After studying the course materials located on Module 4: Lecture Materials & Resources page, answer the following: Description and bioethical analysis of: Pre-implantati

Commentary of The National Catholic Bioethics Cente Volume 32, Number 10 October 2007 Views expressed are those of individual authors and may advance positions that have not yet been doctrinally settled. Ethics & Medics makes every effort to publish articles consonant with the magisterial teachings of the Catholic Church. A Commentary of The National Catholic Bioethics Center on Health Care and the Life Sciences

The ChurCh and AssisTed ProCreaTion

Today, many different techniques of “assisted” human procreation are lumped together: fertility drugs, sperm enrichment, sperm capacitation, artificial insemination, gamete intra-Fallopian transfer, in vitro fertilization (IVF), pre-implantation diagnosis, and even reproductive cloning. In a strict sense, though, some of these techniques assist procreation, while others substitute for it. The distinction between assisting and substituting points to what is ethical and what is not.

Assisted procreation is both expensive and burdensome. At the physical level, it typically involves hyperstimulating the woman’s ovaries hormonally, and extracting anywhere from one to three dozen of her matured eggs; for the man, it involves procuring and washing sperm, in addition to a series of preliminary tests on the couple’s overall physical health. Also, it is taxing at the psychological level because, even after the couple has undergone all the testing and procedures―for months or perhaps years on end―and after they have paid about thirty thousand dollars for each attempt, there are no guarantees that it will work. If it does, it typically involves freezing a number of “spare” embryos for possible future use, thus creating a new set of delicate issues for the couple. There are also serious social concerns. For example, over the past thirty years or so in this industry, about half-a-million frozen human embryos have accumulated in fertility clinics in the United States alone.1 Also, assisted human procreation is perceived as being “pro-life,” but in reality it involves a number of very serious attacks on human life and dignity precisely at life’s most vulnerable stage—the first week of embryonic development.

What, then, motivates the couple to undergo these travails? The desire to have a child. Now, “to have a child” may be taken in two ways. At face value, it is natural for loving couples to want to have children. At a deeper level, however, no child can really be “had,” since a child is not a possession, not an object, and not a thing. Rather, children are a gift from God. All life, and especially human life, is a

gift from God. And, by definition, we do not have a right to gifts. Therefore, no one really has a right to have a child. Couples do have a right, however, to desire children. In fact, in order for their marriage to be valid, the couple has a responsibility to desire children.2 But whether the children come or not must remain the prerogative of God.

Conception, Pregnancy, and Marriage

Within a valid marriage, there are two central considerations: first, the unitive and the procreative dimensions of the marital act must remain intact and, second, each couple is called to responsible parenthood.The unitive and the procreative dimensions are like two sides of the same coin: every coin has two sides, yet the coin remains one. This does not mean that each time a couple has intercourse they are obligated to conceive. In fact, the flagship document on this topic, Humane vitae, states that “in relation to physical, economic, psychological and social conditions, responsible parenthood is exercised either by the deliberate and generous decision to raise a numerous family, or by the decision, made for grave motives and with due respect for the moral law, to avoid for the time being, or even for an indeterminate period, a new birth.”3 Nonetheless, each act must remain open to the possibility of conception. And if conception does occur, then the resulting child should be accepted lovingly.

In a sense, IVF is the converse of contraception: contraception allows the unitive dimension to happen without the procreative; IVF allows the procreative without the unitive. In both cases a radical separation has been introduced between the two essential elements of human intercourse. Yet, like the two sides of a coin, these two dimensions must remain together in order for the act of intercourse to be truly and fully human. In other words, what makes sexual intercourse fully human (as opposed to a mere instinctive act of self-pleasure) is the radical generosity that occurs precisely in desiring children and simultaneously desiring to give the core, the heart, the total love of oneself to the other.

It can also be said that human procreation is a natural act and a vital act. It is natural for a man and a woman to desire each other; in fact, this is such a universal principle that male/female gender complementarity exists in all animal species that reproduce sexually. And procreation is a vital act because it is the only way by which nature perpetuates our species. We do not have the freedom to radically change natural vital human acts, as explained in the next section. Thus, in order for human procreation to be ethical, the sperm must fertilize the egg in the proper place (locus) where nature intends, that is, in the distal end of the fallopian tube (infundibulum) of the wife (in vivo). Although technologically we can extract a human egg, collect sperm and mix them in a Petri dish, we may not do it ethically. The fact that it is legal does not mean it is moral, just as with procured abortion―to which the IVF industry contributes significantly by its own destruction of embryonic human life.

