Infertility

GAMETE
INTRAFALLOPIAN TRANSFER
(GIFT)

Four-month old human fetus

From the Bioethics Center at Loras College, Debuque, Iowa. http://www.loras.edu/~CatholicHE/Arch/Sexuality/Gamete.html

The assisted reproductive technology of Gamete Intrafallopian Transfer (GIFT) involves three steps.

1) THE FIRST STEP

Medications are used to stimulate the woman to produce more than one follicle and ovum, and to aid in stimulating the follicles to release the ova. During this time the woman’s response to the medication and the development of her ova are watched and assessed.

2) THE SECOND STAGE

begins with a laparoscopy performed under general anesthesia to retrieve the ova. The ova are then examined under a microscope to determine maturity. Semen is obtained and processed in a centrifuge, where it is washed and then placed in a test tube so that the active sperm can swim to the top.

3) THE THIRD STEP

consists in transfer of the ova and sperm into the woman's body. Ova and sperm are placed in a catheter, and the catheter is inserted directly into the woman’s fallopian tube through a surgical procedure using a laparoscope. The ova and sperm are then injected into the fallopian tube, with the intent of fertilization occurring in its normal environment within the woman’s body. If fertilization does occur, the developing embryo(s) will remain in the fallopian tube and then move to the uterus for implantation.

The use of Gamete Intrafallopian Transfer (GIFT) by marital spouses is not excluded, provided that the following restrictions are observed:

1) the retrieval of ova and sperm must follow a natural act of sexual intercourse;

2) sperm must be collected from that act of intercourse by morally acceptable means;

3) the procedure must be carried out in such a way as to avoid the possibility of extracorporeal conception;

4) any ova collected but not transferred back into the woman?s body must not be fertilized in vitro, with the resulting embryos frozen for later implantation.

Should a multifetal pregnancy result through the use of the GIFT procedure, pregnancy reduction, that is, the abortion of some of the fetuses, is not permissible.

The Instruction on Respect for Human Life in its Origin and On the Dignity of Procreation from the Vatican Congregation for the Doctrine of the Faith (1987) did not explicitly pass judgment on the GIFT procedure. (2) Cardinal Joseph Ratzinger, prefect of the Congregation for the Doctrine of the Faith at the time the Instruction was issued, gave the following instructions on techniques whose use had been left open: ?When the discussion is still open and there is not yet a decision by the
magisterium, the doctor is required to stay informed, according to classic theological principles and concrete circumstances? and to ?make a decision based on his informed conscience.? (3)

The following directives from the Ethical and Religious Directives for Catholic Health Care Services, based on the Vatican Instruction, are relevant to assessing the moral permissibility of the GIFT procedure:

When the marital act of sexual intercourse is not able to attain its procreative purpose, assistance that does not separate the unitive and procreative ends of the act, and does not substitute for the marital act itself, may be used to help married couples conceive. (no. 38)

41. Homologous artificial fertilization (that is, any technique used to achieve conception using the gametes of the two spouses joined in marriage) is prohibited when it separates procreation from the marital act in its unitive significance (e.g., any technique used to achieve extra-corporeal conception). (no. 41) (4)

The restriction concerning the method of collecting sperm is derived from the Church?s long-standing teaching on the immorality of masturbation. This teaching was reaffirmed in 1975 by the Sacred Congregation for the Doctrine of the Faith in the Declaration on Certain Problems in Sexual Ethics:

...both the magisterium of the Church, in the course of a constant tradition, and the moral sense of the faithful have been in no doubt and have firmly maintained that masturbation is an intrinsically and gravely disordered action. The principal argument in support of this truth is that the deliberate use of the sexual faculty, for whatever reason, outside of marriage is essentially contrary to its purposes. For it lacks that sexual relationship demanded by the moral order and in which ?the total meaning of mutual self-giving and human procreation in the context of true love? is achieved. All deliberate sexual activity must therefore be referred to the married state. (5)

Regarding the third restriction, see the handbook entries on In Vitro Fertilization (IVF) and Cryopreservation (Freezing) of Embryos.

