails, when it does see some aspect of human activity which is not a matter of construction, to recognize the significance of what it sees and to think about it appropriately. This blindness in the realm of thought is the heart of what it is to be a technological culture.[5]

The result is that we then fail to recognize the inappropriateness of applying technology in certain situations: “When every activity is understood as making, then every situation into which we act is seen as a raw material, waiting to have something made out of it.”[6] It is not difficult to see how this ‘mechanization’ of human life can influence our attitude to pregnancy and child-bearing and the unfettered use of interventions such as ART.

Jean Bethke Elshtain points out that the human body is increasingly being thought of as the exclusive property of an individual, to do with exactly as he or she sees fit.[7] Encouraged by the biotech industry, we think of our bodies as malleable, as putty in our hands to be altered and re-shaped in pursuit of our needs and desires. She ponders the difficulty for Christians of arguing against the rush towards genetic and biological engineering when these things are offered to us in the name of progress, freedom and choice.

We can’t hide from the fact that technology does make many aspects of life easier, more comfortable, more pleasant. It makes us healthier, safer and richer. These are good things that all of us enjoy, and it is not wrong to desire them. Many lives have been saved as a result of medical technology. We can use radio to preach the gospel to nations whose borders are closed. Personally, I would hesitate to give up my washing machine. How can Christians challenge technology? Do we even want to?

For those of us living in this fast-paced, youth-oriented culture, the ongoing quest of biotechnology to perfect the human body can be difficult to assess, because it comes to us in the dominant language of our culture—the language of freedom, and of avoiding pain and suffering. We all feel the pull of these things. They promise an escape from the uncertainties of the human condition into a realm of near-mastery. With God supposedly removed as a brake on human self-sovereignty, we see no limit to what human power may accomplish. And if someone objects that it is sinful pride to take the place of God, this is taken as a piece of antiquated superstition. Anyone voicing concerns about the rush towards genetic and biological engineering is seen as either anti-science or callous towards those who may benefit.

Elshtain sees the ever more radical manipulations of the human body as a cultural “flight from finitude”. It undermines recognition of the complexities and limitations and joys of embodiment—the givens of what it means to be human, to be a creature. As creatures we are dependent upon our creator. And it follows that we are not absolutely free, but free only within the limits set by our sovereign God. There is a difference between those projects where we pursue God-likeness for ourselves, and those where we act as co-creators respectful of the limits of our creatureliness. Christians grasp this distinction, and therein lies our real freedom.[8] In Romans 12:2, the apostle Paul encourages us: “Do not be conformed to this world, but be transformed by the renewal of your mind, that by testing you may discern what is the will of God, what is good and acceptable and perfect”.

George Grant questions whether technology really makes society as ‘free’ as we think it does. While the basic knowledge (the science) that underlies technology is itself morally neutral, each technology is inevitably accompanied by an ethic of how it should be used, because each technology is designed for a specific task. We may think it is up to us to decide how to use a computer, but we can only do so within the boundaries of its design. So technology is not neutral, and the ‘freedom’ it gives us is limited to selecting between the options available, rather than expressing our full creativity in search of alternatives. In the example of procreation, for instance, what was once an exercise in receiving and caring for the gift of a child becomes a reproductive project of obtaining a child of one’s own, choosing the best route through existing treatment pathways. “And in doing so, it is difficult to see how such a child cannot be regarded as something other than a commodity.”[9]

Paradoxically, this presumed ‘freedom without limits’ is achieved for the individual through a loss of freedom for others. Parents achieve freedom from caring for a disabled child through prenatal screening, which gives them the information needed to make sure all pregnancies brought to term are normal. As a result, pressure is already being brought to bear on parents who hesitate to screen or refuse to abort: “How could you choose to burden society in this way?” Is this freedom? Elshtain worries not only about the elimination of a whole category of persons, but also about the prospects for those who are born damaged from any cause. There are already moves to screen every pregnancy for Down syndrome. And so, in the name of expanding individual choice, we are narrowing our definition of what it means to be human.[10]

Technology is now harnessed not just for the restoration of normal human function but also to provide options that our ancestors never dreamed of. ART has expanded its market to provide services not only for infertile heterosexual couples but also for single parents, homosexual parents, menopausal parents and now even fetal parents.[11] Some people hope to live forever.[12] What is now possible has created a perceived need that did not previously exist. Who would ever have thought that 60-year-old women would seek children of their own? Supply now drives demand, not vice versa, because we are using medicine not only to overcome disease, but also to overcome and supersede normal human functioning. And the financial rewards are enormous.