Natural Selection and IVF

There are many reasons for fertilization to occur in the place where it does, even at the cellular level. One main reason is natural selection. Natural selection ensures that only the strongest, fastest, and

healthiest sperm reach the mature egg. It does this by a series of biochemical events, beginning with the neutralization of the acidity of the vagina and uterus by means of the first wave of semen upon ejaculation. Then, even when the cervix is dilated during ovulation, most sperm never enter the uterus. Those that do, proceed to navigate through the many crypts of the thickened and spongy inner wall of the uterus (endometrium), where many remain trapped. Eventually, some sperm make their way into the narrow fallopian tubes, where they continue to be selected out by lack of nourishment or strength. Finally, a few reach the mature egg at the distal end of only one of the two tubes, where they then need to burrow through not one but two protective layers of cells and membranes of the egg―the zona pellucida and the corona radiata. Throughout this entire trajectory, a series of complex biochemical reactions occur between the woman’s mucus and the man’s semen, including the capacitation, lubrication, and nourishment of sperm. Many of these reactions are still very poorly understood in the human being.

What is clearly understood, though, is that theoretically it takes only one sperm to fertilize an egg. Yet, unless the ejaculate of a man contains at least about 150 million sperm, he is considered functionally sterile. This biological fact points to an enormous selection process bearing down on sperm cells, precisely to ensure that only the best sperm reaches the mature egg.

If an egg is fertilized, a further process of natural selection occurs at implantation, which in the human being normally occurs about a week after fertilization. Many embryos fail to implant, again due to complex biochemical events that are poorly understood. And even after implantation, many human fetuses do not result in live births. It is estimated that anywhere from 25 to 50 percent of all human pregnancies end in a spontaneous abortion or miscarriage.4 Analysis has proved that the vast majority of these embryos and fetuses carry some kind of genetic or developmental abnormality. As expected, most of these abortions occur very early in the pregnancy, even before a woman realizes that she had conceived.

This sophisticated process of natural selection serves as a type of quality control, and is indeed essential for the survival of our species as a whole. It is preposterous, and dishonest, to think that IVF can adequately replace this intricate process of natural selection.

When a human egg is extracted from a woman and mixed with sperm, the laboratory technique substitutes for the natural place and process of fertilization. In fact, that is precisely what in vitro (in glass) means: that fertilization does not occur in vivo (within the woman’s body). This bypasses natural selection, which is a universal principle of nature and, as such, belongs to the patrimony of all humanity. We simply do not have the right to substitute a manufacturing technique in a laboratory for this vital process of our species―even if a couple can pay for it.

Other Problems with IVF

In addition to these considerations of principle, which makes IVF intrinsically evil,5 there are a number of considerations of practice:

• Ovarian hyperstimulation and egg extraction poses health risks to the woman. The process involves, first, the woman taking fertility hormones. Once her ovaries have matured a relatively large number of follicles (typically evaluated through noninvasive sonography), anywhere from one to three dozen mature eggs are extracted by the insertion of a largebore needle either through her abdomen or through the wall of her vagina (both obviously invasive). The needle is guided by sonographic visualization, but since the ovaries are partly enveloped by the distal end of the fallopian tubes, in addition to being tucked under them, there is always a risk of perforating the reproductive tract as well as other abdominal organs, tissues, and membranes. Hyperovulation can also produce ovarian hyperstimulation syndrome, which can cause the ovaries to swell and poses serious health concerns.

• Sperm is usually collected by masturbation. According to Catholic teaching, this is immoral, even if the man is the woman’s legitimate husband, since masturbation radically separates the procurement of semen from the conjugal act.6 The sad reality is that, with our present social ethos, masturbation is rarely seen as intrinsically evil, even among spouses.

• Typically, between three and four embryos are released into the woman’s uterus; on average, one actually implants. (The overall rate of live births per embryo transfer is between 15 and 42 percent.7) This means that, on average, three human embryos are discarded for every one that implants. These are not natural (spontaneous) abortions, since there is nothing “natural” about IVF. Rather, they are procured abortions, and everyone involved in the process is accountable for them, since they would not have occurred if IVF had not been attempted.

