Friday, 3 February 2012

Embryos and Ethics

The above is a picture of my daughter.  She was eleven cells big.

OK, she could have been the embryo on the bottom, just five cells, but all indications are that it was the eleven cell embryo that took.  (I could also be completely wrong on which embryo is which.  I don't claim to be an embryologist.)

Alternatively, the picture doesn't show my daughter at all; rather the embryo that would achieve its genetic potential of becoming my daughter.

Why am I showing off my embryo pictures?  Because Newt Gingrich recently spoke out against embryonic stem cell research.  To quote from the linked article:
“I believe life begins at conception, and the question I was raising was what happens to embryos in fertility clinics, and I would favor a commission to look seriously at the ethics of how we manage fertility clinics,” Gingrich said at a news conference outside another Baptist church here. “If you have in vitro fertilization, you are creating life; therefore, we should look seriously at what the rules should be for clinics that are doing that, because they are creating life.”
Honestly, I think he makes a good point.  This is in no way an endorsement of Gingrich himself, who I consider odious even for a politician, but I absolutely agree we should all be thinking seriously about this issue and figuring out our ethical views on it.  My ethical views happen to be very different from Mr Gingrich's, but that's not necessarily relevant.

The problem comes when you try and get a hard and fast legal stand on this.  This has been discussed at length before on the internet and in the real world, most recently over The Mississippi Personhood Law.  If life legally begins before birth, it creates a host of issues, from a passport being required for a foetus to mothers being charged for manslaughter over a miscarriage. 

I'm not going to get into that here.  Instead I want to focus on when life does begin.  Even from a legal position it's more than 'at birth'.  There's viability, i.e. the point at which, if a baby is delivered pre-term, doctors will try and save its life (generally around 24 weeks).  This, of course, is not determined by when 'life' begins but rather when saving the baby's life becomes a realistic possibility.  A 20 week old embryo cannot be saved; a 25 week old one can.  A cold, hard truth, and I'm not the only mother who quietly breathed a sigh of relief at the 24 week mark.

However, let's go back to the basics, and look at Gingrich's belief that life begins at conception, something he's not alone in.  Certainly from a scientific point of view, embryos are definitely alive, but nobody's actually talking about the scientific definition.  We're looking at one more spiritual.  When does human life begin?  Or when does it become wrong to endanger / terminate the embryo?

(There are dozens of articles on this at The American Bioethics Advisory Commission if you're interested in something other than my take.)

A Look at Embryos and their Development

While undergoing fertility treatment, I was obsessive about the early stages of pregnancy and embryonic development, which ultimately changed my own thoughts about when life begins, so let's have a review of this.

For the in depth version, I can't do better than point you towards this blog-post by Fertility Lab Insider, but to keep things concise, I'm going to highlight what I consider to be the relevant points.

From conception and for a few days afterwards, the embryo is simply a dividing bundle of cells.  There is no distinction initially as to placenta cells or foetus cells.  It's only five days past conception, when the embryo becomes a blastocyst that an inner cell mass becomes visible: that is what's going to be the foetus.

Not all embryos get to that stage; not all blastocysts have an inner cell mass.  If you're really unlucky, you have a molar pregnancy where the cells implant but just become a (sometimes cancerous) mass rather than a foetus.

At around seven days post conception, the embryo begins to implant.  Many home pregnancy tests can start getting a positive about ten days post conception, and for the average woman, once you see that second line, you are more likely than not to be giving birth within nine months.

At three weeks post conception, the heart starts beating and the brain is beginning to form.  You can see/hear the heartbeat as early as six weeks pregnant, and once it's confirmed that that happens, your chances of miscarriage drop dramatically.

At twelve to fourteen weeks of pregnancy (ten to twelve weeks post conception), you're out of the first trimester.  If the foetus has made it this far, it's probably got what it takes to go full term and become a 'take home baby'.  Many people choose to announce their pregnancy at this point.

My Own Thoughts and Why They Don't Matter

I take a slightly religious slant on this, associating life in an ethical sense with a soul, and my belief (because it certainly can't be proven!) is that there needs to be a body for the soul to go to, so life begins sometime between five days and three weeks after conception, that is, sometime between the mass of cells destined to become the body forming and the basic structure for that body being developed.  The pre-blastocyst embryos are simply genetic material, much like eggs and sperm.  They have all the information set for building a unique human being, but they are not that being.

My stance is, of course, phenomenally vague, faith-driven and personal.  How could I begin to impose it on another person?  If, having read the above, you come to the same conclusion as me, that's great.  But if you come to a different conclusion, then I'd not be particularly surprised.  I think it's a basic human right that we are entitled to form our own beliefs (religious or otherwise)... in fact, I consider it our responsibility to form our own beliefs, giving them careful thought in the process.

