CHAPTER 6 INFERTILITY and ARTIFICIAL REPRODUCTIVE TECHNOLOGY

6.1 INFERTILITY

 Incidence and causes

Ethical debates have not ceased on in vitro fertilization (IVF) since the birth of Louise Brown, the first IVF baby, was born on July 25, 1978 in the UK. In Australia in 1996 there were 3,164 births after artificial re-productive technology (ART), accounting for 1.2 percent of all births.[1] Before entering into a discussion and evaluation of the ethical issues arising from the treatment of infertility, it is necessary to understand what is meant by infertility, its treatment options, their success rates, and the burdens experienced by couples undergoing treatment.[2] 

It is important to distinguish infertility from sterility. A person who is unable to generate any offspring is sterile, e.g. a woman who has no ovarian follicles or a man who does not produce any sperm. Sterility occurs in 3–5 percent of couples.[3] Infertility, on the other hand, is an inability to conceive for one to two years by a couple who are having acts of unprotected sexual intercourse during the woman’s fertile days.[4] From 10–15 percent of married couples are infertile.[5] The incidence of infertility increases with age, particularly of the female partner. Three national US surveys found that 7 percent of couples whose female part­ners were aged 20–4 years were infertile, 9 percent for those aged 25–9, 15 percent for those aged 30–4 years, 22 percent for those aged 35–9, and 29 percent for those aged 40–4 years.[6] Infertility statistics include cases of tubal ligation and vasectomy. While the normal monthly fertil­ity rate ranges from 15 to 20 percent, subfertile couples where the woman is less than 30 years of age may have a monthly fertility rate of 4—5 percent for up to 3 years.[7]

The causes of a couple’s infertility may be in one or both partners. A woman may fail to ovulate due to a hormonal disorder or because of polycystic ovary syndrome. Occasionally a superfertile partner can make up for what is lacking in a subfertile partner. The causes of infertility among couples who presented for infertility treatment in Australia and New Zealand in 1997 were tubal 12 percent, male factor 33 percent, endometriosis 6 percent, other causes 9 percent, multiple causes 27 percent, and unexplained 13 percent.[8] But the rates for tubal and male factors for 1979–95 were 34 percent and 19 percent respectively. The increase in male infertility in 1997 explains the drop in the percentage for tubal causes.[9] In the UK single and multiple causes of female infer­tility in all treatment cycles were tubal disease 36 percent, endometrio­sis 8 percent, unexplained 45 percent, and other 19 percent.[10] Stress is also a seasonal factor that adversely affects female fertility.[11] Although one cause of infertility may be dominant, often more than one factor may affect a couple’s fertility.

In the USA it has been suggested that female infertility is caused by failure to produce fertile eggs in 10–15 percent of cases and by pelvic factors like endometriosis, infection, or tubal blockage in 30–40 percent of cases. Education could prevent, or at least minimize, female infertil­ity caused by infection associated with sexually transmitted diseases. Some women fail to ovulate as a result of chemotherapy, surgery or other causes. Others do not want to use their own eggs if they are carriers of a serious inherited disorder such as hemophilia. In these cases recourse to donor eggs is less frequent if use is made of preimplantation genetic diagnosis (PGD) which enables couples to select and implant only their own healthy genetic embryos. Male infertility is caused in 30–40 percent of cases by low sperm count (less than 20 million sperm per ml. of semen), low motility, high viscosity of semen, or insufficient semen. A further 10–15 percent of infertility is caused by sperm being impeded from penetrating cervical mucus. The cause of infertility is unknown in about 10 percent of couples.[12]

The sperm count in men is falling at an alarming rate of >2 percent every year. The evidence indicates the likely causes are the effects of envi­ronmental chemicals, e.g. pesticides, on the human reproductive system and xeno-estrogens which imitate the action of the female hormone estrogen on male reproductive health.[13] However, an increase in couple fertility compensates for any decline in male fertility.[14] There is also evi­dence of increased mutations in sperm and of more genetic defects in the children of older fathers.[15] The paternal-age effect is less frequent than the maternal-age effect and is more likely to involve inheritable muta­tion disorders or sex chromosome errors, while the maternal-age effect is more likely to be associated with increased risks of obstetrical com­plications, perinatal problems or autosomal trisomies.[16]

Treatment

It frequently happens that women who have been unable to conceive for more than a year, become pregnant while awaiting treatment. Some women who have been using contraceptive pills for years may not need treatment, but simply more time for the resumption of ovulation. These possibilities need to be ruled out before undergoing infertility treatment. For some whose work times permit it, all that is needed is for the couple to make use of “timed intercourse” to coincide with natural ovulation.[17] Though infertility is more akin to a disability than a disease, most infer-tile couples need medical treatment after 12 months of unsuccessful attempts to conceive.[18]

Where there are ovulation defects, or the cause of infertility is unknown, ovulation induction may be used with a mild stimulation protocol of superovulation hormones under controlled conditions. Fertilization may then occur following artificial intrauterine insemination and/or normal sexual intercourse, with a pregnancy rate up to 33 percent.[19] Blocked fallopian tubes can also be treated by microsurgery with subsequent intrauterine pregnancy rates from about 25–50 percent within two years.[20] Microsurgery is not very effective for women who have been sterilized by cauterization due to the width of destruction of the fallopian tubes. After female sterilization with clips, microsurgical reversal is successful in up to 80 percent of cases. Unsuccessful attempts of reversal of vasectomy is a frequent cause of male infertility.[21]