In recent years, new medical technologies are increasingly used to create wealth for small groups of individuals, rather than primarily as tools for the improvement of human health. While most scientists aim to better the human experience, the use of patents and confidentiality agreements are slowly dissolving the community of mutual cooperation that previously existed between international scientists. Previously scientists would work together and share results to enable progress to be made more rapidly, but now results are often kept secret until a lucrative application can be patented.

The power of commercial interests in scientific research has also meant that ethical boundaries have been challenged by the push for profits. Laws have been overturned to clear the way for destructive research on human embryos, as well as the creation of human embryos with three genetic parents.[13] Human cloning is now legal in several countries. These are worrying developments. When the focus of research moves from healing to profit-making, ethical considerations are unlikely to receive much consideration.

So there is a profit motive but also a technological imperative, which is the idea that progress is always good and that what can be done should be done. But as Christians we do not endorse progress at any cost. We may be willing to forego some treatments, despite the material benefits, because we deem them unethical. This is not only because some biblical prohibitions are absolute, but also because of the biblical understanding that there can be meaning in suffering. We can learn from suffering; it can have a purpose.

Suffering

The Christian world view has a distinctive view of suffering. We do not see suffering as illusory or unreal (as a Buddhist would), nor as the ultimately meaningless result of different sets of evolved molecules interacting with each other (as a consistent atheist would). For the Christian, suffering lies within the sphere of God’s sovereign rule as the creator and governor of our world. Indeed, the presence of sickness, decay and death is the result of his judgement on our rebellious world.

In other words, although (like nearly everyone) Christians do not wish to suffer and do not enjoy suffering, we know that we experience suffering under the sovereign rule of God.

Thus, suffering can function as God’s loving discipline designed to correct our ways (Heb 12:5-11). Suffering can test us, prove us and purify us (Ps 66:10; Jas 1:3; 1 Pet 1:7; Rom 5:3-5). Christians will also suffer because of persecution (Mark 10:29-30; 2 Cor 12:10; 2 Thess 1:4-5).

Sometimes suffering is a direct consequence of our sin. Consider the Corinthians who participated in the Lord’s Supper “in an unworthy manner” (1 Cor 11:27-30). We can see other examples in 2 Kings 5:20-27, Psalm 32, John 5:14 and Acts 5:1-10 and 12:19-23. Sometimes suffering is unrelated to our sin. Consider the blind man in John 9, as well as the example of Christ, who suffered though being without sin (2 Cor 5:21; Heb 4:15; 1 Pet 2:22; 1 John 3:5). In the same way, we see around us some people becoming sick as a direct result of their actions (smokers come to mind), while other people who have taken great care of themselves appear to have been randomly struck down with disease.

Yet these ‘random’ events may still have meaning. In John 9, Jesus said the man was born blind in order that God’s work could be displayed in his life (v. 3). We are told that suffering can be for our good even when we don’t understand it (Rom 8:28ff.). Job never understood the reason for his suffering, and doggedly refused his friends’ ‘rational’ explanations. After an overwhelming experience of God himself, he was able to triumph nonetheless.

In other words, although we naturally and rightly want to minimize suffering where we can, we do so under the rule of God. We accept the ethical boundaries he has put in place, and acknowledge that if suffering is to be our experience then good will also emerge from it within the plans of God. We also know that suffering will be temporary and, from an eternal perspective, brief. As Paul says:

Though our outer self is wasting away, our inner self is being renewed day by day. For this light momentary affliction is preparing for us an eternal weight of glory beyond all comparison, as we look not to the things that are seen but to the things that are unseen. For the things that are seen are transient, but the things that are unseen are eternal. (2 Cor 4:16-18)

But the individualistic, secular public isn’t interested in the spiritual benefits of suffering, or in considering whether there might be a higher good than simply avoiding suffering at all costs. I remember hearing a parent at my child’s school talking about prenatal genetic screening: “Of course, it’s normal to want the best for our children; why would we ever hesitate to take full advantage of such opportunities to rule out the possibility of disease?” But in pursuing ‘the best’ for some children, we are prepared to terminate the lives of other children who might experience disease.

