THESIS: It is the responsibility of Christians to become informed of the ever-increasing technology of fertility drugs and forms of technology-assisted reproduction and weigh the ethical implications of their use before acting upon them.

Outline: Technology Assisted Reproduction

I. Introduction

II. Background

A. Infertility
B. Causes of infertility
C. Infertility Tests

II. Technological Methods of Conception

A. Artificial Insemination
B. In Vitro Fertilization
C. Gamete Intrafallopian Transfer
D. Tubal Ovum Transfer
E. Embryo Lavage
F . Surrogate Motherhood

III. Fertility Drugs

A. Hormones involved in reproduction
B. Mechanisms of drugs
C. Risks of fertility drug use

1. Multiple births and associated risks
2. Ovarian cancer

IV. Relating Faith and Technology Assisted Reproduction

A. Cost
B. Surrogate Motherhood
C. Frozen Embryos
D. Interference with Nature

V. Conclusion

Background

Beginning at puberty, the human male makes millions of sperm a day and continues to do so for about the next 50 years. On the other hand, the human female is born with approximately one million eggs, which are all that she will ever have (Infertility, 1996). The onset of menstruation during adolescence signals the beginning of a cycle in which hormones prepare one or two of these eggs for possible fertilization each month. These cycles continue until menopause. Both sexes seem to be more than adequately equipped by biology for parenthood. However, infertility affects 12% of American couples or approximately 4.5 million couples a year (Fertility, 1998).

Infertility is technically defined as the inability to conceive after having regular intercourse for one year without using any form of birth control. Surprisingly, the odds against conception are strong most of the time. A woman has just a 20-35% chance of conceiving during each menstrual cycle, even at the peak of fertility (Infertility, 1996). These odds decline slightly in the women's late 20's and early 30's and more sharply after the age 35. Male fertility also decreases with age, although more slowly than female fertility.

Fertility is impaired in as many men as women. The problem lies within the man a third of the time, another third of the time within the women, and the remaining third is usually a combination of the two (Youngkin, 1997). Health professionals emphasize the need for infertile couples to recognize the problem as "our" problem instead of "mine" or "your" problem. It is less emotionally damaging this way. For these reasons, both partners should be evaluated when a decision is made to make an attempt at conceiving.


Common Causes of Infertility

There are many known causes of infertility. In men, low sperm count and poor sperm motility are usually the culprits. An undescended testicle or dilated veins in the scrotum both contribute to low sperm count and poor sperm motility (Fertility, 1998). Sperm becomes less viable as men become older. In addition, men sometimes form antibodies against their sperm causing infertility (Infertility, 1996).

In women, there is a wider range of potential causes. Endometriosis, irregular ovulation, genital infections, and ovarian cysts are naturally occurring causes that decrease the fertility of women (Fertility, 1998). The use of cancer therapy and multiple abortions also decrease fertility in women. Damaged or missing reproductive structures are sometimes irreversible infertile conditions, and therefore the most serious that women can have. These conditions may either completely inhibit the reproductive system from working or decrease its effectiveness enough for women to be considered infertile.

Infertility Tests

There are a variety of tests that can be done to determine the fertility of men and women. The cervical mucous test involves both the man and woman. This test is done 2-12 hours after a couple has had intercourse. Several samples of cervical mucous are taken and analyzed for proper interaction between the sperm and mucous (Infertility Tests, 1996). The mucous is also tested to see if it contains antibodies against the sperm.

Semen analysis is usually the first test done on men to determine the number and viability of sperm. A healthy, potent ejaculate should contain 1.5 cubic centimeters of semen with each cc containing approximately 70 million sperm that appear to be of normal size, shape, and behavior (Infertility Tests, 1996).

Two special tests done on men to evaluate the potency of sperm are the bovine mucus test and the hamster-oocyte penetration test. In the bovine mucus test, bovine mucus is collected from the cervix and placed in a jar. Samples of semen are then added and measurements are made on how well the sperm can swim through the mucous (Infertility Tests, 1996). The hamster-oocyte penetration test analyzes the sperm's ability to penetrate an egg. It requires sperm to be added to hamster eggs cells with outer membranes removed. Normally functioning sperm will penetrate the hamster eggs indicating that they posses the ability to penetration human female eggs as well (Infertility Tests, 1996).

Technological Methods of Conception

A variety of treatments are presently available for couples who are infertile. The treatments range from simple to medically complex, depending on the cause and degree of infertility. Some couples require only information on sexual practices favorable to conception. Other simple treatments include drug therapy to arrest an underlying infection or hormone deficiency. For difficult infertility problems, assisted reproduction technological procedures are required for conception.

Artificial insemination is the oldest technological method of conception and has been used for over a century (Reproductive Tech, 1996). The technique employs the use of a catheter to place the donor's sperm into the woman's uterus or vaginal canal. It is performed around the time of ovulation and often needs to be repeated over the course of four or five menstrual cycles to obtain fertilization (Nelson, 1973). Studies have shown that artificial insemination offers success rates between 50 % and 65 %.

