Is It Time for The Fertile to Use ART?

The worlds of medical technology and family-building continue to collide at a dizzying pace. As is often the case with fast-moving technological advances and their use, we find ourselves scrambling to catch up with resulting social and ethical dilemmas. In the United States, where diagnostic and treatment choices are virtually untouched by governmental regulation, the questions surrounding assisted reproductive technology and who has access to its miracles are most often answered in private discussions between patient and physician, one case at a time.

Not so long ago, the rigors of infertility testing and treatment were viewed by nearly everyone as last-ditch efforts toward building a family. Who would want to pay thousands of dollars to be poked, prodded, medicated, and scheduled into making a baby, unless it was absolutely necessary? Once the early adopters of new reproductive technology took the initial chances -- and successfully -- people desperate to have a child came forward in droves, looking for hope and answers. It wasn't long before IVF, once considered highly experimental with unknown risks, was being commonly performed all over the country. Hundreds of thousands of children have resulted.

It follows that now even people who don't have to struggle to conceive want to take advantage of what IVF and other fertility treatments have to offer them.

In fact, to people who have grown up hearing about the marvels of reproductive science on such a regular basis as to make it all commonplace, making use of ART to have children may soon appear downright de rigueur.

Laura Abbott, a 22 year old industrial designer in New York, is one woman who looks at IVF and sees tremendous benefits -- not a final option to treat infertility.

While she hasn't put plans into place yet, Laura doesn't rule out using IVF as a technological vehicle to control her future family-building efforts. "I would definitely consider it," she says assuredly. "My generation doesn't see assisted reproductive technology as weird at all. Our point of view is 'why not use it, if it's better?'"

Is using technology to procreate indeed better? That's the question generating a lot of attention at present. Obviously, in some cases, ART provides crucial benefits. The media may do better at creating excitement than educating, however. Dr. Eric Surrey, Medical Director of the Colorado Center for Reproductive Medicine, says that sensible consumers realize the media's tendency to focus on extreme situations.

"For example, extremes like screening for eye color..." Surrey says, "Such stories are highlighted because they get readers' attention. The truth is that you have to separate a technology's potential from the current reality."

The benefits of ART that Laura Abbott sees -- more control over timing of pregnancy, screening for genetic disease, and gender selection -- are very real. The availability of its use for such purposes, however, is very clinic-specific.

Preimplantation Genetic Diagnosis

Nothing highlights the unresolved tug-of-war between technological advance and societal values at present than preimplantation genetic diagnosis (PGD). Originally intended to help anxious parents screen embryos for catastrophic disease, PGD is now sometimes available for purposes of a more subjective nature: family-balancing, gender selection for reasons other than side-stepping X-linked chromosomal disease, and even avoidance of the risk of some adult-onset conditions.

Dr. Arthur Wisot, Executive Director of Reproductive Partners Medical Group in California, illustrates one of the most notable advantages of using PGD to detect conditions in embryos before transferring them to the mother's uterus. "For couples who are aware that one or both of them carry an abnormal gene, we can use PGD to detect the presence of that gene abnormality and then transfer only the healthier embryos. The alternative [to using PGD] for these patients would be to achieve pregnancy naturally and rely on prenatal diagnosis through chorionic villus sampling (CVS) or amniocentesis. Then, if the abnormal condition was determined to be present, they would be in the position to make a choice between knowingly giving birth to a child with a genetic condition or terminating the pregnancy."

As amazing as the promise of PGD can be, consumers still must be reminded that the technology is not necessarily a panacea. For one thing, errors in the lab can occur, as with any medical testing or procedure. Granted, chances of such are highly guarded against and rarely occur. But people who are very anxious about becoming pregnant with a healthy child need to be accurately informed of any risks involved.

Another point to consider -- while more than 1,000 conditions can be located with genetic testing, science has not yet arrived at being able to screen for virtually any abnormality.

Dr. Patricia McShane, Medical Director of Reproductive Science Center in Boston, believes that hopeful ART consumers may not always be fully aware of some pertinent facts.

"Virtually half of all birth defects occur in the uterus and are unrelated to the genetics of the embryo," explains McShane. "If we know what we're looking for [with PGD], that's one thing. But there can be something else that's unknown, for example, autosomal recessive traits that are carried 'silently' through generations."

Thoughtful practitioners are in a position to determine and apply a balanced approach to PGD's use.

Eric Surrey adapts the old adage "just because one can, doesn't mean one should."

Says Surrey, "As the options increase, for example, with genetic testing, patients may be given access to opportunities, but it doesn't mean that they necessarily should take advantage of them."

Recent articles have unveiled the use of PGD not only for pinpointing and eliminating transmission of known genetic disease, but for reducing even the risk of adult-onset conditions such as certain types of cancer and Alzheimer disease.

Dr. McShane refers to the "slippery slope" involved when deciding which cases warrant the use what can be life-altering technology like PGD. "We all must give thought to what is considered 'serious' disease. It's a delicate position to be in, helping patients determine such choices."

Such complicated matters are not handled in a standard fashion across the country. Not only are practitioners able to determine the reasons for which they will use PGD -- one study by the Genetics and Public Policy Center (GPPC) of Johns Hopkins University recently found that 42% of clinics will offer the technology for non-medical gender selection -- but also the way that each practice group makes such choices varies.

Some, like Shady Grove Fertility Center, utilize an ethics committee approach to address individual case issues that arise. Others will consider each patients situation within a conference of the clinic's medical staff. In any case, interested consumers should be aware that, in spite of the free-wheeling use portrayed at times by the media, medical experts are well aware of the power of this new technology, and requests for its use are not casually considered. While government oversight is limited in the United States, several entities -- the American Society for Reproductive Medicine, the Preimplantation Genetic Diagnosis International Society, and the European Society for Human Reproduction and Embryology -- are voluntarily playing active roles in the development of guidelines and policies for guiding the use of PGD.

