COLUMN ONE : Ethics and the Science of Birth : The technology of assisting human reproduction is moving ahead swiftly. Societal rules for dealing with the consequences are not.
It seems so simple now. An egg and sperm are combined in a dish and, nine months later, a baby is born. That’s how Louise Joy Brown came into this world on July 25, 1978, in a London hospital--the first “test tube baby.â€
That was then, this is now: embryos can be frozen for later use, flushed out of one woman’s womb and transplanted into another, and selectively aborted in a multiple pregnancy. A pregnancy can involve five participants--egg donor, sperm donor, a surrogate who bears the child and a couple who will raise the child.
But while the technology of reproduction has raced forward, law and ethics have lagged behind. “Medical technology is far ahead of society and the law,†says Dr. Arthur L. Wisot, a staff physician at South Bay Hospital in Redondo Beach and co-author of a recent book on infertility treatment. “We do the best we can to avoid problems.â€
Still, there are problems, and there are questions. Patients and doctors alike are left to sort them out as “assisted reproductive technology†moves well beyond the pioneering in vitro fertilization 12 years ago:
--How should parenthood be defined? Are the parents those who contribute genetic material to the child, bear the child or raise the child?
--What are frozen embryos? Are they people or property? Who has rights to the embryos in a dispute?
--Should a child born with the aid of an egg or sperm donor be entitled to know who the genetic parent is?
--Should egg donors, sperm donors and surrogate mothers be paid for their services?
--Should infertility clinics be required to reveal success rates--how many couples who undergo treatment end up with a baby? And should couples pay for treatment that many experts still regard as experimental?
Only a few states have laws to regulate reproductive technology; even then, they may regulate only some of the technologies, such as surrogacy or sperm donation.
“It’s a real hodgepodge of laws,†says Joyce Zeitz, spokeswoman for the American Fertility Society, an organization of infertility specialists based in Birmingham, Ala. California, for example, has no laws governing surrogacy while in Florida it is a felony offense.
Rep. Ron Wyden (D-Ore.) has proposed federal legislation requiring infertility clinics to obtain accreditation for each procedure they perform and to report their success rates--a step many experts believe would lay a foundation for resolving unsettled legal and ethical issues. But the bill was tabled in 1990.
The American Bar Assn., the American Fertility Society, the American Assn. of Tissue Banks, the American College of Obstetricians and Gynecologists and other organizations have manuals bulging with their recommendations on how to deal with the technologies. Of course, none are binding on anyone.
The uncharted territory, though, is no deterrent. “We are dealing with people who are hopelessly infertile,†Wisot said. “We are dealing with people whose only chance of success lies with these techniques.â€
Dr. Mark Sauer also struggles to balance laws, ethics and his desire to help couples. The USC infertility specialist recently gained national attention by publishing research demonstrating that menopausal women can successfully carry a child conceived with the egg of a younger woman.
“I’m concerned with legal and ethical issues. But I don’t have an answer to these problems. I don’t think anyone does,†Sauer said as network news cameras crowded his office to report on this latest miracle. “These things will have to be defined in due course by the courts and by social acceptance. The technology is here to stay.â€
In the meantime, Sauer says: “If I think we have a good reason for doing something, these issues are not going to frighten me away. This changes (patients’) lives. They say ‘It allows me to become a complete person.’ I see the goodness to this.â€
Three million American couples are infertile, meaning they have been unable to conceive after one year of unprotected intercourse. Infertility can be caused by physiological problems of the male partner, the female partner or both. Many such couples feel society attaches a stigma to infertility.
The desperation of couples and the advance of technology have combined to produce court cases that are now infamous.
In 1987, the potential for heart-wrenching disputes became clear in the Baby M case involving surrogate mother Mary Beth Whitehead. A court ruled that Whitehead had no parental rights, but a higher court reinstated her legal status as the child’s mother.
