New York Times IVF Article and Dr. Solenni's Responce

Lowering Odds of Multiple Births

By Laurie Tarkan
New York Times
February 19, 2008

In the complex, expensive and emotionally charged world of fertility treatment, doctors are sounding a call to arms to reverse the soaring rate of multiple births. The doctors are responding to an unintended consequence of the success of in vitro fertilization — that it is often too successful. Since 1980, when the technique became available in the United States, the rate of twins in all births has climbed 70 percent, to 3.2 percent of births in 2004. Much of the increase, experts say, is a result of in vitro treatment. The rate of triplets and higher-order multiples increased even more from 1980 to 1998. It is not that twins or triplets are undesirable, doctors say. But multiple pregnancies often lead to risky preterm births and other complications. With that in mind, fertility centers are trying to lower the odds of such pregnancies, even at a cost of slightly lower success rates.

Fertility Center in Boston. “Is it a pregnancy without regard to the number of gestations or a pregnancy with a singleton live birth?” “Now is the time for all of us to rethink what is the paradigm of a successful I.V.F. pregnancy,” said Dr. Aaron K. Styer, a reproductive endocrinologist at the Massachusetts General Hospital. In I.V.F., a woman is given ovulation-induction hormones to produce multiple eggs, which are retrieved, fertilized with her partner’s sperm and transferred back to her uterus. The more embryos transferred, the higher the likelihood of multiples.

To achieve the goal of a single healthy baby, clinics are focusing on transferring fewer embryos and on developing more sophisticated ways to identify the healthiest embryos with the greatest chance of success. “We have been getting better at I.V.F. over the years, and as success rates go up, the number we transfer has to go down accordingly,” said Dr. Judy E. Stern, director of the human embryology and andrology lab at the Dartmouth-Hitchcock Medical Center in Lebanon, N.H. “Where three embryos used to work and give you mostly singletons, now we transfer two, because we’re making better embryos.”

The number of I.V.F. cycles in which four or more embryos were transferred has dropped sharply, to 21 percent in 2004 from 62 percent in 1996. Although the efforts have substantially lowered the rates of triplets born through in vitro fertilization, they have not made a dent in the twin rate. That is because many doctors and patients are reluctant to take the final step to ensure a single birth, a process called S.E.T., for single embryo transfer. From 1996 to 2004, the rate of such procedures rose modestly, to 8 percent from 6 percent.

The American Society of Reproductive Medicine now recommends that women younger than 35 with a good prognosis have just one embryo transferred. Women under 35 make up 44 percent of I.V.F. cycles. In women older than 37, who have a higher incidence of embryos with chromosomal defects, three to five embryos are still recommended, depending on the woman’s age.

The main obstacle to single embryo transfer is its lower success rate. Some experts ask women to agree to two cycles, first transferring one fresh embryo while freezing the others. If the first transfer fails, doctors transfer a single frozen embryo, a much less costly and onerous procedure. That approach yields similar success rates to transferring two at once while drastically reducing twin rates. With momentum building to transfer just one or two embryos, clinics focus on choosing the embryo most likely to succeed. Selecting embryos has traditionally been based on a visual examination of their morphology — shape, number of divisions and other physical factors. But morphology does not tell all, and many embryos that look great under the microscope have undetected chromosomal abnormalities like missing or extra chromosomes, called aneuploidy. One method used to weed out unhealthy embryos is to leave the embryos in a Petri dish for five days, two more than usual, to allow more time for hidden chromosomal abnormalities to show up.

Other researchers are looking at the traits of women at high risk of having multiples. In research presented at the reproductive society’s annual meeting last October, Dr. Stern linked a higher number of oocytes, or eggs retrieved from ovaries, with higher rates of single and multiple pregnancies. “This will change our practice,” she said. “If more oocytes are retrieved, we’ll want to transfer fewer embryos.”

Other experts are turning to genetic screening before transfers to cull embryos without aneuploidy. The screening is used to select healthy embryos in families with histories of genetic diseases. Because one or two cells have to be removed for analysis, there is some concern that the process can damage embryos, lowering pregnancy rates. Another screening, comparative genomic hybridization, can assess all 23 pairs of chromosomes, providing an 80 percent chance of a healthy embryo and a 60 percent chance of a live birth, says Dr. Geoffrey Sher, executive medical director of the Sher Institutes of Reproductive Medicine, a nationwide group of fertility centers.

But Dr. Sher, whose lab performs this procedure, has encountered the same obstacles as others. He has a very high twin rate, hovering around 60 percent, because although the technique yields a higher success rate, women are refusing to have just one embryo transferred. Many women in fertility treatment say that they simply do not view having twins as a risky situation and that they are willing, if not eager, to have them to speed the completion of their family, to avoid the high costs of future I.V.F. cycles or to ensure that their child has a sibling, among other reasons.

