10. Multiple Choices: Navigating the Moral Mine Field

We didn’t put much thought into the "right and wrong" of what we were doing. We wanted a baby and either of us probably would have sacrificed anything for success.

How many to fertilize, what to do with "leftover embryos," whether we’d consider using a donor, destroying embryos without thinking—answering those questions beforehand saved us lots of stress in the midst of IVF.

We didn’t put much thought into the "right and wrong" of what we were doing. We wanted a baby and either of us probably would have sacrificed anything for success.

How many to fertilize, what to do with "leftover embryos," whether we’d consider using a donor, destroying embryos without thinking—answering those questions beforehand saved us lots of stress in the midst of IVF.

Consider how the two Christian couples quoted above handled their fertility treatment quite differently. Some couples give no thought to the hidden landmines and charge ahead unprepared. Others, feeling the Lord’s leading to stay out of the "ethical minefield," end treatment when the doctor recommends fertility drugs. And then there are those who, armed with good maps drawn from scripture, pursue medical treatment and closely monitor their care in striving for the "safe" zone. It is to this last group that I’ll direct my comments.

How do we make God-honoring choices while staying in treatment? We begin by understanding that each unique individual is made in the image of God. It is wrong to take human life (Exodus 20:13)—and an embryo is a human life.

How do we know this? It’s really not too hard. Life begins at the single moment when egg and sperm unite, DNA aligns, and the resulting being begins to function as a coordinated organism. Some infertility specialists (those who have no problem discarding embryos) argue that if we’re so silly as to treat tiny embryos as persons, we should also treat tiny sperm as persons because they’re alive, too. Yet a sperm is not a human life—that is, it is not a being that functions as a coordinated organism. It has only half of the DNA necessary for human life, and it has not united with a human egg. As one expert explains it, "Human embryos are living human beings precisely because they possess the single defining feature of human life that is lost in the moment of death—the ability to function as a coordinated organism rather than merely as a group of living human cells…. Dead bodies may have plenty of live cells, but their cells no longer function together in a coordinated manner. We can take living organs and cells from dead people for transplant to patients without a breach of ethics precisely because corpses are no longer living human beings. Human life is defined by the ability to function as an integrated whole—not by the mere presence of living human cells."

An understanding of when life begins and a commitment to respect the dignity of all human life is essential when making decisions in the infertility lab. It impacts the choices we make relating to multiple follicles, multiple embryos, and multiple transfers. Following are some guidelines.

Stop if you get too many follicles in a non-IVF cycle. The whole point of taking ovulation-inducing drugs is to stimulate a woman’s follicles, those fluid-filled sacs that contain one ovum apiece. During an unassisted cycle, a woman’s body normally regulates the process such that only one follicle matures and releases its egg (ovulation). But fertility drugs override that regulatory mechanism, allowing maturation of up to forty follicles. Multiple follicles mean potential multiple embryos.

To avoid high-order multiples, as mid-cycle approaches, medical personnel must monitor follicles daily via ultrasound. A high number of follicles means a heightened risk of multiple births. If hyperstimulation occurs, the responsible move is for the couple to abstain from sexual intercourse (or IUI) and/or for the doctor to stop administering hormones for that month. (In the case of a patient on clomiphene citrate, the patient has already taken all the medication for that cycle, so abstinence is the only option, though it’s extremely rare for such hyperstimulation to happen on Clomid alone.)

If no sonograms are done, the couple has no idea how many follicles are present. That means they can have a positive pregnancy test before they even know they have the potential for multiple pregnancies—as happened in cases of both octuplets and septuplets. According to ABC News, "While only one or two multiple births have hit the headlines in recent years, more than 80 cases of multiple births of quintuplets or greater now occur in the United States each year. In fact, the country’s birth rate for triplets and higher multiples has nearly quadrupled since 1971." Why? More people are using ovulation induction medications, many of them unmonitored.

Bottom line: If you’re taking fertility drugs, make sure your doctor monitors you appropriately via ultrasound so you know the number of follicles you’re dealing with and can make decisions accordingly. If you end up with too many maturing follicles, despite the cost invested—sometimes in the thousands of dollars—patients need to give serious consideration to the heartbreaking choice of canceling the cycle.

Avoid the creation of multiple embryos. Let’s say you’ve taken clomiphene citrate during an unmonitored cycle, followed by a positive pregnancy test. Your HCG levels have skyrocketed. And when you go for your first ultrasound, the doctor visualizes seven embryos on the screen. Now you face an agonizing decision: should you abort some of the babies in hopes that the others will have a better chance of being born healthy (not to mention minimizing the risk to your own body)? That is what most medical teams would recommend.

Two couples who profess faith in Christ have faced similar situations—one the parents of octuplets (one of whom died) and the other the parents of septuplets. Their difficult choices to carry their children to term rather than taking human life in utero have demonstrated that "it can be done." Yet the best ethical solution here is to avoid getting into this situation! Don’t let the number of mature follicles come as a surprise after conception. And certainly avoid the mentality that says, "We’ll take the risk because we can always reduce later if we get too many."