The most frequently used infertility treatment procedure is the in­semination of eggs by sperm by IVF followed by embryo transfer to the uterus (ET). Semen may be collected following sexual intercourse and be treated to make it less viscous and sperm more motile. The sperm and eggs, separated by an air bubble, may then be placed in a catheter and promptly injected into the fallopian tube where conception occurs. This procedure is known as gamete intra fallopian transfer (GIFT). Sperm can also be injected under the zona pellucida of the egg to enable fertiliza-tion to occur later on when the membranes of sperm and egg fuse. This is called subzonal insemination (SUZI) and may be performed in a way similar to GIFT.

Since the pregnancy rate of single embryo transfer is low, superovu­latory drugs are commonly given to infertile women to induce the matur­ing of many eggs. These can be harvested transvaginally by ultrasound guidance with little or no anesthesia and several eggs can be fertilized by IVF with ET. The remaining embryos are usually frozen for future preg­nancy attempts. Up to 75 percent of frozen embryos survive the freeze–thaw process prior to ET.[22] In an attempt to improve pregnancy rates, reduce the number of embryos transferred and the risk of multi­ple pregnancies, embryos have been successfully grown in improved cultures up to the blastocyst stage before implantation. This avoids implanting up to 50 percent of embryos whose development would arrest prior to the blastocyst stage when implantation begins. In a study 16 morulae and 116 blastocysts were transferred to 56 women with a 43 percent clinical pregnancy rate per transfer. Thirty-three fetal heart beats were detected at 6 weeks gestation giving a 25 percent implantation rate per embryo transferred. If the factors that influence the implantation rate after blastocyst transfer are identified, this may lead to higher ART and natural pregnancy rates.[23]

Sperm that are deficient in number or motility are infertile unassisted. Single sperm can also be micro-injected into the cytoplasm of the egg to achieve a live birth. This is called intracytoplasmic sperm injection (ICSI).[24] In practice, the problem of male infertility can be overcome because a few sperm can always be aspirated from a man’s testis which can give him a reasonable chance to father a child by means of ICSI. If a woman has no eggs, or if they are chromosomally defective, IVF can proceed using donor ova. If her partner has no functional sperm AI with donor sperm can be used. Donor sperm are usually frozen. While this obviates the need for the donor to be present and allows the semen to be tested for HIV, it does reduce the sperm’s motility by about half.[25] If both partners have no functional gametes, donor gametes could be used with IVF and the resultant embryos implanted in the uterus or an IVF donor embryo could be implanted in the infertile woman’s uterus.[26]

When a woman has functional eggs but no uterus, her eggs, fertilized by her partner’s sperm, may be transferred to another woman’s uterus, who becomes a surrogate mother if she gives the child to the commis­sioning genetic mother after gestation and birth. A similar surrogacy arrangement could involve AI and fertilization of the surrogate mother’s own egg by sperm from the infertile woman’s partner. Donor sperm and egg may be used to form an embryo for implantation in a surrogacy arrangement.

The cryopreservation of mature human eggs, their thawing and IVF fertilization and development has not been very successful, with about 2 percent of oocytes producing a pregnancy to term.[27] Eggs can be cryop­reserved more safely after they are dehydrated in a concentrated glucose solution which is vitrified, i.e. becomes glass-like, when frozen and can subsequently be fertilized by ICSI without needing to freeze embryos. Healthy children have been born using this method.[28] Cryopreservation of eggs and even of blastocysts by vitrification offers a promise of healthy ART births.[29]

A woman’s frozen immature eggs in an ovarian tissue slice has the potential to be transplanted back to the woman and restore her men­strual cycles as a future clinical and insurance option. In theory this could restore natural fertility without the need of ART for conception.[30] This could enable younger women to freeze their immature eggs with fewer risks of chromosomal abnormalities than with older eggs and to mature them for later use in an ART procedure.[31] It could also benefit women with severe endometriosis or recurrent ovarian cysts and who are at risk of premature menopause. Prior to chemotherapy cancer treatment for a young woman, scientists have already successfully removed, frozen, and, after therapy, transplanted back into a 30-year-old woman her own ovarian tissue.[32] Postmenopausal women can also be treated by harvest­ing immature eggs from unstimulated ovaries, maturing them in vitro and having them fertilized by IVE Live birth rates of these methods still need to improve and their safety guaranteed with more preclinical trials.[33]

Outcomes of treatment

While there is no confirmed evidence of increased risk of breast or ovarian cancer from the use of fertility drugs, long-term follow-up studies are needed to dissipate fears.[34] Risks of being affected by severe ovarian hyperstimulation and vascular complications are slight. Ovulation induction and intrauterine insemination are not intrusive infertility treatments with about a 33 percent pregnancy success rate per treatment cycle.[35] Since infertile couples seek treatment to have a live baby, ART success is usually given in terms of the number of live births per 100 oocyte retrieval cycles than the number of women treated since some women undergo more treatment cycles than others.