In our world of instant gratification, the public would rather just get results. This attitude is not new. Especially since the 17^th and 18^th centuries, suffering has been considered pointless, and man has sought to eliminate it by the instrumental control of nature. With suffering being thought to hold no meaning, the willingness to endure it has, understandably, been reduced. We find ourselves, then, at an impasse. Christians accept that some degree of illness and disability is inevitable in a fallen world, while the secular community is determined to conquer illness and disability at any cost.

We live in difficult times. The kingdom of God has come in Christ but will not be fully revealed until Jesus returns. We may not be able to control the technological pretensions of those who seek to build their biotechnological towers up to heaven, but the people of God can still bring glory to God as we practise wise stewardship of all the good things he has made. In our personal choices, we can still make practical decisions to ensure our own use of biotechnology reflects the values of God’s kingdom, because in the end we know that our physical bodies, complete with genome, will pass away. In our public and social interactions, we can argue and lobby for healthcare policies that protect and nourish life.

Christians have an advantage in considering these issues because we are under no illusions regarding this fallen world. Even if our community acknowledges there is a risk of misuse with any technology, the usual response is that regulations and prohibitions will control use of new techniques. As Christians, we know better, because we know that all people everywhere are predisposed to sin (Rom 3:23). Regulations don’t work. People break them. This understanding will prompt Christians to lobby against the development of technologies such as cloning. At times, all we may be able to do is encourage the enforcement of prohibitions that already exist. We do this for the sake of those who will be harmed by biotechnology’s excesses.

However, we also need to remember that we are dealing with real people’s problems. We need to extend compassion even when we are morally opposed to what other people want. When I am arguing against the abortion of disabled children, I am very conscious of the burden a mother takes on when she brings a disabled child to term. Of course all babies are beautiful, but we should not underestimate the toll of caring for one of these little ones. I am conscious that I also need to argue for better community support for these families, and I need to encourage fellow Christians to do likewise. Christian ethics are not just about saying ‘No’ to particular technologies, but about practical love and care for our neighbour (Jas 2:14-17).

My final comment is that, regardless of its problems, we as Christians should not turn our backs on technology. I applaud the efforts of bioethicist Nigel Cameron, who promotes the role of Christians in hosting debates on the challenges of technology:

The key need is to mainstream this discussion, and get it out of the hands of transhumanists on the one hand and Luddites, if there really are any, on the other. Our embrace of the technologies of the 21st century depends vitally on our understanding of their implications and our ability to take responsibility for their development.[14]

Those of us who are pro-tech and pro-human need to shape the future…[15]

Out of love, we need to keep engaging with our society on these issues, giving specific attention to the urgent need for moral leadership as we encounter the difficult challenges posed by biotechnology.[16]

Healing

Where does healing fit in? If sickness and death are the results of God’s judgement on human sin, are our medical problems done away with by the victory over sin that Christ has won? And if so, does this render medical treatment and technology a problem for Christians?

This has been a controversial issue among Christians, and it’s not within our scope here to conduct a full investigation of the subject. However, the outlines of an answer would be as follows.

The Old Testament word that comes closest to ‘health’ is shalom. It is usually translated as ‘peace’, but its meaning is much richer. Shalom represents salvation, wholeness, integrity, community, righteousness, justice and wellbeing.[17] This helps us to see health as God sees it. It is a holistic experience that extends beyond the physical and is grounded in our relationships.[18]

There are many Old Testament examples of God as healer. Following the exodus from Egypt, God reassures Israel that he is not only the judge who can afflict them with disease, but also the healer who restores them: “If you will diligently listen to the voice of the Lord your God, and do that which is right in his eyes, and give ear to his commandments and keep all his statutes, I will put none of the diseases on you that I put on the Egyptians, for I am the Lord, your healer” (Exod 15:26). His healing is manifested in physical wellbeing, such as when he used Elisha to restore the Shunammite’s son to life (2 Kgs 4:32-35), or when he restored Job’s fortunes following his time of trial (Job 42:10-17); but it is also connected with spiritual wellbeing and forgiveness (2 Chr 30:18-22).