Much newer than artificial insemination is in vitro fertilization (IVF). This technique was made famous in 1978 by the birth of Louise Brown, the world's first "test tube" baby (Reproductive Tech, 1996). IVF is an option when various other infertility treatments have failed or are inappropriate. It can be used in women who have a uterus and at least one ovary, but whose fallopian tubes are damaged, missing, or diseased. First, fertility drugs are taken by the women to prepare her eggs for fertilization along with preparing her uterus for implantation. Next, the eggs are removed and placed in a laboratory dish where they are incubated with her partner's sperm for 18 hours (Reproductive Tech, 1996). After two days, several (to increase odds of implanting) of the fertilized eggs are transferred by instrument into the woman's uterus. Finally, a fairly new procedure called "assisted hatching" is employed to increase the chances of implantation. It involves opening a small slit around the shell that covers the embryo so that content of the embryo can be extruded in order for it to attach to the wall of the uterus (Youngkin, 1997). A 1988 study involving 41 clinics showed that 15.9% of women became pregnant by using IVF, but only 10.2% carried the fetus to term and delivered a living infant (Reproductive Tech, 1996).

Technological methods of conception developed since IVF are being used as well. Gamete intrafallopian transfer (GIFT), tubal ovum transfer, and embryo lavage are examples of these. They each require the use of a fertility drug in conjunction with the method itself. GIFT is similar to IVF except that sperm and eggs are collected and immediately inserted into one or both fallopian tubes (Reproductive, 1996). Unlike IVF, GIFT requires that the woman posses at least one healthy fallopian tube. However, the success rate of GIFT is similar to IVF.

The embryo lavage method involves a third party. A fertile female donor provides the eggs. At the proper time in her menstrual cycle, she is artificially inseminated with the would-be father's sperm. Upon conception, the embryo is washed out of her reproductive tract and transferred to the uterus or fallopian tube of the woman who is to bear the child who has additionally been treated with fertility drugs to make her uterus receptive to the embryo (Reproductive Tech, 1996). The embryo lavage technique allows women who have no eggs of their own to become pregnant, provided they have a uterus.

Surrogate motherhood is an option for women who do not respond to ovulation induction therapies, who have no ovaries, or lack a uterus. It also may be an option for those for whom pregnancy might be life threatening or have significant risks of transmitting a serious genetic disorder to the child (Reproduction Tech, 1996). First of all, a healthy, fertile woman agrees to be artificially inseminated and also agrees to let the infertile couple adopt the baby. In cases where the female member of the infertile couple can safely provide eggs of her own, they can be fertilized by the IVF process and transferred to the surrogate woman who then carries the fetus to term. The surrogate mother prepares her uterus by taking fertility drugs. If the female member of the infertile couple is unable to provide eggs, the surrogate mother's eggs are used. Surrogate motherhood is controversial and has resulted in many court cases about custody and parentage (Reproductive Tech, 1996).

Fertility Drugs

Hormones released from several organs in the body control the normal female reproductive cycle. The hypothalamus gland produces a hormone called gonadotropin-releasing hormone (GnRH). This hormone in turn stimulates the pituitary gland. The pituitary releases two gonadotropins, follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which are involved in reproduction. FSH and LH effect reproduction by controlling the ovaries during the menstrual cycle. FSH stimulates the growth of follicles. Each follicle contains an egg and produces additional hormones. LH helps FSH to stimulate the production of these hormones, both before and after ovulation. About halfway through the menstrual cycle, a sudden surge of LH and FSH causes the rupture of the dominant follicle and release of the egg from within. At this point, LH is the most important hormone since it enables the egg to mature and prepare for fertilization by sperm (Reproductive Med, 1998).

Fertility drugs have been used for over 30 years and have a range of mechanisms of action. However, the ultimate function of each of them is increasing the level of LH and FSH (Reproductive Med, 1998). Clomid and Serophene are specific drugs that directly stimulate the hypothalamus while Pergonal acts by directly stimulating the pituitary gland. Increasing the level of the gonadotropin causes the ovaries to release multiple eggs thus increasing the chances of pregnancy. The increased level of gonadotropins also helps to prepare the endometrium of the uterus for the impending implantation of the fertilized egg. The stimulation of multiple follicular development, known as controlled ovarian hyperstimulation (COH), is an essential step in the IVF and GIFT techniques. The drugs used for this are mostly naturally occurring gonadotropins, which are extracted from human urine (Reproductive Med, 1998). Usually, a gonadotropin releasing hormone agonist is administered beforehand to control and halt the women's natural hormonal cycle.

Recent research has provided the technology to produce gonadotropins via recombinant DNA technologies (Reproductive Med, 1998). This method of production results in very high purity gonadotropins. In addition, it releases the dependence on the collection of large amounts of urine as a source.