The prohibition against selective reduction is part of the Church?s unqualified opposition to direct abortion; see the Congregation for the Doctrine of the Faith, Declaration on Procured Abortion (1974). (6)

1. Fertilitext, Gamete Intrafallopian Transfer (GIFT), http://www.fertilitext.org/gift.html; FertilityRX.com, Assisted Reproductive Technology, Section IV: Gamete Intrafallopian Transfer (GIFT), http://iop.com/ ~poetsrx/art/gift.html; Reproductive Medicine Group, Tampa, FL, Gamete Intrafallopian Transfer (GIFT), http://www.vbtivf.com/GIFT.htm; Lycos Health by WedMD, Gamete Intrafallopian Transfer (GIFT), and Zygote Intrafallopian Transfer (ZIFT), http://webmd.lycos.com/content/dmk/dmk_article_5461649; Am-I- Pregnant.com, Gamete/Zygote Intrafallopian Transfer, GIFT, http://www.am-i-pregnant.com/giftinv.shtml.

2. Congregation for the Doctrine of the Faith, Instruction on Respect for Human Life in its Origin and On the Dignity of Procreation (Donum Vitae) (Washington, DC: United States Catholic Conference, 1987).

4. National Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services (1994) (Washington, DC: United States Catholic Conference, 1995).

5. Sacred Congregation for the Doctrine of the Faith, Declaration on Certain Problems of Sexual Ethics (Dec. 29, 1975), no. 9, reprinted in Kevin D. O?Rourke , OP and Philip Boyle, OP, Medical Ethics Sources of Catholic Teachings (St. Louis: Catholic Health Association, 1989).

6. Reprinted in Austin Flannery, O.P. (ed.), Vatican Council II: More Post Conciliar Documents, vol. 2 (Northport, NY: Costello Publishing Company, 1982).

The GIFT procedure was developed in 1984 by Dr. Ricardo Asch and his associates at the University of Texas Health Science Center in San Antonio. (1) The procedure is ?most often recommended for couples with unexplained infertility with the female partner having at least one open fallopian tube.? (2) It can also be recommended ?for patients whose infertility is due to cervical or immunological factors, mild endometriosis, or selected cases of male infertility.? (3)

GIFT is considered a variation of in vitro fertilization (IVF), with one significant difference. With the GIFT procedure, it is intended that fertilization occur naturally within the woman?s body instead of in a laboratory. (4) For this reason, GIFT is sometimes described as ?an alternative for patients whose religious beliefs prohibit conception outside the body.? (5)

Reports of the success rate of GIFT in comparison with IVF vary. Some reports indicate a higher successs rate for GIFT in achieving a pregnacy. (6) Other reports indicate similar success rates for GIFT and IVF (7), with IVF supplanting GIFT at some fertility clinics. (8)

A procedure called Tubal Ovum Transfer (TOT), or alternately, Tubal Ovum Transfer with Sperm (TOTS) is very similar to GIFT and has been superseded by it. (9)

The Pope John Center, in consultation with Msgr. Carlo Caffarra, head of the Pope John Paul II Institute for the Family in Rome, approved the GIFT procedure in 1985, with the restriction that sperm are collected during an act of sexual intercourse. (10) However, the legitimacy of the GIFT procedure was not accepted by all theologians, and the controversy continued through the decade of the 1990's. (11) Nevertheless, the GIFT procedure has not, to date, been explicitly rejected by the magisterium. (12) Because of the lack of agreement among reputable theologians, and concomitantly, because of the lack of an explicit pronouncement of approval by the magisterium, the handbook?s policy statement is stated cautiously, namely, that the use of GIFT by marital spouses is not excluded. (13)

Rev. Donald McCarthy of the Pope John Center has defended the GIFT procedure on the following grounds:

The conjugal act in the described procedure remains the essential step in getting the ovum and sperm to meet. This step is followed by the repositioning of the ovum and sperm in a manner which markedly increases the likelihood of fertilization. Hence, GIFT...can be seen as a medical procedure which assists, rather than replaces, the conjugal act...