Sometimes ‘healing’ takes place quite apart from any normal activity or agency, such as when Moses’ hand suddenly becomes leprous and is just as suddenly healed (Exod 4:6-7). Sometimes symbolic actions are undertaken that precede the healing—such as when Elisha instructed the rather sceptical Naaman to wash 7 times in the Jordan River as a cure for his leprosy (2 Kgs 5:1-14). At other times the Lord uses medical means, such as when God heals Hezekiah by getting Isaiah to prescribe him a fig poultice (2 Kgs 20:4-7).

In the New Testament, holistic healing is an integral part of Jesus’ ministry as he announces the coming of the kingdom of God: “And he went throughout all Galilee, teaching in their synagogues and proclaiming the gospel of the kingdom and healing every disease and every affliction among the people” (Matt 4:23). The Greek verbs used to describe Jesus’ healings include therapeuo (to care for the sick, treat, cure, heal), iaomai (physical treatment, to make whole, spiritual healing), sozo (to save, make whole, save from the effects of disease), and diasozo (to save thoroughly).[19] Jesus didn’t just apply a bandaid; he completely restored his patients to full flourishing, whether they suffered from blindness (Mark 8:22-25, 10:46-52; John 9:1-11), deafness and dumbness (Matt 9:32-33; Mark 7:32-37, 9:17-27), or paralysis (Mark 2:3-12). He healed those suffering from demon possession (Mark 1:23-26, 34; 5:2-13; Luke 4:40-41), and could even overcome death (Luke 7:11-15; 8:41-42, 49-55; John 11:1-44). Indeed, healing of the sick was to be the sign that the Messiah had come (Isa 35:5-6; cf. Luke 7:18-23). Jesus also sent out his disciples to heal the sick as a demonstration of the coming of the kingdom (Matt 10:5-8; cf. Luke 10:9). We also know that when the kingdom comes in all its fullness, in the new creation there will be no more evil and death and crying and pain (Rev 21:4).

All this has led some Christians to the view that it is God’s will for all sickness to be cured here and now through miraculous means. This is an understandable desire, and it is certainly true that God can and does heal people now in his kindness and grace—often through medical means, but also in ways that we cannot explain.

However, the idea that God will heal all our diseases now—if we have faith—has two serious flaws. The first is a problem of timing. One of the benefits of Christ’s victory and kingdom is that all death and disease will be done away with—but not until the new creation. In this present age, the whole creation is still groaning, Paul says, and waiting for that day (Rom 8:18-25). Suffering is still a reality, including sickness and death. In fact, it is quite clear from the New Testament that Christians should still expect to sicken and die (if Jesus doesn’t come first). Nearly all human death is a result of what we would call ‘sickness’. No-one dies of ‘old age’. They die because of some medical problem that we can’t cure. In God’s timing and plans, sickness is still an unavoidable reality of our fallen world, and he will not ‘cure’ it until the Last Day.

However, the second flaw in the ‘everything healed now’ view is that it restricts ‘healing’ to the physical. God is interested not just in our physical wellbeing but also in our spiritual, emotional and psychological wellbeing. No illness is beyond his ability to heal, but his intentions towards us are holistic. He wants to see all areas of our lives flourishing. We need to keep this in mind when we pray for resolution of the physical problems that afflict us. It could be that, as for the apostle Paul, God will choose not to relieve our physical suffering for non-physical reasons—for example, to keep us from becoming conceited, or to demonstrate his power in our weakness (2 Cor 12:7-10). ‘No’ is just as much an answer to prayer as ‘Yes’. We pray requests, not answers.

