Edited by
Westview
Press
A Member of the PerseusBooks Group
Contents
36
Sex Selection,
Elizabeth
Helen
Bequaert
Holmes
and
203
Mathiot-Moen
Part Four
Advanced Infertility
Annette Burfoot
Techniques,
37 In Vitro Fertilization-Overview,
SusanDaniel
207
RobertGore-Langtonand
211
38 In Vitro Fertilization-Historical
Development,
RobertGore-Langtonand SusanDaniel
218
39 Ovarian Suppression by GnRH Agonists, Andre Lemay
222
40 Human Pituitary Hormones and Creutzfeldt-Jakob Disease,
Lynette Dumble
229
41 In Vitro Fertilization-Culture
and SusanDaniel
236
Media, RobertGore-Langton
42 In Vitro Maturation and Ova Freezing, Kathy Munro
242
43 In Vitro Fertilization and Male-Factor Infertility,
Michelle A. Mullen
247
44 Gamete Intrafallopian Transfer (GIFT), Richard T. Hull
251
45 In Vitro Fertilization-Risks, Michelle A. Mullen,
Judith Lorber,and Linda S. Williams
255
46 Counseling, Ken Daniels
261
47 Selection and Assessment for Treatment, Ken Daniels
265
48 Egg Donation, Erica Haimes
269
49 Surrogacy, Laura M. Purdy and Helen BequaertHolmes
272
50 "Baby M" Surrogacy Case, Sharyn RoachAnleu
280
51 World Health Organization Report on the Place of In Vitro
Fertilization in Infertility Care, Patricia A. Stephensonwith
Marsden G. Wagner
283
52 Advanced Infertility Technologies and Occupational
Environments, H. Patricia Hynes
289
53 Informed Consent and Advanced Infertility Technologies,
Frant;oiseBaylis
293
~
RICHARD
T. HULL
Fertilization typically takes place high in the fallopian tube, near the point
where the ovum enters the tube after leaving the ruptured follicle. From
this point, passage down to the uterus usually takes two or three days. It
now seems that lower points are less optimal for fertilization either because the chancesfor implantation in the wall of the uterus are decreased
as the time of passageto the uterus is shortened or becauseunknown factors reduce the chancesof fertilization in the lower tubal regions.
Female infertility often is the result of scarring of the fallopian tubes
subsequent to infection by a sexually transmitted disease.In such casesit
is not possible for the ovum to pass down the tube or for sperm to reach
it. Fallopian tubes can sometimes be repaired so as to reopen them, permitting normal fertilization to occur. However, becausesuch surgical procedures often involve removal of the scarred section and reconnection of
the open ends of the fallopian tube, there may be insufficient tube for reconnection or the tube may be so shortened that it is more difficult for the
ovum to pass from the ovary into the tube. Sometimes the upper portions
of fallopian tubes are missing due to malformation or surgical removal as
a part of treatment for cancer or other diseases.
History
and Procedure
In vitro fertilization (IVF) was developed to circumvent persistent tubal
blockage. The procedure's complexity and expense prompted researchers
251
252
Richard T. Hull
to seek other ways to assist conception. In May 1982, the British journal
Lancet reported the first pregnancy resulting from inserting ova and
sperm through the cervix directly into the uterus. This was followed by
another new fertility procedure, announced in 1983: low tubal ovum
transfer, or LTOT. Simply put, it involved a laparoscopy on the woman
immediately prior to predicted ovulation to retrieve one or more ova
(eggs), the relocation of the ova so as to circumvent the area of tubal damage, and then intercourse with the ova in place in the lower portion of the
tube in the hopes that fertilization would take place.
To Catholic moralists, LTOT had several advantages over IVF. It did not
involve a decision whether to implant or discard the embryo; in fact, the
embryo was not manipulated at all. Fertilization would take place in vivo
in the normal manner rather than artificially in vitro, and masturbation to
obtain sperm was not involved. This procedure appeared to most
Catholic commentators to be morally permissible, analogous to a diabetic
person's daily dose of insulin that bypasses the defective insulinproducing gland. Practically, however, LTOT did not work; no pregnancies resulted when LTOT was employed in sixty-five cycles of forty
women over twenty-three months despite the earlier optimism generated
by results in studies with monkeys. A different procedure, tubal ovum
transfer (TOT), soon replaced LTOT.
In TOT, the ovum was placed as high as possible in the tube. Such
placement restricted its application to women whose fallopian tubes were
not damaged. Ova were taken from the woman's body, and the sperm
were collected during intercourse by means of a perforated sheath. Sperm
and ova were then combined and inserted into the upper region of the
tube. The acronym was later changed to TOTS (tubal ovum transfer with
sperm) to reflect the differences in treatment of sperm between LTOT and
the new technique.
During the time between the inauguration of LTOT and TOT, Ricardo
Asch and associatesintroduced a technique similar to TOT /TOTS, which
they gave the acronym GIFT (for gamete intrafallopian transfer). With
GIFT, semen was obtained from the husband through masturbation two
hours before laparoscopy and removal of ova, ova were incubated to permit some additional maturation, and sperm and ova were placed in a
catheter separated by air to prevent in vitro fertilization. The catheter tip
was inserted into each fallopian tube and a mixture of ova and sperm was
delivered into each. A twin pregnancy resulted the first time the procedure was used. Variations on the technique, involving frozen or donated
sperm or the use of laser repair of tubal blockage and GIFT in a single
procedure, were subsequently developed.
