Of IVF, Embryo Freezing And Soapboxes: A Maltese Gynaecologist’s Perspective
What you’re about to read is useless. The things I’m going to discuss probably don’t apply to you. You may or may not agree with my discussion and inferences. You almost definitely won’t change your mind after reading this. And even if you do, there’s probably nothing you can do about it anyway.
Do you sense a feeling of futility? Take that feeling. Multiply it by itself. Then multiply it again and again and again. You might now be getting close to feeling what sufferers of infertility live every day of their lives.
At the moment, amendments to the law regulating assisted procreation in Malta are being discussed in Parliament. This is a law that was enacted in 2012, and it is the law that controls what can or can’t be done in the quest to help people who cannot conceive naturally have a baby. Before 2012, no regulation existed. Anyone was free to fertilise whatever amount of eggs they deemed fit, attempt to impregnate women with as many embryos as were available, and do this using whoever’s gametes were enticing enough.
The IVF law of 2012 settled that once and for all. Under this law, which is the one that practitioners of reproductive medicine practice currently, two eggs can be fertilised per woman (in exceptional circumstances three) and each and every embryo produced must be placed inside its mother’s womb and be given the opportunity to progress. Opposite sex couples who are in a stable relationship can avail themselves of this service until the woman turns 43. Only the couple’s own gametes (sperm and eggs) can be used. The only instances where embryos can be frozen is in case of danger to the mother’s life, and this only temporarily until the mother is well enough for these embryos to be transferred into the womb.
What is being proposed? In a nutshell, this is what will be possible should the new bill pass as is. Same sex couples can apply for assisted reproduction cycles. Single women can apply too. Couples in need can use donated eggs, sperm and embryos. Women may undergo IVF up until the age of 48, but after 43, donor eggs must be used. Donors of sperm and eggs can make one anonymous donation of their gametes. Perhaps most controversially, in the first IVF cycle, a woman can have up to three eggs fertilised (i.e. up to three embryos created). Should this fail, she can have up to five embryos created at the next cycle. Embryos that are not used by the woman will be frozen and, should she opt not to transfer them at a later stage, will be put up for adoption.
Ok thanks, you may think. But is it a good or a bad amendment?
I’m not going to answer that question.
Most of you have formed an opinion by now. Just keep in mind that the fate of many childless people mainly depends upon just that. Other people’s opinion.
What I am going to do is point out issues that exist. Most of you have formed an opinion by now. Just keep in mind that the fate of many childless people mainly depends upon just that. Other people’s opinion.
Although lesbian women carrying babies may ruffle some conservative feathers, in general it will probably be seen as a natural progression of the current state of affairs, where same sex couples have the same adoption rights as opposite sex couples.
But one thing that same sex female couples cannot biologically do is have a child without the help of a few little swimmers: sperm. And this nicely slots in the bit where donating gametes will no longer be illegal. Yes, you read correctly. If I do a nice lesbian couple a favour and inseminate one of them with the sperm of a willing male friend of theirs, I can be fined and sent to prison. This is going to change.
Other users of donated gametes may be single women opting to have a child without the presence of a partner, male or female. Well, single women can adopt a child, so the leap is not too large for this either. Granted, you will have seen the comments underneath the news items: FIRST WE MAKE THEM PREGNANT THEN WE PAY THEM BENEFITS! Whatever. I’m pretty sure society will survive this particular adventure.
A large part of donated gamete use, I suspect, will be by women and men who are unable to produce their own eggs and sperm. Quite a few men have got problems producing enough good quality sperm, and all women eventually stop releasing eggs as they reach the menopause. Add to this women with medical conditions causing lower egg reserves, cancer survivors and unexplained premature failure of the ovaries, and there’s a substantial swathe of the population who might need these particular gifts.
Women may have up to five eggs fertilised in some cycles, but can only have a maximum of two embryos replaced. So what happens to the other three?
The modified law proposes one anonymous donation per person, so as to avoid complications such as people unwittingly marrying their half-siblings sometime in the future. You may have your views about anonymous versus named donation. Does the child borne of this situation have a right to know who his genetic parents are? Should someone who is magnanimous enough to donate her own cells so that another woman can bear a child be forced to shoulder responsibility for that child later on in life? Different countries legislate differently for this. In the UK, offspring are given the right to retrieve information about their genetic parents once they reach the age of 18. In Spain, all donations are anonymous by law. Which system makes most sense?
Now we come to the elephant in the room, the huge issue which was matter-of-factly put on paper and nonchalantly alluded to. Women may have up to five eggs fertilised in some cycles, but can only have a maximum of two embryos replaced. So what happens to the other three? The proposal is that they get frozen and can be used later by the woman. However, she must sign a contract before fertilising these five eggs that, should she reach the age of 43 and not have used these embryos, they must be given up for adoption.