If God does choose to heal one of our physical ailments, he can do so directly and without any human intervention. However, he very often uses some kind of intermediary, such as a doctor—and this makes it no less an example of his kindness and grace. In the example I mentioned at the beginning of this chapter, my husband’s urging led the woman to get medical help and to have her problem subsequently resolved.

Medicine, world views and ethics

Let’s tie these thoughts together. When we go to a doctor or utilize some form of biotechnology, we should not check God in at the door. There is no such thing as a purely ‘medical’ decision that lies outside the context of a world view. We all have a world view that shapes our thinking, our values and our ethics—even your doctor has one!

Secular or scientific neutrality is a myth. When a difficult decision arises in medicine there will often be an ethical aspect that is not recognized for what it is. It may be cast as a completely ‘medical’ decision when in fact it involves issues of morality. For example, should we undergo genetic testing or screening? Should we try an expensive experimental treatment if there is little chance of it working? Should we utilize medical treatments that were discovered and developed by morally questionable means? If we wish to honour God in all areas of our lives, we will bring all these questions before him.

Very often, medical decisions are made on utilitarian grounds—that is, within a world view that sees the ends as justifying the means. Doctors are taught to use the most cost-effective treatment, or the therapy with the best success rate, but they may not stop to think: is this treatment morally permissible? Doctors will often not raise these ethical questions; we will need to do that ourselves. We will then need to use a biblical approach to decision-making,[20] taking into consideration the advice given.

Each decision we make during treatment needs to be approached with prayerful requests for wisdom, and held up to God’s word to make sure it does not breach biblical ethics. But beware—this may make you unpopular in some treatment centres! You may be viewed as difficult and unreasonable by those who do not value human life as you do. You may be considered disruptive if you ask for more time to consider your preferences and get more advice. But in the end we will all have to account for our own decisions before God. The Bible teaches us that we must take responsibility for our actions (2 Cor 5:10), and it is not enough to say, “The doctor made me do it”.

It will certainly help if you can think things through before you go for treatment, so that you can anticipate some of the issues that may arise. You may benefit from asking around and finding a doctor sympathetic to Christian values. God has given us a Christian community for support in difficult times of our lives, and this may be a good time to call on it.

Given all that we have said so far, it is ethical to use medical treatments that respect human life and respect biblical models of marriage and family. It is consistent with biblical teaching to restore malfunctioning body systems to the way they were intended to be, and to facilitate the act of procreation as it is normally performed. Note that I am not saying here that childlessness is a disease that needs a medical remedy. I am pointing to the underlying pathology that may prevent normal marital intercourse from resulting in pregnancy.

From God’s perspective, our health includes our spiritual, emotional and psychological wellbeing, so it is also appropriate to seek help for treatment if any of these are damaged. Accordingly, it would be appropriate to ask for counselling to help cope with the psychological and emotional challenges of infertility if you find it difficult to work through the issues on your own. You might decide to speak to your minister, or you may go to a professional counsellor. Good professional counsellors don’t tell you what to do so much as help you understand your own thoughts and feelings. Some Christians find it easier with a Christian counsellor, although (as with doctors) many counsellors are happy to take your belief system into account even if they don’t share it themselves.

It would also be appropriate for a married couple with medical infertility to seek assistance in treating medical and surgical problems that are a barrier to normal procreation. This might include hormonal supplements to correct deficiencies, surgery to unblock a fallopian tube, or treatment for endometriosis. If these sorts of problems cannot be overcome, bringing the sperm and egg of a husband and wife together to make an embryo by IVF is, I believe, permissible if no unethical practices (such as embryo destruction) are involved. These treatments or interventions all work to facilitate normal conception. However, it would not be consistent with biblical ethics for a single woman to use assisted reproduction to have a baby, since the Bible teaches that procreation is intended to occur within a marriage between a man and a woman, and a family is intended to consist of two parents of the opposite gender. Sometimes, of course, this intention isn’t fulfilled in our fallen world. Single women have children; marriages split up. But these sad realities aren’t justification for arranging it that way intentionally.