Risks of Fertility Drug Use

The use of fertility drugs has a number of potential risks involved. Multiple births are the most common result of using fertility drugs and have increased dramatically since the advent of fertility drugs. Twin births alone have increased by 42% from 1980 to 1994 (Meyer, 1997). Taking the strongest fertility drugs results in a 15% to 30% chance of having twins (Youngkin, 1997). Twins are seven times more likely to be born smaller than single infants leading 50% of all twins to weigh less than 5 ½ pounds compared with less than six percent of single babies. Also, the risk of low birth weight and death increases with multiple births--evident by the fact that more than 90% of triplets born each year weigh less than 5 ½ pounds and 10 out of every 100 die (Meyer, 1997). However, there are examples of success. In November 1997, Bobbi McCaughey gave birth to the world's first set of surviving septuplets, igniting a lot of discussion on the use of fertility drugs (Chance, 1997).

Another potential risk involved with the use of fertility drugs is the development of ovarian cancer. However, there is no conclusive evidence. There are data in support of an association between fertility drugs and ovarian cancer, but there are equally convincing data that suggest that there is no such association (Benjamin, 1996). A retrospective study from 12 published studies conducted on white women in 1992 showed a 3-fold increase of invasive epithelial ovarian cancer in women treated with fertility drugs over women who were not treated. In addition, infertile women with no treatment showed no increased risk (Benjamin, 1996). Contrary to this study, there are additional studies with data that do not link fertility drug use and ovarian cancer. Further studies are needed to establish evidence for either case.

Relating Faith and Technology Assisted Reproduction

The issues surrounding the use of technology assisted reproduction raise difficult questions. There are many ethical, moral, and legal questions that must be contemplated by potential users. Even the simplest procedures may cause consequences revealing the potential risks involved.

An issue of consideration prior to proceeding with any technology assisted reproduction method is the cost involved. These methods are very expensive and are usually not covered by insurance. In fact, Massachusetts is the only state that requires insurance companies to cover fertility procedures. As a result, the state has five times more couples entering technology assisted reproduction treatments (Conrad, 1997). How much money is too much? Most treatments cost $8,000 to $10,000 for each treatment and require at least three or four treatments for successful conception. In the end, the cost of successfully delivering an infant by way of technology assisted reproduction ranges from $44,000 to $212,000 (Conrad, 1997). Even if couples have the resources to spend this much money, is it ethical to do so while many children await adoption?

Problems also arise when one partner is unable to provide the eggs or sperm. In these cases, the parent who did not provide the genetic material may not feel the same bond with the child as the other parent who is the genetic parent of the child (Lockwood, 1985). In situations where the man is unable to produce the sperm, the woman may feel a psychological bond with the man who donated the sperm and eventually feel distanced from her husband. Therefore it is essential for couples planning on taking part in such a procedure to discuss all their options and ways to deal with these potential moral and psychological dilemmas.

Surrogate motherhood carries the most legal implications. In addition, the moral and psychological dilemmas can be substantial hurdles as well. This has led some states to make it illegal to enter a contract with a surrogate mother (Thomasma, 1996). Five thousand legally contracted surrogate births have occurred over the last 15 years. The surrogate mother challenged the contract in 12 cases, but only in two cases were the sole parental rights granted to the surrogate mother (Conrad, 1997). The discussion of all possible consequences that may occur is needed between the couple and the surrogate mother during the decision process so that parental rights are successfully transferred.

Another ethical question that often arises in reproductive technology is the issue of frozen embryos. Embryos resulting from multiple fertilization are often frozen for later use but usually end up being discarded (Cowley, 1995). There is legislation that prohibits the storage of embryos for more than five years (Biggin, 1996). A belief in life at conception would indicate that destroying frozen embryos is morally wrong. Additionally, many IVF's result in multiple fertilization from the use of fertility drugs. What is done with embryos not implanted besides storing them? Is it ethical to do so knowing that they will be destroyed after five years?

Reproductive technology may also stir-up issues of power and control. Does God approve of humans creating technology to make the process of conception possible in cases where conception is naturally impossible? Is it an example of humans trying to play God? Strong opinions are present on both sides. The Roman Catholic church condemns artificial insemination even when the husband's sperm is being used citing that it is not acceptable to interfere with the natural process (Bohle, 1979). Additionally, some theologians and religious groups argue that "God intended procreation be joined with sexual intercourse in the bonds of marriage, and any other methods of reproduction are immoral because they are not sanctioned by God (Conrad, 1997). On the opposing side are those that argue that the relationship in a marriage is to be considered above sexual intercourse. They identify love between the husband and wife as the essential part of a marriage, and therefore technology assisted reproduction does not actually break the bond of marriage since the child is conceived out of love (Bohle, 1979).

Conclusion

The technology available to us is increasing at a rapid rate. Unfortunately, not all of the "technological advancements" come without any ethical implications, and thus we need to be cautious and to carefully evaluate the pros and cons of all of it. This is especially evident in the medical field. Science has provided many new procedures and techniques that enable us to have significant control over many things. However, it is important to keep in mind that we, unlike God, are simply unable to control all things. Christians should be able to make their own decisions based on their personal value systems on whether to employ technologically created methods such as assisted reproduction. However, they are responsible to become informed about these procedures and weigh all of the possible moral and ethical implications their use might have before using them.

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