European experience shows the pregnancy rate of ICSI is generally higher than IVF for male infertility and is becoming the preferred treat­ment option for many infertile couples.[36] In the UK the live birth rate in 1996–7 for IVF and ICSI from 27,288 treatment cycles was 18 percent.[37] In Australia and New Zealand in 1997, the IVF viable pregnancy rate from 6,697 cycles with oocyte retrieval was 13 percent. The ICSI viable pregnancy rate from 6,234 cycles with oocyte retrieval was 14 percent. In the same year the GIFT rate was 20 percent from 1,924 cycles with oocyte retrieval.[38]

Comparisons of pregnancy rates, however, are not very meaningful unless the same definitions and practices are used. Women who have already had a live IVF birth have a higher live birth rate than women undergoing their first IVF course of treatment.[39] A higher pregnancy rate can be obtained by implanting more than three embryos at a greater risk of multiple and preterm births, by including “biochemical pregnancies” in totals, by treating patients with regular cycles below the age of 33 or by avoiding patients in the perimenopausal years.[40] Of 27,981 treatment cycles in the UK, 2,781 had one, 10,617 had two, and 14,583 had three embryos transferred respectively.[41] Of IVF and ET cycles in Australia in 1997, 50 percent involved two and 32 percent three embryos; in GIFT 46 percent had two and 41.5 percent had three eggs transferred.[42] The number of risky and unwanted multiple pregnancies is reduced by trans­ferring no more than two embryos.

In the UK over the two year period 1995–7, of 24,266 treatment cycles only 96 involved women 45 years of age or more (0.4 percent)[43] In Australia and New Zealand in 1997 of 3,488 mothers who gave live births after IVF, 30 (1 percent) were 45 years or more and of 3,488 fathers 336 (10 percent) were 45 years or more. Likewise in 1997 of 505 GIFT pregnancies there were no mothers 45 years or more and 33 fathers (7 percent) were over 45.[44] Since more older women use ART, its birth rate can be expected to be lower than for the general population.

A high proportion of human conceptuses in fertile women is abnor­mal and do not proceed beyond the 18 cell stage of development and this would also occur in IVF conceptuses.[45] The total IVF fetal death rate for pregnancies of at least 20 weeks gestation or birthweight of at least 400g in Australia in 1996–7 was 15 per 1,000 births whereas for all births in Australia in 1997 it was 6.[46] Australia’s IVF neonatal death rate was 9 per 1,000 births in 1996–7 whereas for all Australian births in 1997 it was 3 per 1,000 live births.[47] The stillbirth and neonatal deaths per 1,000 births after IVF or frozen ETs in the UK for the year 1996–7 was 10 for singleton clinical pregnancies and 22 for all clinical pregnancies.[48] These figures need to be interpreted in the light of the fact that we are dealing with infertile women, many of whom are at an age when the risk of fetal death and spontaneous abortion is much higher. With two or three embryos being transferred only about 4 percent of IVF embryos become live babies. Success rates for IVF and GIFT are influ­enced by many factors such as maternal age, the cause of infertility, the quality of the culture medium used, techniques of treatment, and the expertise of practitioners.

In 1996–7 rates for Australian and New Zealand preterm IVF births (<37 weeks) were 24 percent overall and 14 percent for singletons, whereas for GIFT it was 23 percent overall and 13 percent for single-tons. These rates are much higher than the Australian preterm rate of 7 percent of all births in 1997 and a recent US rate of 11 percent.[49] Low birth weight (LBW < 2,500g) is much more frequent in IVF and GIFT pregnancies than in normal pregnancies. The incidence for Australia in 1996–7 for IVF LBW singleton births was 10.6 percent and for GIFT 9.6 percent, whereas the LBW rate for all singleton births in Australia for 1997 was 5 percent.[50] It is interesting to note that the LBW rate for frozen IVF (16 percent) and ICSI (12 percent) babies is lower than for fresh IVF (32 percent) and ICSI babies (33 percent).[51] The rate of ectopic pregnancies is about 2 percent for all pregnancies but after IVF in Aus­tralia and New Zealand in 1997 it was 2.6 percent and for GIFT 3.2 percent.[52]

The rate of major congenital malformations from 1979–97 for all IVF births and from 1985–97 for GIFT births of at least 20 weeks’ gestation was 2.6 percent and 2.4 percent respectively, which is higher than the rate of 1.6 percent given for all births in Australia from 1981 to 1996.[53] Major malformations are generally defined as those leading to functional impairment or needing surgery. What would not count as a birth defect for a naturally conceived child should not count for one conceived by ART.[54] When these figures are interpreted in the light of the older mater­nal age for ART pregnancies, each couple’s reproductive history and the causes of their infertility, the IVF/GIFT abnormality rates are not signifi­cantly different.