What about the next step, where a couple cannot conceive and tests reveal that the husband has no sperm? The standard medical treatment would be to substitute donor sperm to make the embryo, usually by donor insemination. Here the medical intervention is going beyond ‘restoring what is broken’, in that it is not the man’s ability to make sperm that will be mended. Instead, another man’s sperm will be substituted. In this instance, there will be three people involved in making the embryo, thus moving outside the biblical model of two parents per family. Again, I am talking about what we are aiming for. I realize that some families may lose a parent, or gain a step-parent, but God’s intention in creation was for children to be raised by two married biological parents.[21]

In the same way, deciding whether babies may live or die according to their genetic makeup or physical wholeness is outside biblical norms. The Bible teaches that all human beings have value, regardless of their individual characteristics, because we are all made in the image of God (Gen 1:27) and should not be killed (Gen 9:6).

Use of controversial treatments for alternative purposes

What about employing unethical or controversial treatments for purposes other than their original design? For example, if you decide that using the oral contraceptive pill for prevention of pregnancy is wrong, is it also wrong to take an oral contraceptive pill for an unrelated purpose? The hormones in oral contraceptives work on several different mechanisms in the body and may be prescribed to treat problems as diverse as severe acne or abnormal hair growth. I would suggest that such use is permissible for that person. As we have already noted in chapter 5, it is not only the action itself that we need to consider, but also our motives. In this instance, so long as: (a) our intention is to treat the alternative problem, not contraception, even if the action of the pill is contraceptive at the same time; and (b) you do not achieve the treatment effect through preventing a pregnancy; then you have not contravened your ethical opposition to using oral contraception. Even the leaders of the Catholic Church, who traditionally have opposed the use of hormonal contraceptives, allow them for such purposes.[22] This pattern of reasoning is technically called the ‘principle of double effect’.

Having said all of this, there is no instruction in the Bible that makes taking advantage of modern healthcare a moral requirement in itself. Life itself is not the ultimate good. We are not obliged to seek life and health at all costs. In fact, to do so would be to make it an idol.

I began the research that led to this book mainly to assist many friends and acquaintances who had asked me questions about the appropriate use of modern reproductive technology. I had no idea what I would find.

What I found left me deeply unsettled as I realized the extent to which our society has decided to accommodate selfish adults at the expense of the children involved. We want ‘perfect’ children through genetic screening, freedom from inconvenient pregnancies, and the ability to override normal human biology when it suits us—all at the cost of embryonic and fetal human life. Personally, I consider it a travesty that medicine is being used for these ends. This is not what I signed up for when I became a doctor.

Consider, for example, the decreasing tolerance for imperfections in our community. When did we decide that any of us were perfect specimens? We are all of us damaged; it is just more noticeable in some than in others. And why is physical brokenness tolerated so poorly while moral brokenness is not just tolerated but chronicled, accepted and even celebrated in magazines and newspapers?

At the heart of the problem is the persistent human desire to be in control of our own lives, and to determine for ourselves what we should do and be (the Bible has a word for this). We plan our families carefully to fit in with our dreams, and then feel put out when things don’t go according to schedule. We expect to be comfortable. We expect to be safe and prosperous. We do not want needy children who will change our lifestyle for the worse. In a society that has lost touch with any higher purpose in life which might give significance to suffering, we are left with no other purpose than the avoidance of suffering and the maximizing of pleasure and comfort.

As Christians, we know that far from dispensing with the vulnerable, God carries the weak and the helpless close to his heart. And he wants us to do the same: “Religion that is pure and undefiled before God, the Father, is this: to visit orphans and widows in their affliction, and to keep oneself unstained from the world” (Jas 1:27). How can Christians express this care for the weak and defenceless?

One thing we can do is speak up. There is a conspiracy of silence and euphemism surrounding many of the unethical practices I have described in this book. Political correctness has prevailed and we have not named these interventions for what they are. Most people don’t realize what is going on, for example, when doctors say that they can prevent the birth of children with Down syndrome. It sounds like a new cure. It isn’t. It just means that they can now tell (at least most of the time) when a developing fetus has Down syndrome, and can kill the fetus before he or she is born. We need to educate and inform, so that people can make wise and ethical choices with the information in front of them.

