Mixed blessings: ethical issues in assisted conception
Authors: G. Tindall
Journal: Journal of the Royal Society of Medicine (2003)

Assisted reproduction has been with us for twenty-five years—time enough for the first alarmist prognostications to be calmed, but for more specific problems to have become apparent. At an RSM meeting the three principal speakers tended to concentrate on current statistics, hopes and recommendations, while members of the audience raised more controversial questions.

Babies created through assisted reproduction are at excess risk at every stage in their development. Much of this risk is associated with the multiple births that are common when embryos have been implanted, but even IVF embryos that have developed as singletons are at higher risk than natural conceptions during pregnancy. IVF pregnancies carry an increased risk of bleeding, hypertension, diabetes and toxaemia, to which should also be added the treatment risks to the mother of ovarian hyperstimulation and an unproven but niggling suggestion of an increase in ovarian cancer. There is also a suggestion that the fairly new technique of sperm injection—ICSI—which has transformed the situation for severe male subfertility, doubles the risk of chromosomal abnormality or malformation, perhaps because the eggs are being fertilized by substandard sperm which would never have got there naturally. In fact the recent Australian study1 which shows this also indicates a doubled risk of major defect to any infant born through other forms of assisted reproduction. Both Melanie Davies (consultant obstetrician and gynaecologist, UCH) and Neena Modi (consultant in neonatal paediatrics, Hammersmith Hospital) referred to this study, though work in the UK has produced rather more encouraging results.

Both these speakers also referred to the EPICure review of very premature births (under 25 weeks' gestation) made when the babies are thirty months old2. Because of the higher rate of prematurity with multiple pregnancies, this has been a study of the downside of assisted reproduction. With such tiny babies there is a huge immediate death rate, and among the minority who do survive about 50% are severely disabled. Among babies of 26-29 weeks' gestation the survival rate is rather higher, but about 10% of these survivors have cerebral palsy and, alarmingly, between a quarter and a half are thought to have subsequent cognitive or behaviour difficulties. The Human Fertilisation and Embryology Authority (HFEA), the British regulatory body that licenses clinics, is now recommending that only two fertilized eggs are implanted per cycle, not three or more as was the case in the past and still is in some other countries. The overall success rate, in terms of the number of healthy babies produced, does not seem to be lessened by this restriction.

The issue of cost to the NHS was raised: a former chairman of the HFEA has suggested that clinics that implant extra eggs, thereby risking triplets or worse, should be obliged to contribute to the heavy subsequent care costs. However, this was felt to be a red herring; in any case the NHS is geared to respond to need, not to apportion blame. All three speakers felt that the risks associated with IVF and ICSI should have been looked at more carefully earlier. Properly controlled studies have only recently been set up; open-minded longitudinal studies should now be planned.

However, against so much anxiety should be set the fact that large numbers of people have now achieved, through assisted reproduction, the healthy child and children they so passionately desired. UK figures for the last complete calendar year show that 23 737 patients were treated, over a total of 25 273 cycles, resulting in 5513 live births. Although this means that more than three out of four would-be parents are disappointed, it was clear that many of those in the audience appreciated the strength of longing behind the desire to procreate.

This in itself creates difficulties with informed consent—‘couples arrive at the clinic so heavily fixated on the idea of a baby that they don't care about the problems involved’. The third speaker, Richard Ashcroft, senior lecturer in medical ethics at Imperial College, said that in practice the choice is usually between a risky pregnancy and no pregnancy at all. Arguments about whether doctors are being responsible when they initiate such procedures tend to run into wider arguments about the practical extent of medical responsibility, and thence into philosophically incoherent suggestions centring on the idea of harming a baby through its very conception.

It was at question time that the inadequacy of purely objective argument to cope with every aspect of this emotion-laden topic became fully apparent. There is, for instance, a shortage of donor eggs for implantation; Miss Davies remarked carefully that a current scheme that is presented under the name of ‘egg sharing’ (when couples get free treatment if they allow surplus eggs to be given to others) ‘may be regarded as coercion or as mutual benefit’. A social worker, speaking from the floor, commented that, in her experience, this unexplored matter of donation is leading to a great deal of subsequent heart-ache, both among parents who have been induced to give away their own genetic material and among those who have given birth to a baby which is not genetically their own. There is also growing concern that those born from donated sperm (AID) over the last generation know nothing about their inherited DNA. Should the children be told of their origin? This is advocated, but 90% of parents who have benefited from AID apparently do not tell: does this fact indicate a need for further thought about parental feeling and privacy? Another contributor from the floor produced the standard received view that secrecy in these matters, as in adoption cases, causes trouble. However, as Dr Ashcroft pointed out, ways of organizing family life are extremely variable—‘revelation can cause trouble too’. Clearcut principles do not necessarily provide all the answers.