Though about 37 percent of births using advanced reproductive technologies (ART) are multiples (31 percent twins, 6 percent triplets or more), in vitro fertilization actually allows for more precise management of the number of eggs fertilized. After the doctor aspirates the mature eggs from the follicles, each is placed in its own petri dish. Thus, it’s relatively easy to limit the number of embryos created by directing your medical team to expose only the number of eggs to sperm that you can safely carry to term in that cycle in the event that all embryos implant.

Couples may find themselves facing enormous dilemmas if they do not consider the ethical ramifications of their choices ahead of time and choose accordingly. Imagine being in the situation this patient described:

I was shocked when our doctor aspirated more than thirty eggs from my ovaries and exposed them all to sperm.

Avoid multiple embryo transfers. The couple suddenly faced with multiple embryos in the IVF lab (and this should never come as a surprise!) has little choice but to ask the doctor to transfer several embryos to the wife’s uterus and cryopreserve the rest. Yet it’s best to avoid cryopreservation. The freeze/thaw process is hard on sperm because many of them die; the same is true with eggs. Based on embryo survival rates, it appears that the freeze/thaw process is hard on embryos, too.

Depending on what you read, you’ll find that some clinics have a 50 percent thaw survival rate (half of the embryos survive). Others quote between 60 and 70 percent (at best three-quarters survive). Clinics with higher rates often freeze only the "higher quality embryos" in the first place and discard the rest. Thus the numbers can be deceptive as clinics with higher ethical standards (those that freeze even the "lesser quality" embryos rather than discarding) may have lower "success rates" as a result of their higher regard for human life. This poses a moral dilemma:

I met with my doctor about IVF. He wants to fertilize as many eggs as we can—transfer three and freeze the rest. I told him my concerns about freezing. He said the ones that make it through the thawing process are the ones that would most likely survive naturally anyway, but that it’d be unusual if we have any to freeze. He wants to start immediately, but I’m still uncomfortable. My husband wants to do it the way the doctor recommends. But why won’t my doctor respect what I am saying? I think, "Let’s just set our boundaries." At least I won’t have the moral regret.

Until thaw and conception rates improve following embryo freezing, couples should consider avoiding cryopreservation by having fewer eggs fertilized, even though the financial cost may be higher as a result. That is, they may have to try more IVF cycles with smaller numbers of embryos.

Several clinics in England now focus on natural cycle IVF. It’s less expensive without the ovulation induction medications, and while the odds of success in each cycle are lower, couples can try numerous times. Also, some overseas clinics now limit transfers to one embryo per IVF cycle. In Sweden, transferring a single embryo is the overriding rule, with only one in ten transfers allowing transfer of two embryos.* In the U.S., transferring three to five or more embryos is common, though we are seeing a trend toward transferring fewer embryos selected for their higher quality (read: discard or freeze those of "lower quality") with more cell divisions.

While cryopreservation has its problems, it’s still more ethical to freeze embryos (taking risks with human life) than to discard them (destroying human life). But sadly the common practice of cryopreservation has led to 400,000 embryos now sitting in liquid nitrogen. Consider the following true scenarios that have resulted from cryopreserving numerous embryos:

My husband and I had several embryos transferred to my uterus and a bunch frozen. I conceived twins from that original transfer, but then I had major medical problems during the delivery. That made it impossible for me to carry any more pregnancies. The cost of a gestational surrogate: fifty grand!

We’ve had six kids now through IVF, but we still have three more frozen embryos. So we’re going back for one more transfer...

We have three embryos still frozen after four IVF attempts. We long to quit treatment and we’re broke, but if we do embryo adoption, another couple could end up with our biological child while we’re still childless!

Couples with several frozen embryos can face some tough choices. Respecting the sanctity of human life means giving all embryos a chance to live rather than letting them thaw and die—eliminating the options of destruction and research. (Though it might sound noble to donate an embryo for the furtherance of science, it is unethical to take one life as a means of trying to improve the quality of another life.)

To give every cryopreserved embryo a chance means transferring thawed embryos to the genetic mother, entering into an "embryo adoption" agreement, or procuring the services of a gestational surrogate.

My co-author, William Cutrer, M.D., often notes that an embryo is not a potential life; it is a life with potential. Couples will find that some, if not all, members of their medical team will have this reversed. While sensitive to the fact that clinics are usually evaluated on the basis of their success rates (and our needs may impact those rates), we must also stand our ground as consumers needing to make decisions that line up with our belief systems. Forty years from now, when our doctors have all retired, we’re the ones who’ll still be living with our multiple choices.

© 2003 Sandra Glahn, Hannah's Prayer (HP) Advisory Board Member. This first appeared in HP's July 2003 newsletter.

For more information:

Infertility Companion .
Drawing on Sandra Glahn’s decade-long struggle with infertility treatment this coauthored book explores the spiritual, marital, emotional, medical, and ethic issues surrounding infertility. The authors bring their unique male/female, doctor/patient, and clinical/theological combination of perspectives.