GIFT and TOTS require at least one healthy fallopian tube. IVF, where
fertilization occurs in vitro, does not. With GIFT and TOTS, some of the
Gamete Intrafallopian Transfer (GIFT)
253
elements of normal conception occur; the manipulations are to assist
sperm and ova to reach the right place together. Sperm are collected in a
manner compatible with some sperm reaching the ovum naturally; because there is at least one healthy tube, ova are manipulated in a manner
compatible with an ovum reaching the tube naturally. Hence, as no barriers exist to natural conception provided the means of collecting ova and
sperm are approved, some forms of GIFT and TOTS appear to be consistent with Catholic doctrine. However, as GIFT often involves sperm obtained through masturbation rather than in intercourse, its practice often
is at odds with such doctrine.
Complications
GIFT and the associated alternatives have a number of possible complications. One recent study of 1,000pregnancies achieved chiefly through IVF
and GIFT reports that 1 of every 100 pregnancies involves multiple-sited
or heterotopic pregnancies-that
is, concomitant pregnancies either
within the uterus or in the fallopian tubes or the abdominal cavity (also
called ectopic pregnancies). Pregnancies outside the uterus almost never
develop to term and almost always pose grave risks to the mother. Presumably, the process of injecting ova and sperm into the upper reachesof
the fallopian tubes either washes them back into the abdominal cavity or
delays their normal passage into the uterus sufficiently that the stage of
implantation is reached in the tube; also, sperm may bypass the transferred ova and encounter an ovum just at the point of, or just after, follicular release. The technique often involves insertion of multiple ova with
sperm into each fallopian tube (if both are intact). That multiplicity, together with the likelihood of additional ova ripening under the influence
of luteinizing hormone surges both at the time of, and after, retrieval of
ova, can result in multiple concomitant intrauterine pregnancies.
GIFT is a strictly physical manipulation; it can be employed with ova
and sperm from any source and so can be used both as a form of artificial
insemination from a donor and as a form of ovum donation. Indeed, the
acronym GIFT is suggestive of gamete donation. Donor gametes provide
a special problem for Catholic and some non-Catholic moralists in that
the child is denied a perceived right to be conceived and brought into the
world within the institution of marriage.
BecauseGIFT does not require extracorporeal incubation, it is substantially cheaper than IVF, but it does involve drug therapy (to stimulate
multiple ovarian follicles) and laparoscopic (and possible other) surgery
to obtain the ova and sometimes to repair the fallopian tubes. In one 1987
survey, successwas obtained on average in 29 percent of cases(ranging
from 10 to 56 percent depending on the type of infertility) at an average
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Richard
T. Hull
cost of $3,500.Those studying the likely directions of cost containment in
health care see high-technology infertility services at risk of exclusion
from both national and private insurance coverage because they are generally limited to otherwise healthy individuals not experiencing lifethreatening illness. Thus such services are likely to remain, as they are
generally now, available only to those who can afford them.
Couples seeking high-technology infertility services have often invested years of effort and expense to achieve pregnancy. As fertility services offer greater technological intervention in pursuit of the couple's
goal, many couples report increasing anxiety, obsessive preoccupation,
and disruption of other activities and responsibilities. That technology offers such a low probability of successat such a high personal and financial price raises deep questions about the rationality of the pursuit of such
technological fixes, confounding our understanding of the protective role
of the traditional requirement of informed consent. Finally, as infertile
couples have traditionally been the chief pool of likely adoptive parents
and as the world already holds a vast number of orphans and abandoned
and unwanted children, the need to transform infertile couples into parents by reproductive technology raises important social questions about
the prioritization of genetic lineage.
FOR
FURTHER
READING
Bartels, Dianne M., et al., eds. 1990.BeyondBabyM: Ethical Issuesin New Reproductive Techniques.
Clifton, N.J.: Humana.
Cahill, Lisa Sowle. 1996. "The New Birth Technologies and Public Moral Argument." In Sex, Genderand Christian Ethics. New York: Cambridge University
Press.
Catholic Church. Congregation pro Doctrina Fidei (Congregation for the Doctrine
of the Faith). 1987. Instruction on Respectfor Human Life in Its Origin and on the
Dignity of Procreation.Boston: Pauline Press.
Jones, Howard Wilbur, ed. 1988. In Vitro Fertilization and Other AssistedReproduction. New York: New York Academy of Sciences.
Kaplan, Lawrence J., and Rosemarie Tong. 1996.Controlling Our ReproductiveDestiny: A Technological
and PhilosophicalPerspective.Cambridge: MIT.
Peters, Ted. 1996. For the Love of Children: GeneticTechnologyand the Future of the
Family. Louisville, Ky.: Westminster John Knox Press.
Pope John Center. 1987. ReproductiveTechnologies,
Marriage and the Church. Braintree, Mass.: Pope John Center.
U.S. Congress, Office of Technology Assessment. 1988. Infertility: Medical and Social Choices.Washington, D.C.: U.S. Government Printing Office.
Wildes, Kevin William, ed. 1997.Infertility: A Crossroadof Faith, Medicine,and Technology.Boston: Kluwer Academic.