In conclusion, while the GIFT technique uses technology to assist fertilization, it simply re- positions the sperm and ova to enhance the desired outcome of fertilization. The link between the marital act and procreation is realized by technical assistance. (14)

It should be noted that there is theological precedent for regarding the repositioning of ova or sperm after an act of sexual intercourse as morally permissible; see the entry Theological Opinion on Permissible Assisted Reproductive Technologies (ARTs). GIFT likewise involves the temporary exteriorization of ova and the temporary exteriorization and processing of sperm after an act of sexual intercourse. Again, there is theological precedent for regarding these procedures are morally permissible; see the entry Theological Opinion on Permissible Assisted Reproductive Technologies (ARTs).

Further, Peter Cataldo has attempted to spell out more exactly what it means for a technological procedure to replace the conjugal act or to assist it:

A procedure replaces the conjugal act if it determines, of itself, those conditions which immediately secure the success of fertilization; a procedure assists the conjugal act if it does not determine, of itself, those conditions which immediately secure the success of fertilization, but rather allows fertilization to take place under immediate conditions which are natural. (15)

Using this criterion, Cataldo argues that GIFT is a morally legitimate procedure:

...I believe that GIFT with a conjugal act assists that act because the immediate conditions of fertilization are not determined or created by the procedure itself. Unlike IVF and the other procedures which replace the conjugal act, fertilization itself takes place in GIFT within natural conditions which are essentially the same as those in which a pathology is not present. (16)

The central objection voiced against the GIFT procedure is that it does not really assist an act of sexual intercourse, but rather, illegitimately substitutes for the conjugal act between spouses in achieving conception. This objection has been developed in several ways.

William May contends that this procedure makes the conjugal act incidental to the achievement of pregnancy in that an act of sexual intercourse is needed only to obtain sperm in a morally acceptable way:

...I think it must be said that in the GIFT procedure the conjugal act is in truth incidental and not essential to the achievement of pregnancy. The bond between the marital act and the GIFT procedure is not essential. This is quite obvious from the fact that this procedure as such does not require the marital act. There is a complete dissociation between the marital act and the technical method which leads to conception. The only reason to engage in the marital act is to obtain the husband?s sperm in a non-masturbatory way. But this is only incidental to the GIFT procedure as such. ...GIFT, therefore, substitutes for the marital act as far as the conception of the child is concerned and does not facilitate it or help it to achieve its natural objectives. (17)

Donald DeMarco also contends that these procedures make ?the conjugal act...incidental to the achievement of pregnancy? because ?the technical method could be employed in the complete absence of the sex act, or even of love and marriage.? (18) Indeed, some fertility clinics make explicit that sperm for the procedure is usually obtained through masturbation. (19)

Those approving of the GIFT procedure have pointed out that, when the procedure is employed together with the collection of sperm in a perforated condom during an act of sexual intercourse, some sperm does enter the body of the woman, and hence that the possibility does exist that actual fertilization occurs from that sperm. (20) This possibility is used to counter the charge that GIFT makes the conjugal act purely incidental to the achievement of pregnancy.