For a couple in Brooklyn who asked that just the woman’s first name be used to protect their privacy, six years of infertility and several failed procedures was enough. When the woman, Marie, was 28, they requested that three embryos be transferred, even though their doctor advised transferring two. “I wanted a set of twins,” Marie said. “It is such a complicated and sometimes painful thing to go through I.V.F., and to have to go through it all again for a second child was just a waste for me.” In the third in vitro cycle, last June, Marie became pregnant, with triplets. At four weeks, she lost a fetus. At four and a half months, she lost the entire pregnancy. She was devastated, she said, but she added, “I don’t regret my decision.”

Though it is widely accepted that carrying three or more fetuses can have serious complications, some fertility specialists do not view a pregnancy with twins as risky, as long as the patient is carefully monitored. “Yes, twin delivery has more risk than singleton delivery, but with good obstetrical care and educated patients, the risk of twin delivery is minimally higher,” said Dr. Norbert Gleicher, medical director of the Center for Human Reproduction in New York.

Carrying twins or higher-order multiples raises the risk of preterm births; low-birth-weight babies, with the possibility of death in very premature infants; long-term health problems; and pregnancy complications, including pre-eclampsia, gestational diabetes and Caesarean section. Studies show that 56 percent of I.V.F. twins born in 2004 weighed less than 5.5 pounds, and 65 percent were born prematurely, before 37 weeks of gestation. Still, many patients take comfort in the improvements in neonatal care. The survival rate for newborns over 2 pounds 3 ounces is 85 percent. And many people just see the adorable twins cooing in the double strollers crisscrossing Central Park — not the ones that do not make it out of neonatal intensive care — or the fetus that was eliminated in a medical procedure called a reduction to improve the chance of survival for the remaining fetus or fetuses.

Along with changes to in vitro fertilization, experts say, physicians need to improve monitoring drugs used to enhance ovulation. “The biggest problem with high multiples is coming from ovulation induction,” said Dr. Richard P. Dickey, chief of reproductive endocrinology and infertility at Louisiana State University Medical School in New Orleans. If ovaries are too aggressively stimulated with hormones, a woman can produce a nest full of eggs and increase her risk of having triplets, quadruplets and even sextuplets. All ovulation-induction cycles should be closely monitored, and the cycles that produce too many oocytes should be canceled, Dr. Dickey said.

The biggest obstacles to reducing twins in infertility treatment are not medical, experts said, but the lack of insurance coverage, as well as pressure from patients to be aggressive. “People have to recognize that there’s a connection between cost and how the treatment is going to play out,” said Barbara Collura, executive director of Resolve, a patient advocacy organization for people with infertility. “If you have $10,000 that you’ve begged, borrowed and stolen for this one I.V.F. cycle, you’re not going to say, ‘Please just transfer one.’" Even doctors in the vanguard of the trend face resistance from patients like Marie. Despite her pregnancy loss, she said, “With all the hard work I put into getting pregnant, I’d just rather have a set of twins than a singleton.”

Gimme, Gimme
Dr Pia de Solenni

When we go about having children the way we order a customized car, design a kitchen, or buy a wardrobe, maybe it's a sign that we should get a pet or stick to inanimate things like cars, clothing, and cuisinarts rather than babies.....

The New York Times has this piece on reducing the chances of multiple births for women who use IVF to become pregnant. Granted, infertility is a very difficult thing to deal with, but it doesn't follow that we can therefore use any means to achieve what we want - a child, our own child. This article raises some interesting points that deserve consideration. Here are a few:

"Women under 35 make up 44 percent of I.V.F. cycles."

- That's a lot of relatively young women. What IVF clinics won't tell women is that there are natural methods to overcoming many cases of infertility. Dr. Hilger's Pope Paul VI Institute is a very good place to start. Imagine treating women holistically and integrally - there's a revolutionary concept.

"But Dr. Sher, whose lab performs this procedure, has encountered the same obstacles as others. He has a very high twin rate, hovering around 60 percent, because although the technique yields a higher success rate, women are refusing to have just one embryo implanted." [emphasis mine]

- It's all about the baby, right? Yet people are willing to allow numerous embyros to die in the process of getting a "baby." Remember, that embryo is its own unique entity with it own DNA. It's not a clump of cells that will grow into a bit of hair or bone or any other isolated matter. Unimpeded, it will become the "baby" desperately desired by some. It will continue to become the screaming toddler, the morose teenager, the college graduate, the young spouse, and so on.

"Many women in fertility treatment say that they simply do not view having twins as a risky situation and that they are willing, if not eager, to have them to speed the completion of their family, to avoid the high costs of future I.V.F. cycles or to ensure that their child has a sibling, among other reasons."