Let’s do some science here before we go any further. Getting eggs from women is a long, expensive process, with some risk to the woman’s health, including possibly pretty nasty complications. The way things stand at the moment, two eggs are fertilised. The rest of the eggs are frozen, to be potentially used later. Fantastic solution, right? Well, yes, but it’s not that easy. Unfortunately, embryologists are not as good at freezing eggs as they are at freezing embryos. Success rates using frozen embryos are still quite a bit higher than those using frozen eggs. There’s a good chance that, upon thawing those frozen eggs, they may be found to be damaged and useless. Embryos tend to be hardier and most thawed embryos have almost as much chance of making it as fresh ones.
But it gets trickier.
Biology is a callous bastard who doesn’t care about the people trying to get pregnant.
Biology is a callous bastard who doesn’t care about the people trying to get pregnant. If all eggs collected are fertilised and all are allowed to develop, there’s a good chance that around half of them will actually contain genetic problems which make them unable to grow into viable babies. This rate is even higher in older women. So what happens if those two embryos are both non-viable? Well, the woman doesn’t get pregnant. Increasing the number of eggs fertilised may help by improving the odds.
Also, there might be an indication of which embryos are likely to proceed to allow continuing pregnancies, if embryos are allowed to develop for a few days. The ones which would not have developed naturally tend to slow down or stop their development, and the remaining embryos can be assessed for quality and the likelihood of continued development. If embryos which look healthy are placed in a woman’s womb, they have much more chance of growing into babies than the ones which Nature has sadly and wastefully doomed to fail.
Can we do this in Malta? No. Any embryos produced must be placed inside a woman’s uterus, according to the current law. Is this something bound to change? No again. The Minister of Health, Mr Fearne, has categorically declared, on more than one occasion, that every embryo produced will be given a chance to develop.
Will this decrease women’s possibilities of getting pregnant? Yes. Transferring an embryo which has practically no chance of development into a woman’s uterus only means that that woman has undergone a medical procedure which will result in nothing but bitter disappointment.
The proposed amendments will oblige some women to give up their embryos for donation. This part of the amendment is the one which creates the most massive issues.
The proposed amendments will oblige some women to give up their embryos for donation. This part of the amendment is the one which creates the most massive issues. A woman is told, you can choose to fertilise less than five eggs, if you wish. Your chances will be lower, however. Not much choice, right? But hey, if you don’t use your embryos, you’ll have to give them to someone else. Donation of embryos can be a fantastically altruistic gesture, giving hope to other childless people. But is it for everyone? Is it fair to make women give up their potential children, knowing that they may or may not grow up in another family, over which they have no control?
There are three ways we can go about this. We can scrap all amendments and stick to the current law. This will leave us with today’s low success rates, but no ethically worrying quandaries about extra embryos. We can adopt the amendments proposed, thus increasing women’s chances of carrying a child, but also coercing them into giving up any extra embryos. Or we can scrap the notion of an embryo as a human being, and allow for the discarding of embryos which are not used by their parents or given up for donation. This, until now, has been taboo in Malta. Mr Fearne has said time and time again: no embryo will be discarded.
Before you slam your laptops shut in disgust, just keep in mind that this is the option used in most countries around the world. Many societies perceive an unimplanted embryo to be a potential human, who might develop, rather than an individual with rights and ambitions. Is this a correct way of looking at things? Who knows? I’m sure many people know that it is. Probably as many people as those who know that it is not.
Another topic which has been emphatically not addressed is pre-implantation genetic diagnosis (PGD). This is when embryos are tested for certain genetic defects and only the ones which are free from that defect are transferred into the mother-to-be. To put this into context: many Maltese have a condition called thalassaemia minor. This, in itself, is such a mild condition that most people who have it don’t even know that they do. Two parents afflicted with thalassaemia minor, however, have a 1 in 4 chance of having a child with thalassaemia major. This is a serious, life-threatening condition in which lifespan is seriously shortened (sufferers often die before age 20) and repeated blood transfusions make quality of life very low. With PGD, this could potentially be tested for, and only embryos which do not have this problem could be transferred. The health minister has also stated that PGD will not be legal in Malta, since any affected embryos cannot be discarded.
All in all, a tricky subject.
Next time you climb upon your soapbox to preach your morality to the world, just think for a short while. The only people absent from this debate are the most important ones.
You might now be breathing a sigh of relief as you watch your children play, happy in the thought that you don’t need to make these decisions.
But, next time you climb upon your soapbox to preach your morality to the world, just think for a short while. The only people absent from this debate are the most important ones. The people struggling with infertility. You’re probably not one of them. Some people are not that lucky.
Max is an obstetrician and gynaecologist working in the Assisted Reproductive Technologies team at Mater Dei Hospital.