Another version of the objection that the GIFT procedure substitutes for the act of sexual intercourse between spouses is developed by John Hass:

With all the procedures which intervene between intercourse and conception in GIFT an integral link between the marital act and procreation is lost. In other words, there is no longer an inherent, necessary and intelligible link between the marriage act and procreation. (21; italics added)

However, it is not simply the passage of time between coitus and the injection of the gametes which would seem to render GIFT immoral but the fact that the intrinsic link between coitus and new life is broken by the intervening human acts. It would seem that the new life is more the result of the actions of technicians and medical personnel rather than the act of love between a husband and a wife. ...What is morally relevant is that the interventions of the technicians and substitution of a host of procedures come to replace the marital act. (22; italics added)

In sum, ?opposition to the moral acceptability of GIFT is based on the reason that the number of interventions breaks the intrinsic link between marital coitus and new life.? (23; italics added)

The same procedures considered individually and apart from GIFT are found morally wrong within GIFT. The following interventions taken singly (and in conjunction with the conjugal act) are considered licit as means to overcome infertility: collecting semen with a perforated Silastic sheath; placing it in a syringe, injecting semen into the uterus, treating the sperm, the use of ovulatory drugs, laparoscopic retrieval of eggs, and injection of eggs into the fallopian tubes at an atypical site. Thus, what are considered individually licit interventions become illicit in GIFT because there are too many of them. It is the number as such, the total number of interventions, which is found objectionable. Further proof of this is seen from the fact that the very thing which makes each intervention licit individually is that each does not violate the intrinsic link between conjugal act and procreation. If the very thing needing to be preserved is preserved individually by each, then the reason for the rejection of those same procedures must be the size of their number taken in combination.

Hence, there must be some threshold number which makes the moral difference between assistance and replacement for those who disapprove of GIFT. But what is that number, and how is it to be determined? In fact, there cannot be such a threshold because it cannot be objectively determined. Moreover, Donum Vitae does not place an inherent, quantitative limit to the concept of assistance. The number of steps in between conjugal act and fertilization is not morally decisive for the difference between assistance and replacement... (24)

In further defense of the union between the couple?s act of sexual intercourse and conception it might be recalled that fertilization is not simultaneous with the act of intercourse, but is a process that can take up to thirty hours. (25) Indeed, there are cases where fertilization does not begin until two or three days after intercourse because the woman has not yet ovulated and because the sperm still have sufficient viability to bring about fertilization. (26)

Yet a third version of the objection has been presented by Benedict Ashley and Kevin O?Rourke:

We agree, however, with DeMarco that even if fertilization is not extracorporeal, the ethical defect of GIFT is that fertilization is not directly the result of the marital act, since the semen used is not deposited by that act in the vagina, but by a technician?s manipulation which substitutes for the marital act... Hence, ?the immediate condition by which fertilization takes place? it seems to us is not the marital act but the technician?s manipulations. Nor is it relevant to cite as a precedent the traditional statement of the moral manuals, for which also Pius XII made allowances, that it would be permissible (if it were shown to be effective, which seems not to be the fact) for the husband to use some device to move semen higher into the vagina or uterus to enhance the possibility of conception. In that case it was supposed that the semen was deposited in the vagina of the woman by normal intercourse and remained within her. (27)

Those approving of the GIFT procedure might again point out that, when the procedure is employed together with the collection of sperm in a perforated condom during an act of sexual intercourse, some sperm does enter the body of the woman, and hence that the possibility does exist that actual fertilization occurs from that sperm. (28)

When the GIFT procedure was initially developed, the protocol included air spaces between the sperm and ova when they were placed in the catheter for insertion into the woman?s body. This was done in order to keep them separated and to prevent fertilization outside the body. (29) This respected the Catholic view that extracorporeal conception is not morally permissible. (30)

While some fertility clinics have retained this protocol (31), a number of descriptions of the GIFT procedure now speak of the sperm and ova being ?placed together? or ?mixed? during the step of transferring them into the woman?s fallopian tube. (32) At the same time, it is affirmed that fertilization takes place in the normal, natural way within the woman?s body in her fallopian tube. (33) Indeed, GIFT is described as ?an alternative for patients whose religious beliefs prohibit conception outside the body.? (34)

Once sperm and ova are in contact, how can it be claimed unequivocally that fertilization takes place within the woman?s body? Here it might be replied that ?fertilization is a series of processes rather than a single event.? (35) Specifically, fertilization involves penetration of the corona radiata, attachment to and penetration of the zona pellucida, fusion of sperm and egg, prevention of polyspermy, metabolic activation of the egg, decondensation of the sperm nucleus, completion of meiosis in the egg, and the development and fusion of male and female pronuclei. (36) The short time in which ova and sperm are mixed extracorporeally while being transferred into the woman?s body during the GIFT procedure, combined with the temporal series of events needed for fertilization, may well undergird the claim that fertilization takes place in the natural way in the woman?s fallopian tube in this procedure.