• The “spare” embryos that were not inserted in the first attempt are dipped in liquid nitrogen (about minus 300° F) and stored frozen in steel tanks. Anything dipped into liquid nitrogen crystallizes instantly, becoming rock solid, like a piece of diamond. This freezing is done in case none of the three or four embryos released into the uterus actually implants, or in case the woman loses her pregnancy at any time during the nine months. If that happened, the technician would go to the steel tanks, pull out four more embryos, thaw them, and attempt a new implantation. Considering the fact that even the early human embryo is human, how can one justify freezing a fellow human being, especially without his or her consent? In addition, typically only one of the four thawed embryos survives, because of damage to the others during either the freezing or the thawing process.

• In a market economy such as ours, and in view of the perceived potential for cures through embryonic stem cell research, the so-called spare embryos are fueling an expanding industry that routinely involves experimenting with live human embryos. Even if these embryos are only a week old (technically, a blastocyst consisting of only a few dozen cells), they are human and they are alive. The eugenics mentality that is developing in this field is being fed, in large part, by the fact that, once a couple has had the children they want, they tend to abandon their frozen embryos. In the past, clinics have simply discarded them. But now clinics can actually profit from the non-implanted embryos that they hold “in stock.”

• A number of high-profile cases have already appeared in the news media about divorced or remarried couples and frozen embryos.8 Often, one party wants the embryos implanted―either into the new wife, or the original mother with the new husband―but the former spouse does not. This creates a legal and social morass that threatens to throw into question what civilized society means by “my parents,” “my children” and “my family” at the very biological level of human procreation.

• In addition, every person has the natural right to be gestated by his or her biological mother in relationship with his or her biological father, since it is through that familial biochemical interaction that the embryo has the possibility to develop best.9

Permitted Assistance to Human Procreation Despite these concerns, the Church does not reject all medical intervention on human procreation. Ethical medical advancement in itself is a positive expression of the inspiration of the Holy Spirit upon the medical and scientific community. Hence, it can be said that the practice of medicine for the purpose of true healing is certainly a means of glorifying God. What, then, is allowed in assisted reproduction? Precisely that: to assist the sperm to achieve its natural goal of insemination, including by means of artificial insemination, provided several conditions are in place:

• The couple is validly married

• The sperm of the husband is collected ethically (for example, using a perforated condom during intercourse with his wife and collecting the semen that remains within the condom immediately afterward)

• Conception takes place within the wife’s infundibulum

• The resulting embryo is not subjected to disproportionate risk or harm What the modern fertility industry calls “artificial insemination” (or intrauterine insemination) is allowed under these conditions because conception occurs in the natural setting of the woman’s reproductive tract. It is therefore understood that the Church also allows less dramatic assistance, provided similar conditions are in place. Such assistance includes semen and sperm analyses to determine the husband’s potency; analyses to determine the wife’s fertility; and the use of fertility drugs with great caution, accepting the possibility of twins, triplets, or more and caring for all of them.

Faith and the Infertile Couple

The issue of human infertility is extremely complex. For example, at the physiological level, infertility may be caused by something as banal as tight underwear on the man (pushing the scrotum up against the body, resulting in the death of sperm from too much heat), to something as complicated as both spouses having Down syndrome. At the psychological level, one hears of “infertile” couples who conceive shortly after adopting a baby or having a baby through IVF, which suggests that the anxiety of not conceiving may itself be a cause of infertility. Also of note is the extremely low percentage of rape victims who conceive, compared to the normal rate in the general population of women of the same age.10 Clearly, then, there are both physiological and psychological causes of infertility.

What, then, is left for the infertile couple? Medical technology today can certainly assist in the ethical ways noted above. But ultimately, in the case of a persistent inability to conceive, the Church invites the

couple to reflect on the apparent silence of God in this aspect of their marriage at this point in time. I say “at this point in time” because it could well be that their infertility is not permanent but temporary. Also, I say “in this aspect of their marriage” because, while children are certainly welcomed and a great joy to have in a marriage, they are not essential to the marriage; if the couple does not have children by no fault of their own, they certainly still have a marriage and their loving relationship. In fact, this point could be a litmus test for the marriage as such; is it their mutual love and respect that are keeping the couple together, or is it the children? If the latter, what happens to the couple when the children finally grow and leave home?

