The number of twins is multiplying. Since 1980, the twin birth rate in the United States has increased by over 75 percent, and the birth rate for triplets and other higher-order multiples has increased at even higher rates. More women are becoming pregnant with more than one baby principally because more women are using in vitro fertilization (IVF).
As part of the IVF process, a woman takes drugs to enable her body to produce multiple eggs. These eggs are removed from the woman’s body and fertilized in a petri dish. After the embryos develop over a period of several days, a select number of them are then transferred to the woman’s body with the intent to achieve pregnancy.
When IVF first became widely available, it was common for fertility doctors to transfer three or more embryos in order to increase the chances of achieving pregnancy. Not every embryo that is transferred will necessarily implant, so transferring four embryos, say, might yield a pregnancy of twins. By 2009, 41 percent of infants born via IVF were from multi-fetal pregnancies, compared to 3.5 percent of infants among the general population.
The fertility industry has long realized that multi-fetal pregnancies are less than desirable from a standpoint of public health. The mother who is pregnant with multiples faces increased chances of having placental abnormalities, preeclampsia, anemia, gestational diabetes, Cesarean delivery, and even death in childbirth. Premature birth occurs in multi-fetal pregnancies at a rate six times higher than singleton pregnancies. Preterm babies are more likely to have low birthweights, cerebral palsy, brain damage, birth defects, visual impairment, and long-term educational and behavioral problems. Twins have a fivefold to sevenfold increased risk of suffering from stillbirth or neonatal death compared to singletons.
Given these outcomes, assisted reproductive specialists sought strategies for reducing the number of multi-fetal pregnancies their industry spawned. European countries initiated a precedent of transferring a smaller number of embryos without suffering a lower success rate of live births. The American-assisted reproduction industry has followed suit in recent years, encouraging women normally to transfer between one and three embryos. These efforts have been effective: the rate of IVF infants born from multi-fetal pregnancies was reduced from 41 percent in 2009 to 22 percent in 2014.
Now, the American College of Obstetricians and Gynecologists has gone one step further in a new set of guidelines, strongly recommending that only one embryo should be transferred to attempt to achieve pregnancy. Elective Single Embryo Transfer, as it is called, has just as good success rates as transferring more than one embryo (at least for patients with a good prognosis), but avoids the risk of an artificially achieved multi-fetal pregnancy.
What About the Other Embryos?
What is not directly mentioned by the fertility industry or the media outlets that cover the new recommendations is the converse of a decreasing number of transferred embryos: an increasing number of leftover embryos. In the course of a normal IVF treatment, between five and twenty eggs are fertilized and examined before the highest quality embryos are selected for transfer. Most of the remaining embryos are stored frozen in fertility clinics where they can be thawed and possibly used in later IVF treatments.
If only one embryo is selected for transfer rather than three or four, that leaves two or three extra embryos in addition to the ones that would have otherwise been left over. Yet there has been no proposal by the assisted reproduction industry to reduce the number of eggs that are initially fertilized.
Since the inception of IVF, the moral and legal status of unused embryos has been a conundrum for almost anyone who cares to think about it. There may already be as many as one million embryos awaiting an unknown fate in the freezers of fertility clinics. Individuals who initiate IVF treatments frequently do not know what to do with their leftover embryos when they are no longer needed. Discarding them seems cruel. Turning them over to science turns them into instruments. Donating them means having one’s progeny raised by strangers. Freezing them avoids the decision.
While pro-life critics of IVF have long pointed out the problem of leftover embryos, this problem is not internal or essential to the process and nature of IVF. That is because one can avoid the problem of leftover embryos simply by committing to transfer all the embryos that are produced. Some prominent pro-lifers have provided their tacit blessing to IVF for married couples on the condition that every embryo is transferred. In this way, some argue, “pro-life IVF” need not be an oxymoron.
The new guidelines promoting single embryo transfer, however, put the potential pro-life user of IVF in a catch-22. Concern for nascent human life compels one to avoid leftover embryos and so to transfer all of them, but concern for the health and viability of nascent human life also compels one to avoid transferring too many embryos. Damned if you do and damned if you don’t.
But this catch-22, like the problem of leftover embryos, can be avoided. If it is best for the mother and her pregnancy to transfer, say, one embryo, and she wishes to avoid leftover embryos, then only one egg should be fertilized.