Nevertheless, as a mattter of moral caution, Catholic couples seeking to use the GIFT procedure are encouraged to inquire how it is being performed at that particular fertility clinic and to request the original protocol in which air spaces are included between the sperm and ova when they are placed in the catheter for insertion into the woman?s body. The original protocol is a simple one, and it should not be a burden on the clinic to carry out the procedure in this way.

Use of the Procedures In Vitro Fertilization (IVF) and the Cryopreservation (Freezing) of Embryos in conjunction with GIFT

In its Revised minimum standards for in vitro fertilization, gamete intrafallopian transfer, and related procedures the American Society for Reproductive Medicine makes the following recommendation:

Because technical considerations at the time of oocyte recovery may prevent tubal transfer and/or oocytes in excess of those recommended for tubal transfer may be obtained, it is recommended that GIFT only be performed in a facility that is prepared to carry out IVF, as an alternative or in addition, in the event that the GIFT procedure turns out not to be feasible and/or excess oocytes are recovered. Accordingly, a GIFT program must have an embryo laboratory and personnel capable of performing IVF. In addition the program should be capable of fertilizing nontransferred oocytes and freezing the resulting embryos if they are of good quality. (37)

Because in vitro fertilization (IVF) and the freezing of embryos are considered to be morally impermissible practices by the Catholic Church, it is never permissible to use the GIFT procedure in conjunction with them. See the entries In Vitro Fertilization (IVF) and Cyropreservation (Freezing) of Embryos.

Because a number of ova are used in the GIFT procedure in order to enhance the chances of achieving a pregnancy, the possibility exists of this procedure resulting in a multifetal pregnancy, that is, in a pregnancy in which two or more fetuses are present in the womb. (38) The following is one set of statistics on multi-fetal pregnancy rates for the GIFT procedure:

Multifetal pregnancies carry risks for both the fetus and the mother. Risks to the fetus include ?an increased chance of miscarriage, birth defects, premature birth, and the mental and/or physical problems that can result from a premature delivery.? (40) Maternal risks include ?premature labor, premature delivery, pregnancy-induced high blood pressure or pre-eclampsia (toxemia), diabetes, and vaginal/uterine hemorrhage.? (41)

Multifetal pregnancy reduction consists in removing one or more of the fetuses in a multifetal pregnancy ?in an effort to increase the likelihood that the pregnancy will continue? (42), and concomitantly, to reduce the risks to the mother and remaining fetuses. (43). Pregnancy reduction is more likely to be performed when four or more fetuses are present, although it may be considered under special circumstances in the case of triplets or twins. (44)

Multifetal pregnancy reduction, as an instance of abortion, is never permissible.

2. Fertilitext, Gamete Intrafallopian Transfer (GIFT), http://www.fertilitext.org/gift.html. See also FertilityRX.com, Assisted Reproductive Technology, Section IV: Gamete Intrafallopian Transfer (GIFT), http://iop.com/~poetsrx/art/gift.html; Infertility, Gynecology, & Obstetrics Medical Group of San Diego, The Assisted Reproductive Technologies Procedures at IGO Medical Group, Gamete Intrafallopian Transfer, http://www.igomed.com/fertilityserv.htm; Lycos Health by WedMD, Gamete Intrafallopian Transfer (GIFT), and Zygote Intrafallopian Transfer (ZIFT), GIFT, http://webmd.lycos.com/content/dmk/dmk_article_5461649; Am-I-Pregnant.com, Gamete/Zygote Intrafallopian Transfer, Gift, http://www.am-i-pregnant.com/ giftinv.shtml.

