The Question of Ethics by Cate House

Placing human values above the triumphs of technology.

ny time the manipulation of eggs and sperm is involved, a lot of ethical questions arise,” says Marc Fritz, chief of reproductive endocrinology. “It seems like every day there’s a new one.”

Intracytoplasmic sperm injection (ICSI), for instance, is controversial because it was first performed with human eggs and sperm without prior animal testing. Bruce Lessey, professor of obstetrics and gynecology, says ICSI was developed in Belgium for expediency by clinicians who had access to the technology.

But just because something is technologically possible does not mean it’s wise, Lessey says. “We’re just finding out that some of the ICSI babies may have some problems, so it’s not always good that things are applied right away,” he says. Since ICSI has only been performed for the last few years, researchers still aren’t sure of the possible effects. ICSI babies are no more likely to have physical deformities than those conceived by IVF or natural means, but it is possible for male offspring to inherit the same genetic defect that caused their fathers’ infertility.

To help Carolina’s fertility doctors deal with ethical questions, the Department of Obstetrics and Gynecology has formed the Assisted Reproductive Technologies Ethics Committee. Headed by William Meyer, associate professor of obstetrics and gynecology, the committee includes a community attorney, a social worker, a genetics counselor, a clergywoman, a psychiatrist, a practicing obstetrician, an embryologist, a nurse, and a couple who gave birth to twins after treatment in Carolina’s IVF program.

“The purpose of the committee,” Meyer says, “is to give us [the fertility doctors] guidance and direction not only for what kinds of procedures are appropriate but also for specific cases. It’s easier to advise patients when you’ve reviewed the case before a committee.”

ne of the first issues the committee discussed was the use of gestational carriers (also known as compassionate carriers)—women who provide only the womb (uterus) to infertile couples. Gestational carriers are different from surrogate mothers in that surrogates provide both the eggs and the womb to an infertile couple and are usually paid for the service. While cases are discussed on an individual basis, the committee has decided in general that they will use gestational carriers but not surrogate mothers. The ethical issue of paying a surrogate is complicated, and consent forms between an infertile couple and surrogate mother may not be enforcable.

Donated eggs are another issue. Meyer explains that egg donors were initially used when a woman had a heritable disease, but now most cases involve older women who want to “borrow” eggs because their ovaries aren’t able to produce quality eggs. First, the ethics committee had to decide if there should be an age limit on receiving donor eggs. They decided on a maximum age of 47. Then, they had to discuss how much donors should be paid and whether they should be notified if the recipient conceives. Donors typically are paid around $2,000 per donation and can request to be notified if pregnancy occurs.

Ultimately, the most important question the committee has to answer, says Stan Beyler, clinical assistant professor of obstetrics and gynecology, is “what type of program do we want to be?” There are some clinics, for instance, that place great importance on their success rates and only accept promising patients or encourage them to use egg donors even when it might not be necessary. Other clinics, including Carolina’s, want to give people their best chance at pregnancy even if they’re not “ideal” candidates. “There’s almost no case where we tell patients we can’t help them because we know we’re the end of the line,” Beyler says. “We try to give couples an honest assessment and let them know up front what their chances of success are based on their age range.”

Then there are the questions that couples have to answer for themselves. How much money and time should we devote? Would it be better to adopt? Can we handle a multiple pregnancy?

“Older women are biologically more likely to conceive a multiple pregnancy,” Fritz says. “But there is no doubt that modern fertility treatments are the primary cause of the recent dramatic rise in the number of multiple births.” To avoid repeating expensive procedures, couples often elect to implant multiple embryos to increase the odds that at least one will survive.

“It’s unfortunate that the media tends to report multiple pregnancies as a triumph of technology and never as the complication of treatment that they are. It gives people the wrong impression.”

In November, UNC-CH’s fertility services will become part of the new North Carolina Women's Hospital.

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