We also need to learn and communicate our history. I have ended up including more history in this book than I had originally planned because it seems to me that our society, including the Christian community, has the lowest opinion of developing human life than of any other time in Western history. At a time when we have more understanding than ever of the intricacies and wonders of intrauterine life, we see it wantonly destroyed in the name of freedom and choice and autonomy.

Christians can also offer genuine and practical support to couples that struggle with the brokenness of life. We can help men and women talk about their dilemmas and share their deepest needs and concerns. We can get alongside those who are faced with hard decisions and help them with the day-to-day consequences of their choices.

Christians also need to model a richer understanding of what it means to be human—including an understanding of responsibility for the little ones who depend on us to protect them. We can slow down and accept the relationships we are given, and find joy and contentment in service and obedience even though we know it will often be costly.

In choosing to love and serve at the cost of our comfort, we are imitating the God who loved us and gave himself up for us (Eph 5:2). Dorothy Sayers puts it strikingly:

For whatever reason God chose to make man as he is—limited and suffering and subject to sorrow and death—he (God) had the honesty and the courage to take his own medicine. Whatever game he is playing with his creation, he has kept his own rules and played fair. He can exact nothing from man that he has not exacted from himself. He has himself gone through the whole of human experience, from the trivial irritations of family life and the cramping restrictions of hard work and lack of money to the worst horrors of pain and humiliation, defeat, despair, and death. When he was a man, he played the man. He was born in poverty and died in disgrace and thought it well worthwhile.[1]

I hope that as we make decisions about pregnancy and childbirth, we will also think it worthwhile to live in faithfulness and love. And I hope and pray that this book has provided the necessary information, as well as the biblical ethical framework, for you to do just that.

~

I can vividly remember the nights each of my two daughters was born—lying in bed in a quiet room, just the two of us, with the yellow light of a lamp allowing me to savour every detail of the perfect little person before me. Dark eyelashes on the cheek, tiny little nails that already needed cutting, soft little breaths that caressed my bare arm. I could barely contain the sense of amazement and love I felt at each occasion. Is there anything more wonderful that holding your own baby for the first time?
It is so good and normal to long for a child. I thank God that I have had this blessing of being a mother. I look forward to the day when all children are as welcome as ours were.

There has been much discussion in Christian circles about whether the oral contraceptive pill (OCP) causes early abortions. The debate began in 1997 when Randy Alcorn, an American pastor, published a book called Does the Birth Control Pill Cause Abortions? The debate is significant because the OCP is widely used and regarded as an easy and effective method of birth control. There is concern that this controversy will mean many Christian families will be unable to reliably control their fertility. As a result, this has caused much anxiety on the part of believers who wish to protect human life from its earliest stages.

It is worth recognizing at the outset that there are people on both sides of the debate who are sincerely pro-life and have much in common. All are concerned about the protection of unborn human beings from the time of fertilization, given that they are all made in the image of the God who imbues them with dignity and worth. All recognize that since we have been able to work out how fertilization occurs through application of human reason, we now have the responsibility to use that knowledge to ensure that the process of embryonic development is not interrupted.

To understand the debate, you need to know how the OCP works. The OCP is known to work as a true contraceptive, by:

1. inhibiting ovulation, so there are no eggs available to be fertilized
2. thickening cervical mucus, making it difficult for the sperm to get through the cervix, so they are not available to do the fertilizing.

People on both sides of the debate agree on these points. But it also has a third effect:

3. it makes the lining of the womb thinner and hostile to the embryo.

This third effect is where the contention lies.

The argument goes this way: If a woman taking the pill experiences failure of the first mechanism, and she ovulates so that an egg is produced; and if the second mechanism fails and sperm gets through the cervix; and if an embryo is then formed; and if the third mechanism prevails; then it means that the endometrium may be unable to support the embryo that is formed, and an early abortion may occur. The study quoted to support this hypothesis claims to demonstrate that women who had ovulated while taking the pill had atrophic (thinned) endometrium.[1]

The problem lies in the methodology: the investigators’ criterion to ‘establish’ that the women had ovulated was to have a blood progesterone level over 4ng/ml. So far so good. But most medical experts would say that you need a progesterone level over 9ng/ml to be sure that ovulation had occurred,[2] so it is possible that women in the study with progesterone levels over 4ng/ml but under 9ng/ml may not have ovulated. The results therefore do not help prove the theory. If the women did not ovulate then the condition of the endometrium doesn’t matter, because if there is no egg then there is no embryo to implant.