3. Fertilitext, Gamete Intrafallopian Transfer (GIFT), http://www.fertilitext.org/gift.html. See also FertilityRX.com, Assisted Reproductive Technology, Section IV: Gamete Intrafallopian Transfer (GIFT), http://iop.com/~poetsrx/art/gift.html; Infertility, Gynecology, & Obstetrics Medical Group of San Diego, The Assisted Reproductive Technologies Procedures at IGO Medical Group, Gamete Intrafallopian Transfer, http://www.igomed.com/fertilityserv.htm; Lycos Health by WedMD, Gamete Intrafallopian Transfer (GIFT), and Zygote Intrafallopian Transfer (ZIFT), GIFT, http://webmd.lycos.com/content/dmk/dmk_article_5461649.

4. See, for example, Fertilitext, Gamete Intrafallopian Transfer (GIFT), http://www.fertilitext.org/gift.html;

FertilityRX.com, Assisted Reproductive Technology, Section IV: Gamete Intrafallopian Transfer, http://iop.com/~poetsrx/art/gift.html; Infertility, Gynecology, & Obstetrics Medical Group of San Diego, The Assisted Reproductive Technologies Procedures at IGO Medical Group, Gamete Intrafallopian Transfer, http://www.igomed.com/fertilityserv.htm; IVF.com, Introducing the GIFT Procedure, http://www.ivf.com/ gift.html.

5. FertilityRX.com, Assisted Reproductive Technology, Section IV: Gamete Intrafallopian Transfer, http://iop.com/~poetsrx/art/gift.html. See also Fertilitext, Gamete Intrafallopian Transfer (GIFT), http://www.fertilitext.org/gift.html; Infertility, Gynecology & Obstetrics Medical Group of San Diego, The Assisted Reproductive Technologies Procedures at IGO Medical Group, Gamete Intrafallopian Transfer, http://www.igomed.com/fertilityserv.htm; Reproductive Medicine Group, Tampa, FL, Gamete Intrafallopian Transfer (GIFT), http://www.vbtivf.com/GIFT.htm.

6. See, for example, Fertilitext, Gamete Intrafallopian Transfer (GIFT), http://www.fertilitext.org/gift.html;

FertilityRX.com, Assisted Reproductive Technology, Section IV: Gamete Intrafallopian Transfer, http://iop.com/~poetsrx/art/gift.html; Lycos Health by WedMD, Gamete Intrafallopian Transfer (GIFT), and Zygote Intrafallopian Transfer (ZIFT), GIFT, http://webmd.lycos.com/content/dmk/dmk_article_5461649; Am-I-Pregnant.com, Gamete/Zygote Intrafallopian Transfer, GIFT, http://www.am-i-pregnant.com/ giftinv.shtml; Women?s Health Interactive, Treatments for Infertility Assisted Reproductive Technologies (ART), Gamete Intrafallopian Transfer (GIFT), http://www.womens-health.com/ inf_ctr/inf_trt_art.html.

7. See, for example, Infertility, Gynecology & Obstetrics Medical Group of San Diego, The Assisted Reproductive Technologies Procedures at IGO Medical Group, Gamete Intrafallopian Transfer, http://www.igomed.com/fertilityserv.htm

8. See, for example, Institute for Reproductive Health, Cincinnati, Ohio, In Vitro Fertilization, http://www.cincinnatifertility.com/ivf.htm. See also Sherif Awadalla, M.D., In Vitro Fertilization, http://www.FERTILITYNETWORK.COM/articles/articles~ivf.htm.

