Part II- Assisted Reproductive Techniques

(This is a guest post by Indu Ravishankar. Indu is a MBBS from Kasturba Medical College, Manipal. This is the second of a two part article)

RELIGION and ART

The Roman Catholic Church does not approve of ART, just like its views on contraception.
It is considered morally unacceptable, as it dissociates the sexual act from the procreative
act. To quote- “The act which brings the child into existence is no longer an act by which two persons give themselves to one another, but one that “entrusts the life and identity of the embryo into the power of doctors and biologists and establishes the domination of technology over the origin and destiny of the human person”. Islam, on the other hand, does not condemn IVF, or AI, as long as the donor sperm belongs to the husband. AI, with any other donor sperm amounts to adultery. The same seems to hold good for Hinduism as well.

I came across a very interesting paper extensively describing the controversies, ethics
and practice surrounding the use of IVF in Islamic and Jewish countries.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1705533/

For sperm donation, the procedure requires the donor to submit a semen sample- which
involves the act of masturbation, which again is condemned by many religions.

CONTROVERSIES and ETHICS

Multiple pregnancy and Embryo Reduction

One important consequence as I mentioned earlier of using these methods, is the possibility
of multiple pregnancy. Any conception following infertility treatment is classified as
a ‘precious pregnancy’ or a high risk pregnancy. Multiple pregnancy per say is also a high risk
pregnancy. In the field of obstetrics, one and one do not add unto two, instead, it is viewed
as eleven, because the rate of complications is more than additive. Besides, as the number of
fetuses increase, so do the rate of deformities, abortion, preterm labour and many more such
complexities. So sometimes, when there are more than two or three implanted fetuses, there
is the option of “embryo reduction”. Embryo reduction amounts to abortion of one of the
successfully implanted embryos. This raises a controversial issue, that of abortion. It is
more contentious, simply because an embryo is ‘created’, only to be destroyed later. How
ethical is that? Life is created, and destroyed, even if it has to be done with due consideration,
for the saving the lives of the mother and the other embryos, how can we make such a
decision?

Since multiple oocytes are withdrawn and multiple embryos are thus generated, the
consequent problem of the fate of the excess embryos poses a dilemma. Previously, these
embryos were destroyed as they ceased to serve their purpose. The same argument of
destruction of a life holds good. Unethical, greedy minds have even used these embryos,
and ‘sold’ them to other couples at later dates. To solve this disconcerting problem, the
following ingenious alternative was thought of. The best approach to this seems to be the
implantation of such embryos into women who are unable to ovulate and/or men who have
azoospermia. These ‘adopted’ embryos are called snowflake children. This is a relatively
new concept- and less than a few hundred children have been born this way.

Another alternative is with the use of a new technique called ‘cryopreservation’ which allows for the eggs/sperms/embryos to be stored under proper conditions, for later use by the
same individuals, in case of future pregnancies.

PGD/PGS
Other medical intervention procedures such as PGD (Preimplantation Genetic Diagnosis), or
more specifically PGS (Preimplantation Genetic Screening), used to increase the chances of an ongoing pregnancy, so as to minimize losses due to chromosomal aneuploidies have a high abuse liability. When used for the purpose of sex selection, it poses a significant problem.

Even in developed countries, sex selection is used for purposes of ‘family balancing’. Again,
as these techniques most often involve testing on the zygote at various stages, and if the
zygote is not selected for various reasons, and discarded, it maybe viewed as destruction of
life.

Designer Babies
In case of single mothers and homosexual couples, there is an increasing trend towards
selection of a sperm donor, with specific characteristics. This results in ‘designer babies’.
It can be argued that, this infact is a form of positive eugenics. For example, it is not
uncommon for a recipient to state the exact characteristics, right upto the grades and
scores that the prospective donor acquired in college apart from the physical attributes,
and the family history. Although the thought of a random sperm is disturbing, this approach
seems to be at the other extreme end of the spectrum.
As a stark contrast to the above, there have been a few stray cases reported, of
couples who wish to transmit certain of their ‘deformities’ to their progeny, and hence
ask for those embryos carrying that defect to be selected. The best known example of such
as case was reported in the UK, where a deaf couple was adamant that their child should also
be deaf. Now, what is the ethics in dealing with such a situation? On what grounds, can they be denied, if at all they should be denied?

Special circumstances
Another situation, which creates a lot of confusion, is concerning women who are well
into their menopause. A couple in their fifties or sixties, who have the desire, and who can
afford the treatment. What quality of life will they be able to give the children conceived
that way? However, it is argued, it cannot be denied that they will face more obstacles and
challenges than any other normal couple, as they start with a disadvantage/handicap.
HIV positive couples- two scenarios come to play. An infertile HIV positive couple, and a
fertile couple. In the latter case, IVF maybe done in order to mainly decrease the rate of
transmission of HIV. The main controversy in these cases is more on lines of a psychosocial
basis- the risk of the child being subjected to the emotional trauma of being orphaned in
early childhood. In both cases, however, there seems to be a consensus that ART maybe
applied only to sero-discordant couples- i.e.; only one among the couple being HIV positive,
so that the resultant child will still have one non infected parent with longevity comparable to the normal adult population.
(see http://humrep.oxfordjournals.org/content/19/11/2454.full)

Secondary infertility is defined as infertility that occurs following atleast one normal conception/pregnancy, irrespective of the fate of the pregnancy. For cases that have resulted in one or more viable healthy babies before, who undergo ART, coupled with the probable
likelihood of a multiple pregnancy- what is the solution? The perfect example for such a case
is that of Nadya Suleman, who made quite sensational headlines last year. She used IVF,
despite having prior children, and it resulted in octuplets. Quite obviously, she cannot care
for all her children without help from the state. Now, what is the point of such an action?
Most countries do not impose restrictions on the number of children an individual can have.
It is after all, a basic human right. Nevertheless, is there a difference between natural and
artificially created actions? Should there be one? Where is the boundary line in such
cases?