When respondents to the GPPC survey (representing medical, lab, and other directors of 190 U.S. ART clinics) were asked about the future, 75 percent believe that eventually whole genome embryo screening will become a routine part of IVF use.

Oocyte Cryopreservation

Another attention-getting use of ART by people who are not infertile is still considered experimental. Oocyte cryopreservation, or egg freezing, is being offered by a handful of clinics to young women for two primary reasons. The first group to be considered for egg freezing have been young women who need to undergo sterility-causing cancer treatment and who wish to preserve their fertility. Following close on the heels of the technology's advent were innovative practitioners and entrepreneurs who see egg freezing as a path to delayed parenthood for healthy young women.

Making use of oocyte cryo requires that women patients use fertility medications in order to ovulate more eggs than normal. The eggs are retrieved, frozen, and stored until the woman decides at a later date to attempt conception through IVF using the egg cells.

Eric Surrey's clinic in Colorado is one of several that offers egg freezing as part of an approved experimental protocol. While there are no greater health risks than with any other superovulation and retrieval procedure, this technology still garners an "experimental" label due to the fact that not many live births have resulted from it. There's still some fine-tuning to be done through research in order to make previously frozen egg cells a regularly viable option for IVF.

Gay & Lesbian Family-Building

Another group of patients who can be assisted by ART regardless of their fertility status are gay men and lesbians. Here, too, it is a service made available at the discretion of the physicians and clinic policies.

Associate Medical Director at Reproductive Science Center in Boston, Dr. Samuel Pangreports that theirs was the first clinic in New England to provide ART services for gay couples, starting a decade ago when the hopeful parents-to-be were turned away by other practitioners. They also see patients who come from surrounding states that will not allow the use of ART by non-heterosexual couples. The screening practices utilized by RSC are the same for all patients inquiring about IVF, regardless of whether they are straight or gay.

Pang explains how men and women have been assisted at RSC, regardless of both fertility and sexual orientation. "Often, lesbian couples will use an egg from one partner while the other will carry the pregnancy. That way they both feel an intrinsic part of creating their child. Male partners will typically use gestational surrogacy, in which a donor provides an egg and a second woman carries the pregnancy."

Pang says while the laws in Massachusetts are famously lenient in favor of rights for homosexual families, gestational surrogacy is preferred over traditional surrogacy due to a past Supreme court ruling. In brief, if a traditional surrogate, that is, a woman who provides both the egg cell and carries the pregnancy, changes her mind after the child is born, the courts will likely decide in her favor. With gestational surrogacy, where the pregnant woman has no genetic connection to the child, such worries can be put aside.

Advanced Maternal Age

Media attention about the prominent use of IVF, especially with donor egg, to help older women conceive has caught the attentive and worried eye of Laura Abbott's generation. She echoes the sentiments of other twenty-somethings who feel compelled to consider fertility treatment after less than a year of trying to conceive.

"When you see so many stories about women who waited too long to get pregnant," Laura relates, "it just highlights the impatience that people my age already feel about everything. Everything feels like a rush to the finish -- you have to hurry to get a good job, settle down, plan for retirement even. Earlier just seems better for everything."

Patricia McShane worries that young people, especially, may not have a clear understanding of the entire IVF process. "I think people aren't aware that there are risks for the woman. There are surgical risks, increased chance of multiples, and frankly, experts still don't entirely agree on later unknown connections between using fertility drugs and later female cancers."

Those risks are nothing new, and in fact, they lessen with time as science develops. But there's an inherent difference between women who have learned through diagnosis that taking such risks will quite possibly be the only way they'll have a child, and those who could very likely conceive and have a baby without putting their health at risk in the first place.

Young women aren't the only ones who are starting to see IVF as a preferred way to make a baby. Women in their late 30's, 40's, and sometimes older have gotten the message that trying to conceive naturally for a full year before seeking help could be an unproductive waste of time. That still doesn't mean that every clinic will render ART services upon request by virtually anyone. Reproductive specialists understand that they are essentially pivotal in not only the creation of individual families, but in the bigger picture as well.

Dr. Pang demonstrates the serious regard given to hypothetical requests by fertile people who may come to RSC's doorstep. In one example, a single woman with a high-powered career doesn't want to carry a pregnancy for reasons of inconvenience. Though the financial costs of a surrogate would be no burden for the woman, the decision-making staff has yet to determine their level of agreement with the reasons for such a request. Another scenario that is still undecided involves a young single man who hopes to use services of an egg donor and gestational carrier. The staff is concerned that the man's sense of urgency about having a child before he is 30 might not in and of itself warrant even the minimal risks posed to both donor and surrogate.

Eric Surrey has seen many later-life couples who come in as soon as they wish to conceive, but not so many very young, fertile couples in a hurry. He expects they will arrive eventually at Colorado Center for Reproductive Medicine, and their situations will be considered case by case. He's reminded of the past when new technologies like IVF and tests like amniocentesis were both marveled at and fretted about. He recalls a time when each and every patient heading toward IVF was required to undergo thorough screening, including psychological.

"Reproduction always gets held to a different standard than any other medical arena," Surrey says, "and it's much more politically charged. As physicians, we have to be aware of that, not treat it lightly, but our job is first to help our patients."

Asked if she gets any sense of foreboding from thinking about a future in which ART is the more typical way to make babies, Laura Abbott responds thoughtfully, "Not at all. If anything, it gives me a sense of security, knowing that science can allow us to have a perfectly healthy child, exactly when you want it."