I've always considered myself pro-choice.  I would hate to face the prospect of an abortion myself (I could say I'd never do it, but that's too easy when I'm never likely to be in that situation), but I have every sympathy for any woman who has one, all the more so because it's not something you can talk about openly.  I have always been grateful for the fact that nobody in our acquaintance has rebuked us for doing IVF, although chances are that some of them feel it's an immoral decision.  It's been respected as our choice (I'm not expecting the internet to grant me the same courtesy, but that's no reason not to post).

This respect is so important to remember.  I once witnessed a well-meaning person tell a woman to stop mourning her miscarriage because the foetus hadn't been alive.  That diminishing of her grief was one of the cruelest things I've ever come across.  I don't consider myself to have had a miscarriage, although technically, I've lost three embryos that were transferred into my uterus and never implanted (or failed soon after implantation).  For some women, that is a loss, and I respect that.

Even for me, the lines are blurred.  When we transferred the two embryos in the picture, we had wanted to avoid twins, had strongly considered just transferring one embryo, and felt guiltily relieved that one of the embryos was rather sorry-looking.  Yet I couldn't help but root for them both to make it, even though the thought of a twin pregnancy terrified me (and I was opposed to selective reduction).  I still attached sentiment to both those embryos, whether I considered them alive or not, and wanted to give them every chance.

The Attrition of Embryos in IVF

Now Gingrich was specifically addressing IVF, so let's look at the realities of that.  One of the common errors the media makes when discussing IVF is saying that the doctors implant the embryos into the woman's uterus.  The fact is, nobody fully understands what makes embryos implant.  All the doctors can do is transfer the embryos to the uterus and hope for the best.

To maximise the odds, they try to create lots of embryos so that they have some choice, although it still comes down to guesswork.  Transfer usually happens on day three or day five.  Waiting until day five (the blastocyst stage) means that you have a clearer idea of which ones are developing the best and thus are more likely to implant; however, there's a train of thought that embryos do better in the uterus than in a petri dish, so it's better to transfer on day three rather than risk weakening the embryo.  (There are probably other factors at work too, but this is how I understood it when we did IVF--we had day three transfers).

In either case, you should expect leftover embryos after the best have been transferred.  This, obviously, is where the ethical minefield comes into play.

Firstly, I'd like to point out that lots of IVF cycles don't have any embryos left over--some don't even have any for transfer.  The number of embryos is largely dependent on the number of mature eggs the woman can produce after undergoing hormone stimulation (the man's fertility issues may or may not be a factor).  Some women produce more than twenty... some less than five.  There isn't really a normal.

What is normal is a heavy attrition rate from eggs to viable embryos.  Not all eggs fertilise, some won't fertilise normally, and a high proportion of embryos stop dividing after the first day or two.  With fertile couples, there's only a 20% chance of well-timed intercourse resulting in a positive home pregnancy test.  Infertile couples obviously have even worse odds, and that's what medical science is trying to overcome by fertilising several eggs at once.

The Catholic stance on IVF is generally a firm 'no', but I understand that there are some Catholic IVF clinics, who take the line that it's OK as long as every embryo is transferred.  To achieve this without resulting in Octomom, they fertilise only as many eggs as they are prepared to transfer.  This, of course, reduces the odds considerably, and means that the couple is at greater risk of having gone through all the cost and effort for nothing.

As an illustration, I'm going to provide the stats for my own IVF cycles below.  As I said, there is no normal, so I can't be considered representative.  However, I'm not atypical either.  To give the relevant factors, my husband and I were thirty at the time of our first cycle and thirty two for our second.  I have polycystic ovarian syndrome; my husband has no fertility problems (actually, he received compliments on his sperm.  Smug git).

10 eggs
3 did not fertilise
2 abnormal fertilisations
5 fertilised normally

Day 3:
1 seven cell embryo
1 six cell embryo
1 five cell embryo
1 four cell embryo
1 three cell embryo

We transferred the seven and six cell embryos.    A single pregnancy and live birth resulted.

The remaining embryos were given a day in culture to see if they would develop further, but were ultimately discarded.

15 eggs
5 were too immature to fertilise
1 did not fertilise
1 abnormal fertilisation
8 fertilised normally

Day 3:
1 eight cell embryo
1 seven cell embryo
3 five cell embryos
1 four cell embryo
1 three cell embryo
1 one cell embryo

We transferred the seven cell embryo.  No pregnancy resulted.

The eight cell and five cell embryos were frozen (I do not know the exact cell numbers at time of freeze, although they would have continued to divide up until that point).  The remaining embryos were given a day in culture to see if they would develop further, but were ultimately discarded.

FET (Frozen Embryo Transfer)

1 ten cell embryo thawed perfectly
1 embryo lost some cells during the thaw, but continued to divide afterwards

Transfer (the day after thaw)
One eleven cell and one five cell embryo were transferred.    A single pregnancy and live birth resulted.