The success rates for these procedures are not clearly defined. Implantation of the zygotes
does not guarantee continuation until term. Coupled with the fact that, these procedures
are extremely expensive, this is often out of reach for a majority of the population.

Surrogacy
With surrogacy reaching great proportions, especially commercial surrogacy, as a part of fertility tourism, there is a fear that in the future, more and more fertile rather than infertile
couples who can ‘pay’ will use surrogate mothers who ‘need’ the money, so as to reduce
the stress associated with natural pregnancy and childbirth. This actually sounds scary.
The question of human ethics plagues us when the surrogate mother is related to the biological mother or father. For instance, the grandmother
agrees to carry the pregnancy for her daughter. Now when the child is born, what does the child call her? Mother or grandmother? In theory, the biological mother is the natural mother, but this can prove to be very confusing and conflicting to the child later, as the grandmother will play an important role in his/her life, anyway, whereas with an unrelated surrogate, she has no such fixed role in the family.

LAW and ART

ART procedures, quite obviously are tightly regulated, as they need to be. Since there are quite a few ethical issues involved, laws have been created to circumvent every problem, andprovide for just solutions. For instance, sperm donors reserve the right to be anonymous, if they chose to. But there also exists a conflict between the interests, andthe rights of the donor to remain anonymous, and the right of the child to know the biological father. Registries are maintained to trace back the origin; in the event the child wants to know the identity of the biological father. Such registries also to some extent prevent the minute, but ethically catastrophic possibility of ignorant consanguineous relationships, between siblings of the same donor. A limit is posed on the number of children that a donor can father and this decreases the possibility of later ‘incest’. The woman is also allowed the option of choosing the same sperm donor for her future pregnancies, to ensure full biological relationship between the so conceived siblings. Some countries are also very stringent about the criteria, on which the recipients of ART are decided, with some allowing only homosexual couples and single mothers to benefit from AI. This is where cross border reproduction, fertility tourism flourish. Surrogacy in particular, has a high demand, with it being ‘outsourced’ to developing countries like India, where women are ‘judiciously compensated’ for their efforts to bear a child. These women, in a desperate
attempt to earn money, enter into contracts, without comprehending fully the consequences.
Studies have proved that most of the time surrogate mothers do not have an emotional
bond with the child, contrary to popular belief. However, in developing countries, as the
maternal mortality rate is not as low as it should be, this is a cause for concern, as it could
very well amount to ‘exploitation’. However, it is argued that, since these pregnancies are
well paid for, and these procedures mostly take place in the better institutions of the
country, mortality is not as big a threat as it is considered to be.

Recently, there has been a decrease in the number of donors leading to a ‘shortage’ of
sperms. This has resulted in ‘exporting’ sperm from other countries. From medical tourism,
we have moved on to ‘fertility tourism’, and pregnancy ‘without borders’.
This practice called ‘cross border reproduction’ as mentioned earlier has its own list of ethical
arguments. See:

http://humrep.oxfordjournals.org/content/23/10/2182.full?sid=1e28a773-e137-4b96-9937-72d0f435920f#ref-1

On one hand, this may just as well improve our overall genetic pool, as many children
will now be born, regardless of differences in race, caste, social and monetary status etc.
This would create a lot of diversity, creating better possibly genotypes, akin to an ‘artificial
selection’ compared to the ‘natural’ selection of Darwin.

I am not sure, what IVF has done to the practice of adoption, whether it has resulted in a declining trend. All I was able to get was the adoption rates in the last 10 years, which do not
seem to have changed drastically. (http://www.adoptionindia.nic.in/database.htm)

CONCLUSION

ART has served a boon for many couples and families throughout the world, saving
many marriages, and minimizing a lot of psychological trauma that is associated with
infertility. ART will also go down as one of the greatest achievements of humankind, and we
will never cease to wonder at the pure ingenuity of creating life outside the womb.
However on the downside, it has in effect, reduced the act of reproduction to a purely
technological ‘game’, allowing multiple entry points of interference with the natural process
of selection of an embryo, molding it into something that ‘we want’, manipulating and
complicating what is primarily a physiological process, and by bringing in laws to minimize the associated malpractices and the innumerable
ethical intricacies that it raises. This is a big responsibility that we have
conferred upon ourselves- the ability to choose life. Hence, it is in our hands to
see to it that this is not exploited. Various organizations have been established for the
primary purpose of moral policing, and at every stage, just solutions have been made
to offset the disadvantages and problems that these procedures have created. As long as
technology and ethics go hand in hand, this will continue to be a blessing.