- ["And I'll have one of those, and one of those, and that one, and that one, and one of those in every color, and...."] Sorry, not to trivialize infertility, but this sounds ridiculous. Only in a culture that has lost the sense of what gifts are (think of those endless registries for every occasion besides getting married; think of how acceptable it has become to buy gifts for ourselves or to select the gifts that other people will "give" us) would be so blind as to realize that we lose what it means for a child to be a gift. This is about having a baby my way, when and how I want it, without thought even for the well being of the baby that I want. Because, after all, I want it.

"And many people just see the adorable twins cooing in the double strollers crisscrossing Central Park — not the ones that do not make it out of neonatal intensive care — or the vanishing twin, a fetus that was eliminated in a medical procedure called a reduction to improve the chance of survival for the remaining fetus or fetuses."

- Need I say more? It's about getting what we want, no matter the cost to others.

"Despite her pregnancy loss, she said, 'With all the hard work I put into getting pregnant, I’d just rather have a set of twins than a singleton.'"

- Well, that's one way of looking at it.

Again, I don't intend to belittle infertility in any way. My only point is that maybe there are some good reasons for rethinking IVF. A friend of mine, faced with infertility, was ready to adopt. Her husband was completely opposed. But my friend reasoned, "Whether I have the baby or someone else does, there's no guarantee that he will be good, honest, intelligent, good looking, whatever." Even with all the choices that IVF offers, there are no guarantees of this kind. In the meantime, there are children who already exist and need homes. What about helping out one of them? Granted, it won't happen on our terms, but do we really think that having a baby on our terms with IVF will mean that everything will continue to be on our terms after that? That wouldn't really be life, would it?

Some Thoughts on Hormonal Contraceptives

The issue of birth control came to the foreground for me when I was diagnosed with Polycystic Ovarian Syndrome. Basically my ovaries were maturing oocytes but often were unable to release these eggs, resulting in cysts. In response to the first grouping of ova sacks not rupturing my body would mature subsequent groupings that were unsuccessful, utilizing more of the unregenerative number of immature gametes. Following this revelation my prior doctor gave me a limited time to have children and informed me that I would have to rely on fertility medications and possible artificial interventions like IVF and ICSI. That doctor's advisement was to begin taking an oral hormonal contraceptive for 3 months followed by a cycle of Clomid, an ovulation inducing medication.

That doctor's suggestion became an immediate subject with our Priest, who graciously made it known that even though it is an abortifacient there would not be any moral dilemma with using the contraceptives as long as we were abstaining during the interval I was taking the medication. Abstinence would be a necessary precaution do to the contraceptive's abortive properties. If we were not to abstain while I was ingesting the medication and a child was conceived, the baby would not be received in to the naturally hospitable environment of the uterus, but rather into a hostile, chemically transformed habitat incapable of fostering implantation.

Our priest also warned us that he did not think abstaining for that duration would be conducive to the beginning of a healthy marriage. Even the abstinence required for accurate Natural Family Planning practices is only a few days a month. After the discussion with our Priest I switched from my pro-life doctor to a Catholic ob/gyn and midwife that were family centered, NFP oriented, and did not provide contraception. We felt very strongly that the professionals that would be aiding our family needed to be in complete conformity with church teachings.

For most gynecologists and obstetricians their first course of action for fertility concerns is to prescribe the regiment of hormonal birth control for 3 months to restart the reproductive system, essentially by stopping its function, and follow that time period with a prescription for an ovulation inducing medication like Clomid. This instant response is a result of connections with major pharmaceutical companies and not the need of the misinformed patients who are unaware of there options. Often times, on the occasion that the ovulation inducer does provoke ovulation, a large number of oocytes are expelled producing multiple babies, therefore greater health risks for all parties involved.

In addition to putting yourself and children in danger, there are all the side effects from the contraceptives themselves. These adverse effects, include increased heart disease, breast and ovarian cancer ovarian cysts, and uterine fibroids, are why we will not be using the recommended hormone regiment and now use a Catholic obstetrician/gynecologists and midwife. On a side note, the use of hormonal contraceptives as an aid for PMS or to regulate cycles still hold the same long term side effects. And further women are given this endowment of pain each month as an opportunity for penance as with child birth. Clomid has side effects of its own, like hot flashes and ovarian hyperstimulation. Another draw back to using Clomid is that the drug inhibits the production of the viable cervical mucus crucial to the survival of sperm within the female reproductive tract. A possible solution to this side effect may be the use of Preseed, the only nonspermicidal personal moisturizer, with a make up similar to that of fertile cervical mucus. There are also many natural and licit measures for PMS, cycle regulation, and conception assistance through the help of the Creighton Method and Dr. Hildgers at the Pope Paul VI Institute.