Evidence is firming that major malformations following ICSI are not highly significant when large numbers are studied for reliable figures. Clarifications over methodology and inclusion criteria for major and minor congenital malformation are needed for both children born after ICSI and for the general population if comparisons are to be helpful. A major Belgian study of 1987 children born after ICSI found there was no specifically higher incidence of malformations with figures compara­ble for IVF and natural conceptions.[55] However a statistically significant increase in sex-chromosomal aberrations was found – 0.83 percent com­pared to 0.19–0.23 percent. This is not surprising since some fathers of ICSI children have structural sperm anomalies and, despite screening, may transmit them as well as infertility to their male children.[56] A slight increase in autosomal aberrations, mainly trisomies, in ICSI children may be explained by advanced maternal age.[57] But recent data does not suggest that ICSI causes a substantial increase in the risk of birth defects compared to the general population or IVF births.[58]

Intact thawed embryos have a viable pregnancy rate approaching that of fresh embryos but thawed embryos up to eight cells have a lower viable pregnancy rate if up to half of their cells perish.[59] Fresh embryos have a higher pregnancy rate compared to frozen-thawed embryos (9 percent versus 7 percent) and also a lower miscarriage rate (18 versus 21 percent). But frozen–thawed embryos have a lower rate of patholo­gies after implantation (17 versus 26 percent).[60] The implantation rate of frozen–thawed embryos is improved by implanting only those which resume dividing 24 hours after being thawed.[61] The long-term effects of cryopreservation of embryos need to be monitored in adolescents and adults.

A recent Australian study showed the general development of single-ton children conceived through IVF was appropriate, but that, though normal, their language development was less than in their control group. The increased behavior difficulties reported may be more related to their mothers’ concerns.[62] A survey found no independent effect on the growth and physical outcome of 2-year-old children when matched for plurality and gestation.[63] An earlier study of 83 IVF children and 93 naturally con­ceived children matched by age, multiple birth, sex, race, maternal age, and socioeconomic factors, found no evidence of physical defects or developmental delay after assessing them at 12–30 months. Long-term studies are needed to assess ART, including its psychosocial effects in children so conceived.[64]

Burdens and costs of treatment

It is not easy for a couple to admit that they need treatment for infertil­ity. There is often anxiety over which partner is the cause of the couple’s infertility. This may introduce strains in the relationship and counseling may be required. Many infertile couples who desire to have children feel unfulfilled if they cannot be parents. Society generates pressure to have children without giving them sufficient socioeconomic support and incentive when they are biologically best prepared to have children. They are frequently made to feel a stigma, be it ever so subtle, and this leads to them making great sacrifices and financial outlays for each infertility treatment cycle.

Some women establish themselves in a career before having children later in life, when there is a higher incidence of natural infertility. It is not easy for a woman to submit to years of tests, internal examinations, having temperatures taken, and having sexual intercourse at prescribed times – to say nothing of enduring investigative and surgical procedures. Women’s partners share these burdens and stresses. About a third of infertile couples have a baby after the first treatment cycle and many experience emotional setbacks after a failed pregnancy attempt. It grad­ually dawns on many couples, after enduring a huge emotional and finan­cial outlay, that they will never be able to have children of their own, and the option of donor gametes is not welcomed by all.

In the UK in 1995 an IVF treatment cycle cost £700–£2,500, depend­ing on the clinic chosen, most of which are private.[65] Based on the Fifth National Survey of the National Health Service (NHS) it was reported in the House of Commons in 1998 that the cost to the NHS of an IVF treatment cycle, including drugs, was £1,500–£1,800, with some units providing it for £1,000. The average cost at private units was estimated to be £2,500.[66] In the USA from 1994 to 1996 the basic IVF cycle cost about $8,000. In 1992 the cost per delivery was $44,200 for IVF. In a more cost-efficient program, including GIFT with their higher pregnancy rates, the overall cost in 1992 for an ART delivery was $30,252, includ­ing multiple births, while the cost per infant was $22,991.[67]

Treatment for infertility is well financially subsidized by governments in Spain, Italy, and Australia. The priority given to public funding of ART depends on each nation’s evaluation of health services priorities. From 1991, Australia’s Medicare subsidized up to six stimulated cycles of treatment, and from November 2000 this limit was abolished. Frozen ET cycles are also covered. Clinics vary in their fees, but generally for each basic IVF treatment cycle in Australia in 1998, an infertile couple paid a minimum of AU$750 while public funds paid about AU$1,800, plus the cost of any additional drugs. The costs for an overseas patient is about AU$5,200 since no subsidy is paid by Medicare. For each basic GIFT procedure, the patient would pay at least AU$600, while Medicare would pay about AU$1,800.[68]

6.2 ARTIFICIAL REPRODUCTIVE TECHNOLOGY and ETHICS

Utilitarian perspectives

In discussing the ethics of ART, sensitivity to infertile couples is required. On utilitarian grounds the benefits of ART have to be weighed against any likely harmful effects for infertile couples, their children, the family, the institution of marriage, and society.[69] Many believe ART does not present great ethical obstacles. Just as science and technology use artifi­cial means to benefit a person’s impaired sight, hearing or heart, it would be ethical to use ART to enable infertile couples to have children. The use of artificial means in ART does not per se make it unethical because all medicine intervenes in nature.