Furthermore, the argument that opposes the abortifacient theory claims that ovulation and endometrial thickening go hand in hand. It rejects the notion that the first two mechanisms could fail and the third mechanism could still prevail. Instead, it suggests that if you had failure of ovulation inhibition, and an egg was produced (this is known as escape ovulation), and if you had failure of cervical mucus thickening and the sperm got through, the hormone surge that normally accompanies ovulation would be released and it would stimulate the endometrium to grow and prepare the uterus for implantation of an embryo, as it is designed to do, over the 7 days it takes for the embryo to reach the womb. In this case, if the egg were fertilized, you would not have an early abortion but an unplanned pregnancy. Supporters of this argument note that the endometrium isn’t ready for an embryo in the two weeks before ovulation in a fertile woman even if she doesn’t take the pill. The endometrium always needs the hormone surge to prepare for an embryo, and it is this thickened endometrial lining that is shed each month in menstruation (the woman’s ‘period’ bleed) when no embryo arrives. It builds up again following ovulation the next month, and so the cycle continues. These doctors see no reason biologically why the pill would stop this automatic response to ovulation.

Nobody disputes that with normal OCP usage, the pill-user has a thin endometrial lining. What is important is to find out what happens when ovulation occurs while taking the pill. Just because the pill can cause endometrial thinning does not mean it relies on that thinning for its effectiveness. Suppression of ovulation is the most important aspect of its function.

Ectopic pregnancy risk

A further line of argument used to support the abortifacient position is related to ectopic (tubal) pregnancy rate for hormonal contraceptives. This argument is a bit more complicated. It is postulated by OCP opponents that if the OCP has no effect after fertilization (i.e. it does not interfere with the embryo once it is formed), then reductions in the rate of intrauterine (normal) pregnancy in pill-users would be the same as reductions in the rate of pregnancy outside the uterus (ectopic pregnancy). They argue that if the action of the OCP is occurring before implantation then it has a general reduction effect on all pregnancies regardless of where they would have ended up if they had been fertilized. Those supporting this position suggest that as there is a lesser reduction in the incidence of ectopic pregnancy (that is, there are more of them) with hormonal contraceptive use compared to non-pill users, the most likely explanation is that the OCP does something to prevent the embryo from implanting in the right place (once again, the hostile endometrium hypothesis) and therefore forces the newly conceived child to implant in the wrong place. They quote papers that they say demonstrate an increased extrauterine/intrauterine pregnancy ratio in women taking the pill.[3]

Those opposing this argument acknowledge that there is an increased tubal pregnancy rate with some contraceptives, but point out that the studies cited put other hormonal contraceptives (which work differently) in the same category as the OCP. They suggest that if you look at the research for the hormonal contraceptives individually, in fact the increase (per pregnancy) in ectopic pregnancy occurs only with the progestin-only pill and Norplant, not with injectables or the OCP.[4] This increased risk of ectopic pregnancy may be the result of progestin acting on the fallopian tube to delay egg transport to the uterus, so the embryo is still in the tube when it is time to implant—but it is not fully understood.[5] There is no evidence to support that it is due to a hostile endometrium. Opponents of the abortifacient theory suggest once again that if escape ovulation occurs, the hormonal surge will prepare the endometrium in time for implantation. They suggest that an incorrect conclusion has been drawn from this research. They postulate that the fact that an embryo can implant in the fallopian tubes or other places in the abdomen suggests that an ideal endometrium is not actually necessary for successful implantation and thus further supports use of the OCP.

This is a simplification of the debate—there have been further lines of argument offered and refuted. Please review the given references if you would like to pursue this question further.[6] And as I said in chapter 6, do not use the pill if your conscience forbids it (Rom 14:23b).