A few clarifying notes: there is more to embryo quality than cell count, which is why in our second cycle, we had a seven cell embryo transferred over the eight cell (though, as it turned out, the seven cell wasn't viable, while the eight cell likely resulted in our daughter).  I never asked for a more detailed grading of my embryos, simply because I didn't want to know.

Our clinic made the decision on which embryos were worth freezing, but note that they gave all embryos four days in culture to confirm that they had stopped dividing (i.e. that they had died).  That included a one cell embryo... or a normally fertilised egg that never actually divided in the first place.  They were, however, candid with me at all times about which ones we could expect to be viable, so I never had false hopes.

So what about those leftovers?

The astute among you will have noticed that at the time of my last transfer, we still had two frozen embryos.  I am not going to talk directly about those embryos, since that would mean bringing my husband's point of view into it.  Another post, perhaps.

But we're the perfect example: a family has two children (one of each, in fact), and could quite reasonably be considered to be complete.  Yet they have two more potential children hanging around in deep freeze.

Nobody goes into IVF wanting to have leftover embryos--most people want to have some to freeze in case the first try doesn't work, since a frozen cycle is so much easier and cheaper than a full cycle, but the secret ideal is to finish your family with nothing frozen.

Of course, when you just want to have a baby, it's easy to put off such thoughts and think: "We'll cross that bridge when we come to it."  Reportedly, there are thousands of embryos frozen across the States because the couples responsible can't make the decision about what to do with them.

What are the options?  Well, one is just to transfer them anyway.  If they don't take, at least you gave them the chance.  If one does take, then your family is a little bigger than you planned, but that's not a big deal--obviously, this becomes less feasible if you have several extra embryos.

Another is to just keep paying the fees for freezing them indefinitely, so you never have to make the decision.

The more conventional options are as follows:
  1. Donate them to another couple
  2. Donate them to science (embryonic stem cell research)
  3. Thaw and discard them
Obviously, the pros and cons of these choices will depend on the individual's point of view.  Maybe it seems straightforward to you, or maybe it seems impossible.  Perhaps it would be easier or harder if you were facing this in reality rather than on a hypothetical basis.

Once we made the decision to do IVF, our clinic gave us a huge amount of paperwork to fill out before we could begin.  I don't know how much of this was required by law and how much of it was their own policy.  As part of this, we had to indicate our wishes regarding any frozen embryos in the event of one or both of us dying. 

This obviously was a prudent move to avoid lawsuits down the road, but it had the effect of making us think about it and discuss it with each other before we even started the drugs.  While my husband and I didn't have much trouble reaching an agreement, I can't imagine what it would be like if you find that you disagree after the embryos have been created....

The Role of the Clinic

So far, I hope I have made it clear that I do take the responsibility of these embryos seriously.  So in many ways, I am agreement with Gingrich.  However, he said: "We should look seriously at what the rules should be for clinics that are doing [IVF], because they are creating life."

Notice where we part ways?  Gingrich is placing responsibility on the clinics, rather than the parent, perhaps because it would be easier to get laws in place controlling the clinics.  But such laws could take ownership of the embryos away from the parents.  What exactly Gingrich thinks we should do with the thousands of embryos in storage, I've no idea, but I'm not going to assume I'd agree with him.

I would have no problem with regulations being enforced to make sure prospective patients are counseled about embryos and encouraged to discuss with each other what they would do with any spare.  But I would be fiercely opposed to anything that denied the parent the right to choose.  I shudder to think of somebody disposing of my embryos in a way that contradicted my ethics.

Obviously, the other concern is that this is simply Gingrich's way of beginning a crusade against IVF in itself, but that's a whole other set of ethical issues, and I'm not going to get into those--not in this post, anyway.

In the end, it doesn't matter to me whether the embryos pictured are my children or my genetic material.  I took on the responsibility for them, and I'm hugely grateful that I was granted the right to do so.

1 comment:

  1. There's a lot to think about in this post. The first thing that always strikes me when I think about this topic is how saddening it is that so many of the people with strong opinions on the subject have so little understanding of what it's like to yearn for a child and not be able to have one. I feel like no one should be allowed to have beliefs about it unless they've been there. But of course, that ain't how ethics works.

    Like you, my feelings about LIFE have changed since becoming super preoccupied with conception and the early days of embryonic development. And hey, if life begins at conception, an awful lot of people die. The stats for number of fertilized eggs that don't implant or don't make it much beyond initial implantation--- range from like 40-70%? So yeah, your view has a certain logic to it. I certainly don't agree with Gingrich.

    And I certainly agree with your final point on the issue of unused embryos. It's just GOT to be the parents' choice.