But especially I say “the apparent silence of God” because it is well known that God can speak volumes in his apparent silence. Perhaps God is calling an infertile couple to adopt, or to become foster parents. Or perhaps He is calling them to dedicate themselves to other generous acts and commitments that they could not accomplish if they had to devote most of their energies to raising their own children, and to being a solid witness to the generous gift of self―a testimony that is sorely needed in our society today.

Ultimately, a couple’s acceptance of their infertility can be a great act of humility, obedience, faith, hope, and charity. As such, it provides the potential for tremendous growth in mutual love, as they realize that all they have to keep them together, at the human level, is their love for each other. It is the mutual recognition that God is in control, and the acceptance of his Divine Will in our lives, since people of faith are called to recognize that He always wants what is best for us. In a world where we are more and more intent on doing our own will―even if it costs thirty thousand dollars per IVF trial―accepting the Divine Will is an exceedingly powerful witness and a tremendous source of grace.

In view of the event of the Incarnation―God becoming a human being, starting as an embryo in the womb of Mary―all human life can be said to be a specific act of Divine Will. Therefore, when a married couple surrender to the Divine Will in every aspect of their marriage, including conception or its absence, this is especially redemptive and sanctifying. In this sense, infertility in the life of a married couple can also be seen as an extension of their wedding vows, when they promised each other “to be true to you, in good times and in bad, in sickness and in health, to love and honor you all the days of my life.”11

Rev. Alfred Cioffi, S.T.D., Ph.D.

Father Alfred Cioffi is a staff ethicist at the National Catholic Bioethics Center and a priest of the Archdiocese of Miami. He holds a doctorate in moral theology from the Gregorianum, the Jesuit university in Rome, and a doctorate in genetics from Purdue University, Indiana.

1. A national survey of the number of frozen human embryos in the United States was done in April 2002. Of the 430 clinics surveyed, only 340 responded, reporting a total of 396,526 frozen human embryos. Because ninety of the 430 clinics did not respond, and because these data are five years old, half-a-million frozen human embryos is actually a very conservative estimate. D. I. Hoffman et al., “Cryopreserved Embryos in the United States and their Availability for Research,” Fertility and Sterility 79.5 (May 2003): 1063–1069.

2. The desire for children is one of the three goods of marriage, the other two being: fidelity and indissolubility. For an extensive explanation of marriage from the Catholic perspective, please see John Paul II, Familiaris consortio (November 22, 1981).

3. Paul VI, Humanae vitae (July 25, 1968), trans. NC News Service (Boston: Daughters of St. Paul, 1968), n. 10.

4. Generally, the older the woman, the higher the rate of spontaneous abortion and miscarriage. For example, women over forty-five years of age have a 75 percent risk of losing the pregnancy. A. M. Nybo Andersen et al. “Maternal Age and Fetal Loss: Populationbased Register Linkage Study,” British Medical Journal 320.7251 (June 24, 2000): 1708–1712.

5. Congregation for the Doctrine of the Faith, Donum vitae (February 22, 1987). 6. Congregation for the Doctrine of the Faith, Persona humana (December 29, 1975). See also the

Catechism of the Catholic Church, n. 2352. 7 As expected, many factors influence this rate. See Centers for Disease Control and Prevention, 2004 Assisted Reproductive Technology Success Rates: National Summary and Fertility Clinic Reports (Atlanta: CDC, December 2006), 81.

7. One of the latest Hollywood fads is to have IVF babies. See, for example, “More Celebrities Adopting Frozen Embryos, Swift Report, August 23, 2005, http://swiftreport.blogs.com/news/2005/08/ more_celebritie.html.

8. See, for example, findings cited in Nicanor P. G. Austriaco, O.P., 9. “On the Catholic Vision of Conjugal Love and the Morality of Embryo Transfer,” in Thomas V.

Berg, L.C., and Edward J. Furton, eds., Human Embryo Adoption: Biotechnology, Marriage, and the Right to Life (Philadelphia / Thornwood, NY: National Catholic Bioethics Center / Westchester Institute, 2006), 123–125.