9. Benedict M. Ashley, O.P. and Kevin D. O?Rourke, O.P., Health Care Ethics A Theological Analysis, 3rd ed. (St. Louis: Catholic Health Association, 1989), p. 285; Donald T. DeMarco, ?Catholic Moral Teaching and TOT/GIFT? in Donald G. McCarthy (ed.), Reproductive Technologies, Marriage and the Church (Braintree, MA: Pope John Center, 1988), p. 127. One no longer finds references to the TOT/TOTS procedure in the literature on assisted reproductive technologies.

10. Rev. E. Bayer, Letter to Rev. William Gallagher with translation from Msgr. Carlo Caffarra regarding GIFT. Pope John Center, July 9, 1985.

11. See, for example, DeMarco, ?Catholic Moral Teaching and TOT/GIFT?; William May, ?Catholic Teaching on the Laboratory Generation of Human Life? in Marilyn Wallace, R.S.M. and Thomas W. Hilgers (eds.), The Gift of Life The Proceedings of a National Conference on the Vatican Instruction on Reproductive Ethics and Technology (Omaha, NB: Pope Paul VI Institute Press, 1990); John M. Hass, ?GIFT? No!? Ethics & Medics 18/9 (Sept. 1993): 1-2; Benedict M. Ashley, O.P. and Kevin D. O?Rourke, O.P., Health Care Ethics A Theological Analysis, 4th ed. (Washington, DC: Georgetown University Press, 1997), p. 247

12. Ashley and O?Rourke, Health Care Ethics A Theological Analysis, 4th ed., p. 247.

13. Compare the assessment of Thomas J. O?Donnell, S.J., on the question of Catholic couples using the GIFT procedure: ?Moral Conclusion Regarding LTOT and GIFT: It is of some significance that although the Vatican Congregation for the Doctrine of the Faith studied these procedures there was no comment on them in the instruction of February 22, 1987. This would seem to signal an intention to leave the matter open for further study. Thus while reliable and responsible Catholic theologians view the procedures as at least probably acceptable, they may be adopted in practice barring any statements by the Holy See.? Medicine and Christian Morality, 2nd rev. ed. (New York: Alba House, 1991), pp.239-40.

14. Donald McCarthy, ?GIFT? Yes!? Ethics & Medics 18/9 (Sept. 1993): 3-4 at 4.

15. Peter J. Cataldo, ?Reproductive Technologies,? Ethics & Medics 21/1 (Jan. 1996): 1-3 at 2.

17. May, ?Catholic Teaching on the Laboratory Generation of Human Life,? p. 88. The same point is made by Hass, ?GIFT? No!? p. 2.

19. See, for example, the Reproductive Medicine Group, Tampa, Florida, http://www.vbtivf.com/ GIFT.htm.

20. Donald G. McCarthy, ?Catholic Moral Teaching and TOT/GIFT: Response? in McCarthy (ed.), Reproductive Technologies, Marriage and the Church, p. 144; Donald G. McCarthy, ?Infertility Bypassed,? Ethics and Medics 11/3 (March 1986): 3-4.

24. Ibid., pp. 2-3. See also the entry Theological Opinion on Permissible Assisted Reproductive Technologies (ARTs).

27. Ashley and O?Rourke, Health Care Ethics A Theological Analysis, 4th ed., p. 247.

29. See, for example, Hass, ?GIFT? No!? p. 1. This point was confirmed in a letter of May 16, 2000 from Craig H. Syrop, M.D., Director of the IVF/GIFT Program, The Iowa Women?s Health Center, Advanced Reproductive Care, University of Iowa Hospitals and Clinics.

30. National Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services, no. 41 (1994) (Washington, DC: United States Catholic Conference, 1995).

31. See, for example, the GIFT program at the Iowa Women?s Health Center, Advanced Reproductive Care, University of Iowa Hospitals and Clinics; protocol for GIFT transfer, 6/10/99.