Using utilitarian criteria ART is judged to be ethically permissible, subject to professional ethical guidelines. The importance of personal autonomy in making decisions on reproductive choices carries much weight. The freedom of women to decide on what is done to their bodies by ART to have children is taken to be axiomatic. In the name of auton­omy it is assumed that a person, endowed with a rational and free nature, a sense of moral responsibility, and a need to express interpersonal love sexually, should not be subordinated to the biological dispositions.[70]

Individual autonomy does not mean other persons may be ignored in making decisions about ART. An evaluation of the social effects and implications of ART need to be made. The state as a matter of public policy may ban some ART procedures or restrict public funding for ART treatments that are not cost effective, e.g. advanced age. The state may also regulate ART in the interests of the dignity and equality of all con­cerned, including children conceived and born through ART and the protection of marriage and the family as basic social institutions. The interests of all are protected when the law bans any form of exploitation of the weak and vulnerable and requires all involved to be accountable. Within the legal limits of ART, couples make their own evaluation of its ethics and its risks of benefits and harms. Laws differ in each country, depending on the cultural perceptions of the common good, the preva­lence of moral pluralism, the relative importance given to personal autonomy and privacy vis-a-vis the accepted role of law in society.

Some question whether ART ought to be used for women in their sixties when they would be nearly 80 years of age when they have teenage children.[71] This does not imply that older mothers or fathers cannot care for children as experience attests. It is better to be reared by loving and caring parents of any age than by uncaring and unloving parents. As we have seen above, there is no danger of many elderly people wanting ART, apart from a legal ban on the number of years embryos may be stored to prevent damage to future offspring. Imposing bans may not be wise. Before making a decision older infertile couples should consider the morbidity and mortality risks of pregnancy for postmenopausal women, and the need of children to have at least one parent capable of caring for them in their formative years in addition to having “a stable home with mature caring adults who themselves have a sound relationship.”[72]

The use of donor gametes in donor insemination (DI) for human pro-creation is not new. Resnik sees human gametes as commodities and sup-ports their commercialization while Lockwood sees practical advantages in this over altruistic donor donation.[73] Few women would want to donate their eggs to an infertile couple because they usually receive hormone injections for 12 or more days to ripen their eggs. Due to the shortage of donor ova it has been suggested that eggs retrieved from aborted fetuses could be matured in culture for use in ART.[74] Utilitarian evaluations of the use of donor gametes vary. Many couples opt to use donor gametes to have children even though one or both of them will not be the child’s genetic parent(s). This is not seen to be ideal, but an ethical option in the circumstances.

There is ample evidence that social parents who are not the genetic parents of their ART or DI children can be good parents. They can be as loving, dedicated, and caring as natural parents usually are. What is important is the quality of the relationships between parents, children and parents and the security of children’s attachment to parents. Susan Golombok rightly says parental responses and love count more than genetic connectedness. There is some evidence that children conceived of donor gametes relate better with their parents than those who have been conceived naturally. It seems that a strong desire of parenthood is more important than the genetic link of natural parents for fostering family relationships. The same applies to single heterosexual mothers with ade­quate finances and family living circumstances. These children would not miss their genetic fathers as much as children who miss their fathers after divorce. Research also shows that children of lesbian mothers are not disadvantaged in their socioemotional well-being, self-esteem, quality of friendships, or gender development. Partners of lesbian mothers are more involved with the children than are fathers in two-parent heterosexual families.[75] Golombok concludes current findings suggest that aspects of family structure such as genetic relatedness, number of parents and the mother’s sexual orientation, may matter less for children’s psy­chological adjustment than warm and supportive relationships with parents, and a positive family environment.[76]

On the other hand Golombok admits her conclusions are based on research on children whose average was about 6 years. By utilitarian cri­teria it seems that once children conceived of donor gametes by ART reach their teens and think of questions of identity it would be prefer-able to heed their natural desire to know their genetic parents. Not all social parents tell the truth to their children about their genetic origins. An Australian survey found that parents had told only 22 of 420 DI chil­dren (5.2 percent) of their genetic origins. Surprisingly 71 percent (182/257) had told others of the origin of their children but 94 percent (24 /257) had not told their children. This creates a risk of somebody other than the parents informing these children of their genetic origins. Of 22 children, 21 reacted positively to the disclosure.[77] It is increasingly recognized that nondisclosure causes major emotional and psychologi­cal trauma because many adult DI offspring feel they have a right to know of their genetic origins.[78] Once DI children grow and suspect the truth of their origins has been concealed, they experience mistrust in the family and a lack of genetic continuity as they come to grips with their identity as donor offspring.[79] The widespread practice of DI would tend to undermine trust in parents.[80] Growing youngsters need love, trust, and security during their formative years.

Surrogacy arrangements vary, but Laura Purdy thinks they all are an emotional, ethical, family, and legal minefield. But this does not mean they need always be harmful.[81] She does not give arguments drawn from human nature much credit, denies contract surrogacy involves selling a baby and recognizes “surrogate mothering” could empower some women and enable them to improve their social and/or economic status.[82] On utilitarian grounds, it could be argued surrogacy may be ethical, especially if the commissioning mother supplies her own egg and it is fertilized by her partner’s sperm prior to implantation in the uterus of the surrogate mother. Others say that surrogacy is more socially acceptable now that it is practiced in the USA with approbation of the law and discuss conditions for its ethical practice.[83] Even if donor gametes are used, Charlesworth says there would be no intrinsic immorality involved provided no extramarital sexual act was involved. He holds it would be an act of love and generosity to provide one’s womb to gestate a baby for another without any financial return other than remuneration for expenses. He argues that a surrogate mother would not demean herself if, after being warned of all the consequences and taking precautions to lessen the risk of psychological harm to the child, she freely consents. Since it would be against natural justice to oblige the birth mother to give up the child against her will, it would have to be legally permissible for her to keep her child, notwithstanding contracts to the contrary. He thinks fears of harm for the child should not enter the utilitarian calculus unless empirical evidence for obvious harm sup-ports them. He believes altruistic surrogacy ought to be legal since the stability of marriage and the family would not be undermined by the few who want surrogacy.[84]