10. The national rape-related pregnancy rate was 5 percent in 1996. 11. M. M. Holmes et al., “Rape-Related Pregnancy: Estimates and Descriptive Characteristics from a

National Sample of Women,” American Journal of Obstetrics and Gynecology 175.2 (August 1996): 320–324. The national pregnancy rate has been declining for the past fifteen years, and is influenced by fluctuating factors such as immigration and economics, but averaged about 10 percent in the 1990s. Stephanie J. Ventura et al., “Revised Pregnancy Rates, 1990–97, and New Rates for 1998: United States,” National Vital Statistics Reports 52.7 (October 31, 2003): 1–15.

12. National Conference of Catholic Bishops, Rite of Marriage (New York: Catholic Book, 1991).

• FINISH IVF

• NATURAL FAMILY PLANNING

• Preimplantation Genetic Diagnosis (PGD)

• Surrogate motherhood

• “snowflake babies”

• Artificial Insemination (AI)

Preimplantation Genetic Diagnosis (PGD)

ZYGOTE

M O

RU LA

COMPACTION

BLASTOMERES

MALE & FEMALE PRONUCLEI

Surrogate motherhood https://en.wikipedia.org/wiki/2014_Thai_surrogacy_controversy

INTRINSIC BIOETHICAL EVIL/WRONG:

NATURAL RIGHT TO BE GESTATED BY BIOLOGICAL MOTHER

“snowflake babies” = ivf embryo transfer http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_20081208_dignitas-personae_en.html

Artificial Insemination (AI)

NATURAL FAMILY PLANNING (NFP)

1.OVULATION SYMPTOMS

2.BIOETHICAL EVALUATION

NATURAL FAMILY PLANNING (NFP)

1.OVULATION SYMPTOMS

a) 3 PRIMARY

b) 7 SECONDARY

PRIMARY OVULATION SYMPTOMS:

1) BASAL BODY TEMPERATURE (BBT)

2) CERVIX ACTIVITY

3) CERVICAL MUCUS

SECONDARY OVULATION SYMPTOMS:

1) MITTELSCHMERZ

2) SPOTTING

3) SWOLLEN VAGINA AND/OR VULVA

4) INCREASED LIBIDO

5) BREAST TENDERNESS

6) GENERAL BLOATING

7) FERNING

SOME MAJOR PROTOCOLS AND METHODS:

• CREIGHTON MODEL (NaPro Technology)

• COUPLE TO COUPLE (CCL)

• SYMPTO-THERMAL METHOD

• BILLINGS METHOD

• FAMILY OF THE AMERICAS (BASED ON BILLINGS)

ACTIVITY OF THE CERVIX AND CERIVCAL OS DURING MENSTRUAL CYCLE

INFERTILEFERTILE

1 DAY BEFORE OVULATION: OS OPEN, CERVIX HIGH,

SOFT AND CENTRAL, EGGWHITE FLUID

INFERTILE PHASE: OS CLOSED, CERVIX FIRM,

ANGLED SLIGHTLY, TACKY FLUID

Examples of cervical mucus

during various days of the

menstrual cycle.

Transparent and elastic

is fertile.

Opaque and tacky

is infertile.

WHAT ABOUT THE HUSBAND?

• DISCIPLINE, RESPECT, COMMUNICATION, SACRIFICIAL LOVE

• OPENNESS TO THE PRESENCE OF GOD IN THEIR DAILY LIFE

2. BIOETHICAL EVALUATION OF NFP:

a) AS A MEANS

b) AS AN END / GOAL / OBJECTIVE

a) AS A MEANS:

• NO SEPARATION ÷ UNITIVE / PROCREATIVE DIMENSIONS

• RESPECTFUL OF HUMAN NATURE

• MARRITAL INTIMACY = UNION OF BODY AND SOUL

b) AS AN END:

HUMANAE VITAE 16b:

“If therefore there are well-grounded reasons for spacing births, arising from the physical or psychological condition of husband or wife, or from external circumstances… then take advantage of the natural cycles immanent in the reproductive system…”

b) AS AN END:

THEREFORE, TO BE AVOIDED IS A CONTRACEPTIVE MENTALITY, WHEREBY PREGNANCY / CHILDREN ARE SEEN AS AN EVIL, TO BE AVOIDED BY ANY MEANS.

INSTEAD, A FUNDAMENTAL OPENNESS TO LIFE, COLLABORATING WITH GOD’S PLAN TO BE CO-CREATORS OF A UNIQUE HUMAN LIFE.