32. See, for example, Fertilitext, Gamete Intrafallopian Transfer (GIFT), http://www.fertilitext.org/ gift.html; FertilityRX.com, Assisted Reproductive Technology, Section IV: Gamete Intrafallopian Transfer, http://iop.com/~poetsrx/art/gift.html; Infertility and IVF Center, St. Louis, MO, ZIFT and GIFT, http://www.ivfctrstl.org/ht-ziftgift.htm; Infertility, Gynecology & Obstetrics Medical Group of San Diego, The Assisted Reproductive Technologies Procedures at IGO Medical Group, Gamete Intrafallopian Transfer, http://www.igomed.com/fertilityserv.htm; Lycos Health by WedMD, Gamete Intrafallopian Transfer (GIFT), and Zygote Intrafallopian Transfer (ZIFT), GIFT, http://webmd.lycos.com/content/dmk/dmk_article_5461649;

Am-I-Pregnant.com, Gamete/Zygote Intrafallopian Transfer, GIFT, http://www.am-i-pregnant.com/ giftinv.shtml; Women?s Health Interactive, Treatments for Infertility Assisted Reproductive Technologies (ART), Gamete Intrafallopian Transfer (GIFT), http://www.womens-health.com/ inf_ctr/inf_trt_art.html.

33. See, for example, Fertilitext, Gamete Intrafallopian Transfer (GIFT), http://www.fertilitext.org/ gift.html; FertilityRX.com, Assisted Reproductive Technology, Section IV: Gamete Intrafallopian Transfer, http://iop.com/~poetsrx/art/gift.html; Infertility and IVF Center, St. Louis, MO, ZIFT and GIFT, http://www.ivfctrstl.org/ht-ziftgift.htm; Infertility, Gynecology & Obstetrics Medical Group of San Diego, The Assisted Reproductive Technologies Procedures at IGO Medical Group, Gamete Intrafallopian Transfer, http://www.igomed.com/fertilityserv.htm; Women?s Health Interactive, Treatments for Infertility Assisted Reproductive Technologies (ART), Gamete Intrafallopian Transfer (GIFT), http://www.womens-health.com/ inf_ctr/inf_trt_art.html.

34. FertilityRX.com, Assisted Reproductive Technology, Section IV: Gamete Intrafallopian Transfer, http://iop.com/~poetsrx/art/gift.html. See also Fertilitext, Gamete Intrafallopian Transfer (GIFT), http://www.fertilitext.org/gift.html; Infertility, Gynecology & Obstetrics Medical Group of San Diego, The Assisted Reproductive Technologies Procedures at IGO Medical Group, Gamete Intrafallopian Transfer, http://www.igomed.com/fertilityserv.htm.

35. Bruce M. Carlson, Human Embryology and Developmental Biology (St. Louis: Mosby, 1994), p. 27.

37. American Society for Reproductive Medicine, Revised minimum standards for in vitro fertilization, gamete intrafallopian transfer, and related procedures, http://www.asrm.org/Media/Practice/revised.html.

38. American Society for Reproductive Medicine, FACT SHEET: Multiple Gestation and Multifetal Pregnancy Reduction, http://www.asrm.org/Patients/FactSheets/multiple.html.

39. About.com, Facts about Multiples, http://infertility.about.com/.../aa111399.htm?iam=dp&terms= infertility+%22multiple+births%2. These statistics are taken from Overcoming Infertility by Dr. Robert Jansen and date from the year 1993.

40. American Society for Reproductive Medicine, FACT SHEET: Multiple Gestation and Multifetal Pregnancy Reduction, http://www.asrm.org/Patients/FactSheets/multiple.html.

42. Ibid. See also Mayo Clinic Health Oasis, Fertility Drugs, http://www.mayohealth.org/mayo/9902/htm/ fertility.htm.

43. American Society for Reproductive Medicine, FACT SHEET: Multiple Gestation and Multifetal Pregnancy Reduction, http://www.asrm.org/Patients/FactSheets/multiple.html.

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