On utilitarian grounds it can also be argued surrogacy is unethical. Robyn Rowland reports on the nightmares and devastating effects of wit­nessing the “giving away” of a sibling on the surrogate’s young and teenage children.[85] It is hard to justify the needless removal of children from their birth mothers with whom bonding occurs during pregnancy. The lack of alienation experienced by a few children reared by their non-genetic parents does not justify embarking on experimenting with the lives of many children by legalizing surrogacy. In the light of the nega­tive experience of some cases of adopted and DI children, on the balance of probabilities, it may be assumed it would not be in the best interests of children conceived and born of surrogacy arrangements. Ethically, this presumption should stand until the contrary is demonstrated.[86] Most Australian states do not recognize surrogacy contracts, ban the use of ART in all forms of surrogate parenthood and advertisements for it![87] This lessens the pressure on relatives to volunteer as surrogates.

Where ART is legalized, the birth mother is recognized as the legal mother. It would be anomalous for the law to recognize two legal defi­nitions of the mother, the genetic and the birth mother. Consideration also needs to be given to what legalizing surrogacy arrangements would say to society about split motherhood.[88] Commercial surrogacy contracts risk reducing pregnancy to incubation, and children to the status of com­modities: they would not be in the public interest.

Reproductive cloning of children goes a step further than the cloning of human embryos discussed in chapter 4. While cloning human individ­uals does not have much appeal, it has been defended by Harris in the name of “procreative autonomy” because he does not think it would be contrary to human rights or dignity.[89] Tooley believes it is in principle morally acceptable, though many would prefer the actual world without human cloning. He mentions the benefits of human cloning would include a development in our understanding of human psychology, the social benefit of having many people similar to outstanding gifted persons, the bearing and raising of children with desirable traits, and helping certain infertile couples, including homosexuals, to have a child related to one of them.[90] Pence accepts the cloning of human beings and rightly insists they should be treated as persons with the same rights as others without discrimination.[91] McCarthy holds that human clones would not be worse off than nonclones.[92] Savulescu goes further and claims the cloning of human embryos and fetuses is not only morally permissible but morally required to provide cells, tissues, or organs for therapeutic purposes, followed by eventual abortion of the cloned fetus.[93]

Protection of children’s interests

An ethical consideration of importance for all ART procedures must be the best interests of the children. This principle is encoded in law in Victoria and the UK, including a reference to the need of a child for a father.[94] Research, based on the responses of both children and parents, shows that children living with their biological parents are likely to thrive in the vast majority of intact families of heterosexual parents who care for each other and their children.[95] Society should allow couples to follow their own informed consciences if the risk of harm to offspring is pre-vented. Contrary to C. L. Ten, I think parenthood should not be achieved by ART to conceive children destined to be raised without their fathers.[96]

We have a history and relationships which belong to us as persons and whose origins are genetic. It belongs to our personal identity to have this father and mother, brother and sister, cousin, grand-parents, uncles and aunts. This network of relationships is not chosen but determined from our genetic origins. Unlike animals, we are aware of this and appreciate the importance of genetic family relationships and bonding. Research by social workers strongly endorses the view that the interests of children conceived by DI should take precedence over the interests of their medically or socially infertile parents or the donors of the gametes used for their conception.[97]

It seems unethical to deliberately break the natural tie engendered by nature: the gestational mother and the social father should also be the genetic parents of the child. When the genetic parents are the social parents family bonding and beneficial relations are likely to be strength­ened where good family relationships exist. It is regrettable that after adoption due to tragic circumstances, some children are deprived of the knowledge and benefit of their genetic parents. This is not to say adop­tion is not beneficial. It is one thing to adopt a child whose natural parents are unable to discharge their responsibilities – but quite another thing to engineer anonymity of a child’s genetic origins by the use of donor gametes.

It is hard to justify the anonymous, impersonal giving or selling of sperm or eggs to become a genetic father or mother without a care in the world for the resulting child. Human gametes for procreation should not treated as commodities nor their transfer be commercialized. The donation or trading of gametes lacks respect for children who are deprived of the knowledge, love and care of their own genetic fathers and/or mothers during their formative years. The same applies to donor embryos. Parenthood is important, but it should not be achieved to the detriment of children.

If laws are to protect children, they should regulate ART.[98] This occurs for adoption and the use of drugs that might prove dangerous for chil­dren, be they born or unborn. Once children born from donated gametes become adults or sufficiently mature they should have a legal right to identifying information about their genetic parents. This has already been done in some states.[99] Such laws go some of the way to protect the legitimate interests of the child and leave scope for parents to use their own discretion when to disclose this information. It is also necessary to know of one’s genetic origins for health reasons, e.g. in cases of preventable genetic diseases.[100] It seems obvious that nondisclosure of the relevant information to children conceived by donor gametes is unethical.