The question is how seriously this possibility will be considered by an industry whose objective is to produce healthy newborns and whose profits depend on it. Only about 27 percent of IVF cycles (from hyperovulation to embryo transfer) actually lead to live births. Some women will undergo multiple cycles and still never deliver a baby. In the process, they can spend tens of thousands of dollars. In this situation, fertilizing a single egg asks fertility specialists to roll the dice multiple times—hoping that the single embryo produced by IVF survives until it can be transferred, hoping that the single embryo is of high enough quality for transfer, hoping that the embryo will implant and that the pregnancy will last. It would be hard to think of a scenario that is more inefficient from an infertility treatment perspective.
The pro-life objective to transfer every embryo already swims against the tide of the IVF industry. When Nadya Suleman gave birth to octuplets in 2009 after transferring all her remaining embryos from previous IVF treatments, her motivation, at least in part, was that she did not want any embryos destroyed. Her fertility doctor was widely criticized for allowing such a high-risk pregnancy. When it was later revealed that he actually transferred twelve embryos, his license was revoked.
Convincing fertility doctors to transfer every embryo becomes significantly harder as medical science continues to demonstrate that it is best to transfer the smallest number of embryos possible. And there is no question in which direction assisted reproductive specialists will push their clients to resolve the catch-22. The fertility industry does not care about leftover embryos. IVF is a technique intended to meet a demand for babies, and fertility specialists will do almost anything to perfect their ability to deliver, maximizing their profits in the process. If this means proposing a method that multiplies the number of frozen embryos, no one blinks an eye. Ironically, then, the fertility industry is effectively anti-life.
There are many people who nevertheless use the services of the fertility industry (and some who provide them) who think the embryo is more than a clump of cells. The new guidelines push these people into a stark dilemma that practically forces them to get comfortable with freezing (and ultimately destroying) some embryos. It will be the rare fertility doctor who allows her client’s moral hangups to diminish her clinic’s overall success rate.
Technology and Ethics
Decades ago, the philosopher and theologian Jacques Ellul observed how technology marches toward greater rational efficiency, impervious to social conditions and norms, writing:
A principal characteristic of technique is its refusal to tolerate moral judgments. It is absolutely independent of them and eliminates them from its domain. Technique never observes the distinction between moral and immoral use. It tends on the contrary, to create a completely independent technical morality.
This technical morality has, in fact, already asserted itself in other efforts to reduce multi-fetal pregnancies. In a procedure sometimes known as selective reduction, twins and other higher-order multiples are intentionally “reduced” (that is, aborted), leaving a smaller number of fetuses, ideally a singleton. This procedure has increased steadily alongside the increasing number of multi-fetal pregnancies from IVF.
IVF is certainly not in the business of saving embryos or fetuses. It is not even in the business of providing babies if the number provided is the wrong number. Its business willfully destroys perfectly healthy fetuses for the sake of a single healthy newborn.
Selective reduction shows how, over time, the internal norms of a technique extinguish all other norms. Twelve years ago, one of the leading obstetricians who practices multi-fetal pregnancy reductions publicly changed his stance from opposing reduction of twins to supporting it. “Ethics evolve with technology,” he said.
Ethical objections to IVF, of course, extend beyond the pro-life concerns about leftover embryos or selective reduction. One prominent strand of thought objects to IVF in principle because it shows disrespect for the dignity of the human person in the very act of creation. On this understanding, IVF amounts to a dehumanizing form of technical manufacture of children outside a conjugal act. Other objections similarly show concern about the assertion of choice and will in the process of reproduction. The IVF user must decide: How should the gametes be obtained? Should a third party’s gametes be used if mine fail? Which third party should I choose? How many eggs should be fertilized? Which embryos should be selected and on what basis? How many embryos should be selected? What should be done with the remaining embryos? Should a surrogate be used if I can’t get pregnant? Which surrogate should I choose? Should I continue to carry all of the fetuses that have implanted? With so many difficult “elective” choices, it is not hard to see why some have thought the whole thing should just be shelved.
Nevertheless, in a stark and vivid way, the in vitro catch-22 highlights a significant problem with making reproduction a matter of will. An attempt to bring in values where they are not respected collides with the technical efficiency of the procedure itself and its goal. What inevitably happens is that the former is sacrificed on the altar of the latter, as the fertility industry promises to quash any sliver of ethical hesitation that remains. In this way, the in vitro catch-22 teaches something the pro-life movement has known for a long time: the more choices we provide, the harder it can be to make good ones.
Philip Reed is Associate Professor of Philosophy at Canisius College in Buffalo, New York. His research interests are in ethics and moral psychology.