A different kind of dispute erupted in Tennessee last year when a divorcing couple, Junior Lewis Davis and Mary Sue Davis, disagreed over the fate of their seven frozen embryos. A judge ruled in favor of Mary Sue, who wants to keep the embryos in storage for later use. But Junior Davis wants the embryos destroyed because he feels their use now would force him into unwanted fatherhood and has appealed.
And, in October in Orange County, Superior Court Judge Richard N. Parslow Jr. was asked to resolve the parentage of a child conceived from the egg and sperm of Crispina and Mark Calvert yet born by surrogate Anna L. Johnson. Parslow ruled that Johnson has no parental rights, but the case is on appeal.
The public is still largely undecided about whether the advantages of the new reproductive technologies outweigh such problems, says Elaine Gordon, a Santa Monica psychologist who counsels couples undergoing infertility treatment. The public views patients “as these desperate, crazy infertile people,†Gordon says.
Even more sensational disputes are likely in the next decade. Egg and sperm donors may seek to remain in contact with the child, mirroring open adoption where the birth mother retains a relationship with the adoptive parents and the child.
But such court spectacles aren’t typical. “For every one of those cases you hear about there are many other situations where things work well that you never hear about,†says Dr. Val Davajan, co-director of women’s health and the perinatal center at the Hospital of the Good Samaritan in Los Angeles.
The real problem, Davajan said, is that infertile couples are charged steep fees for technologies that are largely experimental and often fail. “A lot of procedures are being marketed, and patients are paying for (procedures) that really have not been proven yet to be efficacious and scientifically acceptable. The patients are paying for research.â€
As a result, while some insurance companies pay for diagnostic tests and perhaps in vitro fertilization, many deny coverage for sophisticated treatments.
“It’s clear you’re a guinea pig when you do this stuff,†says Patty, who joined several other women in Gordon’s cozy Santa Monica office on a recent afternoon to share their experiences on infertility treatment.
The women are ardent supporters of the new technology--although not all of them have benefited from it. They include an attorney who has just decided with her husband to end 10 futile years of infertility treatment; a woman who has undergone six unsuccessful in vitro fertilization procedures and will try again; a woman who will bear a child in January after becoming pregnant on her third try at in vitro fertilization, and a woman carrying a child conceived with her husband’s sperm and her sister’s egg.
All say that the intense desire for a child combined with the allure of technology can cloud decision-making.
“I think there is an obsessiveness that goes with this,†says Randy Barrow, an adoption attorney who has decided, after 10 years of treatment, to stop trying to bear a child with her husband. “There is always that carrot that has been put in front of our faces.â€
And, she says, “You always hope 200% even if there is only a 10% chance (of success).â€
The percentage of women who become pregnant and have a live baby is often as low as 10% to 20% for infertility treatments. In vitro fertilization (IVF), which costs about $7,000 per attempt, succeeds in about 12% of all attempts, although success rates are 25% to 30% at the best centers. Success rates are slightly higher for other procedures, such as when eggs and sperm are placed in the Fallopian tube, and might be as high as 40% to 50% when donor eggs or sperm are used in IVF.
But low odds rarely deter infertile couples, says Patty, who is pregnant after three attempts at IVF. “The percentages (for success) are low, but there is a hook,†she says, rubbing a hand across her stylish baby-doll maternity top. “It’s hard to know when to start (treatment) and when to get off. When adoption was the only choice available, it was more clear cut.â€
What is less clear is whether infertility patients anticipate the problems that can arise if the technology succeeds.
Most directors of infertility treatment centers require patients to sign contracts that govern potential ramifications of such treatments as surrogacy, freezing embryos, and egg and sperm donation. About 25% of the programs that offer surrogate matching services have an attorney on staff, according to a 1988 Office of Technology Assessment report.