It has been suggested that sperm from one’s deceased partner could be used to create a child. Timothy Murphy sees no ethical problem withusing sperm from dead men in infertility treatment.[101] Others hold that prior explicit or reasonably inferred consent of the deceased man would suffice ethically to retrieve sperm for this purpose in the absence of perceived harm to the child.[102] After a wide public consultation which drew 9,000 responses, the UK Human Fertilization and Embryology Authority “did not consider the use of fetal ovarian tissue was accept-able in the treatment of infertile women.[103] It would be contrary to the dignity of a child to be conceived using gametes from a corpse or an aborted fetus. The use of gametes from corpses and aborted fetuses should be banned by law from use in ART out respect for the inherent worth of children and common human decency.

Disrupting the natural links between marriage, conception within mar­riage, gestation, birth, and the rearing of a child conflicts with our under-standing of the meaning of marriage and motherhood. It does not serve the long-term interests of children who are conceived and born in this way. It is not helpful to blur one’s sense of personal identity by distort­ing one’s concepts of parenthood, family, and relationships.

Motherhood includes the genetic dimension and gestation followed by the rearing of the child together with one’s partner. Pregnancy cannot be discounted as having little significance for the mother and child. It constitutes a significant natural interpersonal relationship of dependency of the unborn child for nurture and protection. It places on the mother and father a corresponding duty of care. Gestation and giving birth are of paramount importance in human culture: the mother is the one who bears and gives birth to the child and is presumed to be the genetic mother unless proven to the contrary. The mother’s role should not be reduced to that of an incubator, divorced of all ongoing maternal rela­tionships with her child. Where donor gametes are legally permitted in ART with the consent of one’s partner, common law has usually, and rightly, been changed by statute law to determine that the birth mother is the legal mother of the child rather than the genetic mother.[104] Even the legal sanctioning of altruistic surrogacy would weaken the impor­tance of motherhood.

Autonomy should not be overrated and interpreted in an individual­istic way, divorced from personal relationships and responsibilities. Adults involved in surrogacy arrangements cannot act as though they were the only ones involved. An individualistic notion of personal auton­omy opens the way to overlook the personal identity and dignity of the child who may be treated as an object. As a result, the notion of harm can be so narrowed as to exclude the psychological damage to the child’s sense of personal identity. It is not a question of it being better to be than not to be. Accepting this line of argument could lead to justifying the conception of children from adulterous affairs. Adultery is immoral and ought not be committed even if it gives rise to children who may live happy lives. Respecting the moral beliefs of adults should not go so far as to risk harm to children. Though some private altruistic surrogacy arrangements may sometimes occur, the law should not give them legal standing for the common good, even if it may not be necessary to make them criminal.

Cloning a child seems contrary to human dignity and natural justice because it deprives the child of the genetic basis of a father, mother, and other family relations. Being cloned would negatively impact on the child’s identity and family relations based on a genetic father and mother. A cloned child would be a human individual, a person, a subject and not an object to be created as a mere means for the benefit of others, such as a source of tissue for transplants. The conditions for the transmission of human life are determined by the natural moral law and may not be deliberately frustrated at will nor be directly subordinated to medical or technological dominion. Furthermore, it would be unfair to place unreal expectations on a cloned child. In addition to the safety concerns of cloning, the President of the European Union was rightly advised that “Considerations of instrumentalization and eugenics render any such acts unacceptable.”[105]

Professional ethical guidelines

 ART clinicians have to be professional in providing services to infertile couples, maintaining confidentiality of records, and the safe custody of gametes and embryos. It is imperative that infertile couples receive spe­cific counseling in all aspects of infertility treatment as a prerequisite for informed consent, including the prospects of failure to achieve an ART pregnancy and the ethical balancing of their own interests and the well-being of existing and future children. For reasons of privacy and auton­omy infertile couples should have the option of access to independent counseling.[106] Couples should be encouraged to seek advice from advisers of their choice on the ethical aspects of their treatment. They need to be given in advance adequate and comprehensive written and oral information on known risks of the short- and long-term harmful effects of ART on the health and psychological well-being of the mother and her ART children, as well as increased risks to their embryos.[107] They should be told of the clinic’s relevant success rate and whether the treat­ment is conventional or experimental.[108] With the consent of the parents, there should be follow up of children born after ICSL As the children grow older, observations and tests would require the consent of the chil­dren concerned.[109]

Doctors practicing ART have their professional ethical responsibili­ties and they should not be reduced to mere technicians who comply with every wish of their clients. People who are not suited for ART on medical grounds ought to be refused in the same way as for any other unwar­ranted medical treatment. Apart from the right to try to have a child in the natural way, there is no strict right to a child. Think of a woman suf­fering from active anorexia nervosa which naturally causes the suppres­sion of ovulation. Before she was cured of anorexia it would be professionally unethical to offer her ART to achieve a pregnancy, includ­ing hormonal treatment, simply because she asks for it. It would also be unethical for clinicians to offer ART to a couple whose parenting skills are very deficient. If there is evidence of abuse of addictive drugs, includ­ing alcohol, a history of detention in jail, or previous children aban­doned, caution is needed. The exercise of professional discretion by ART clinicians should not be confused with unjust discrimination. Firm evi­dence, however, would be needed before deeming a person unfit for ART on the grounds of a previous unsuitable lifestyle, e.g. a reformed drug addict or prostitute.[110]

Marriage and procreation in the Catholic Christian tradition

Marriage and procreation in the Catholic Christian tradition

From a Catholic Christian perspective, marriage is an “intimate part­nership of life and love” grounded in the covenanted relationship of its partners.”[111] “Children are the supreme gift of marriage and greatly con-tribute to the good of the parents.”[112] Children should be conceived within marriage and raised with provision for all their basic needs. Catholic teaching says

The procreation of a new person ... must be the fruit and the sign of the mutual self-giving of the spouses, of their love and of their fidelity. The fidelity of the spouses in the unity of marriage involves reciprocal respect of their right to become a father and a mother only through each other.[113]

Referring to ART techniques in general Pope John Paul II said

they are morally unacceptable since they separate procreation from the fully human context of the conjugal act.[114]

Marriage enshrines a right for a couple to try to have a child by a con­jugal (marital) act whereby spouses seal an irrevocable commitment to each other and their children, including their responsibilities to bring them up in a suitable environment. Children of the marriage are equal and genetically related members of the family with a right to be cared for and loved. These are some of the reasons why Christians generally believe marriage is needed for human procreation and Catholic teaching rightly insists that out of respect for the personal nature of a human being the child ought to have a fully human origin, i.e. ought “to be con­ceived and to be born within marriage and from marriage.”[115]

On account of its social importance marriage has been, and should be, legally recognized and protected. Society needs to identify legally the parents of children and their respective obligations.[116] These ethical and legal requirements protect children by providing a firm basis for the family, parental duties and the good of society. Many states require mar­riage or a stable relationship of a man and a woman for access to ART.[117] Catholic teaching also says that conception by ART

brought about outside the bodies of the couple by the actions of third parties . . . establishes the domination of technology over the origin and destiny of the human person . . . contrary to the dignity and equality that must be common to parents and children.[118]

But it is not obvious that ART necessarily involves the domination of technology if its purpose is to facilitate the fusion of sperm and egg for conception, without discarding or harming human embryos. The fact that some embryos are discarded in some ART procedures does not imply that this need always happen. To the extent that the use of ART veers from offspring being conceived and born within marriage and from mar­riage, it is deemed to be immoral by many in the Christian tradition, especially Catholics.[119]

Recourse to ART does not imply that the child cannot be a child of the marriage. Catholic teaching says that if ART facilitates the conjugal act or helps it reach its natural objectives, it can be morally acceptable.[120]

This would obviously morally permit assisted intrauterine insemination within marriage. If semen collected following a marital act were used to fertilize the wife’s egg within her body using GIFT it would seem to be assistance to the marital act to enable sperm and egg to meet in the fal­lopian tube. The object of the assistance is to enable conception to occur at the normal site. Before judging this to be unethical one would need to be certain that the assistance given by GIFT, and a procedure similar to it, SUZI, prevents the child being conceived within and from mar­riage.[121] Catholic teaching has not pronounced on the moral permissi­bility of GIFT. In practice, GIFT is permitted in Catholic fertility clinics.

While the Church does not approve IVF, she does admit, however, that IVF for a married couple

is not marked by all that ethical negativity found in extra-conjugal pro-creation; the family and marriage continue to constitute the setting for the birth and upbringing of the children.[122]

The Church, of course, holds that all newborn children should be accepted as living gifts of God’s goodness.[123] I think it is necessary that any morally permissible ART procedure to assist infertile couples to have children would need to protect the dignity of the couple, the children, and marriage. In practice, this means that children should be conceived and born within marriage and from the marriage, i.e. within the fully human context of the conjugal act. I do not believe any ART technique would be morally acceptable if it could be shown to be inconsistent with the moral values enshrined in the above principle, bearing in mind the couple’s infertility. While many disagree with Catholic teaching on ART, it is helpful to understand its underlying reasons.

 Challenges Ahead

The suffering caused to infertile couples by their condition and its treat­ment warrant more research on its causes and how its incidence may be reduced. Governments world-wide need to address the issue of the causes of female and male infertility. Better public education is required to avoid preventable infertility in men and women, including sexually transmit­ted diseases. There is a need to create a society where infertile couples can freely choose to remain childless without feeling compelled to have recourse to ART.[124] There is also a need to research and address the soci­etal causes of couples seeking to begin their families later in life when there is an increase in the natural incidence of infertility, miscarriages and genetic abnormalities in newborns. The risks of any eventual nega­tive impact on children conceived by ART, natural family formation, society or culture should be monitored. ART clinicians should promote prospective studies on the long-term effects of ART on its offspring. Comprehensive and thorough evaluations need to be conducted because ART clinicians “do not repair an organism, they help to create a new being.”[125]

Far from being enslaved to ART, we should assert ourselves as its morally responsible masters. ART should be at the service of persons, not young persons at the service of ART.