“What we do is try to put together the best legal documents we can ensuring everyone’s legal rights and hope these stand up, given that that the Legislature has never ruled on the legality of these contracts,†said Wisot, co-author with Dr. David R. Meldrum of “New Options for Fertility.â€
“I would say to any consumer if they go through embryo freezing or egg donation or surrogacy and they are not presented with a document to take into account all the potential problems that could occur, they better think twice about going through with it.â€
Andrea Shrednick, a reproductive psychologist and USC faculty member, compares infertility patients to cancer patients in their desperation to obtain help. One of the first mental health professionals in Los Angeles to begin counseling infertile couples, Shrednick now views the field of infertility treatment with some disdain.
“When couples are desperate they become anxious. When they become anxious, they become non-objective. When they become non-objective, they become vulnerable. Therefore, they do not make clear decisions,†she says.
Shrednick advocates counseling before beginning infertility treatment. Some couples decide to stick with nature in their pursuit of parenthood, even if nature has little to offer.
“Physicians get pissed off at me because they think I’ve talked their patients out of a procedure,†she says. “But there needs be one person who works with the patients who is on the patient’s level. Not someone with the power to play God. Not someone with the power to make them a baby. But someone who can sit down with them and help them work through and understand the issues involved.â€
INFERTILITY TREATMENT
Medical advances to treat infertility pose many legal and ethical problems.
Egg donation
After treatment with drugs to produce eggs, a physician inserts a needle through the abdomen into the mature follicle, suctions the follicular fluid containing eggs out and places the fluid in a test tube.
In vitro fertilization
Lab technician adds a drop or two of sperm sample to a dish containing an egg. The dish is put in an incubator and cells are allowed to divide until the embryo reaches a four- to eight-cell stage and may be transferred to the uterus.
Embryo transfer
A thin catheter is threaded through the cervix into the uterus. Within minutes, embryos are loaded into the catheter and propelled into the uterus.
Frozen embryos
Excess embryos that are not transferred to the uterus can be frozen in case a woman fails to conceive or wishes another child later. These embryos can then be thawed and transferred to the uterus.
Selective reduction of pregnancy
A physician injects a lethal chemical substance into one or more of the developing embroys in order to improve the chances that the remaining embryos will survive. The embryos that succumb are absorbed by the body.
LEGAL AND ETHICAL DILEMMAS
1. Payment for sale of body parts: Is it ethical to pay an egg donor for the sale of an irreplaceable part of her body? Current transplant laws forbid the sale of such things as livers, kidneys and skin tissue.
2. Who is the mother? In case of dispute, should the woman who donates the egg or the woman who gives birth to the child or both be considered the mother?
3. Disposition of frozen embryos: What should become of embryos in the case of death of one or both spouses, divorce or disagreement?
4. When does life begin? Does the embryo have any moral value? Is selective reduction of pregnancy ethically or morally correct? When does life begin?
5. Rights of the child: What access to information should the child have regarding his or her biological origin?
REPRODUCTION LANDMARKS
Landmarks in reproductive technology : 1799: Pregnancy reported from artificial insemination. 1890s: Artificial insemination by donor. 1953: First reported pregnancy after insemination with frozen sperm. 1976: First commercial surrogate motherhood arrangement reported in the United States (surrogate is artificially inseminated and paid to carry child for an infertile couple). 1978: Baby born after in vitro fertilization (IVF) in the United Kingdom. 1980: Baby born after IVF in Australia. 1981: Baby born after IVF in the United States. 1983: Embryo transfer after uterine lavage (female donor is artificially inseminated but embryo is flushed out of her uterus and transferred to waiting recipient). 1984: Baby born in Australia from embryo that was frozen and thawed. 1985: Baby born after gamete intrafallopian transfer (egg and sperm are mixed and injected into Fallopian tube).
First gestational surrogacy arrangement reported in the United States (woman who gives birth has no genetic tie to child).
First reported pregnancy after fertilization of frozen egg. 1986: Baby born in the United States from embryo that was frozen and thawed. 1989: Baby born to oldest reported patient--49-year-old menopausal woman--to undergo one of the advanced reproductive technologies (embryo from husband’s sperm and a donor egg is transferred to woman). Source: “Infertility: Medical and Social Choices,†Office of Technology Assessment.