I have been charting for fertility awareness for a few years now, and that was also the counsel given by my ob/gyn and midwife, to determine when ovulation occurs and at what frequency. It may take longer for us to conceive than those using artificial conception methods but most importantly we will not unknowingly be killing our children, moreover it will serve as a reminder to us that a child is not a right, but in fact gift that deserves to be conceived, as Pope John Paul II expressed, though a natural and marital act of love.

"Body weight and infertility linked"

Body weight and infertility linked

Penelope Debelle, Adelaide

The Age, Australia
August 24, 2007

RESEARCH has confirmed the empirical link between obesity and infertility by showing the "fat eggs" of obese women do not develop into healthy embryos.

The eggs were damaged by high levels of fat and cholesterol, which made diet a key factor in infertility, according to research by PhD student Cadence Minge from the Adelaide University Research Centre for Reproductive Health. The eggs of female mice, which were fed a high-fat diet that made them insulin-resistant and pre-diabetic, were harvested and grown in vitro but were unable to develop into healthy embryos. "They were much slower to divide and grow," Ms Minge said. "And the way that the cells developed was also disturbed."

Ms Minge said scientists were yet to understand exactly why the "fat eggs" were infertile and how they were damaged. But her research had established that a protein in cells that surrounded and nourished the egg was linked to the induced fertility and its effect could be reversed by using an anti-diabetic drug such as rosiglitazone (marketed as Avandia). The drug activated the protein that helped the egg to mature before its release so that normal embryo development function was restored. However, Ms Minge said the drug had side effects and was not advocated as "a quick fix" for infertile women.

"The rosiglitazone findings are of great significance for scientists researching egg maturation within the ovary. But at this stage, the research findings have only been made in mice," she said. "Also, the drug itself can have possible harmful side effects and more research is needed to find other, safer ways of activating the protein." She said weight loss was by far the most effective way to restore fertility and even shedding five to 10 kilograms was enough to trigger ovulation in obese women who had ceased to ovulate.

Ethical Answers to Infertility 5

The Gift of Infertility, Part 4

Dr. Jameson and Jennifer Taylor

Catholic Exchange
August 19, 2007

Part one of this series discussed natural family planning (NFP) as a means of treating infertility and introduced readers to the basics of artificial reproductive technologies (ART). Parts two and three explained the Church's teaching on human sexuality, with special attention paid to the link between infertility treatments and the contraceptive mentality. A Response to Readers clarified the Church's teaching on the use of Intrauterine Insemination (IUI). Here, we enter into the heart of the mystery of infertility. If, as the Church teaches, children are the "supreme gift" of marriage, how are couples (like us) to understand their infertility as a gift?

Infertility: A Gift?
Tears were streaming down my face and they were not tears of joy. Clutching the freezer door with my left hand, I stood holding a tiny test tube in my right. With each attempt to spit, I struggled to see if my tears or my saliva were filling the vial. At any minute, I was sure I was going to fall beneath the weight of the pain. Only the cold of the door handle between my fingers kept me focused on the task. "They want a stress test as part of my infertility workup," I thought to myself. "Well, they're sure going to get it!" It was the week of my 30th birthday, and I'd never been more miserable.

The first year of our marriage seemed like an extension of our honeymoon. Jameson had a good job, and I was working part-time from home in expectation of soon becoming a mom. When we hadn't conceived after six months, we suspected something was wrong. Yet, we continued to hope that "things just hadn't come together yet" and "it wasn't the right time." Still not pregnant and nearing a year of marriage, I called one of the NFP organizations. "Give it a little more time," they said, "and if, after a year you're still not pregnant, go and see an NFP specialist."

Traditionally, primary infertility is defined as the inability to conceive after 12 months of noncontraceptive, targeted intercourse. We've come to learn, however, that for couples who are charting (or women over 35) the time frame is 6 months. If you have concerns about your ability to conceive, it's never too early to make an appointment with an NFP doctor.

Several months later, we finally met with one of the best NFP doctors in the country. Just like that, we were caught up in a whirlwind of testing — the spit test I mentioned above, as well as semen analyses and blood tests — and a strict schedule of targeted conjugal relations.

By now, we'd been married almost two years, and Jameson had been laid off. Then, I lost my part-time job; a publisher pulled out of a book contract we were counting on; and my parents lost the family farm. In the meantime, we switched doctors and started learning about the Creighton Model System. While we remain among the small percentage of couples who haven't conceived through Creighton's "NaProTechnology," thanks to our Creighton doctor we discovered that I have hyperprolactemia (elevated levels of prolactin). This condition, however, is also associated with brain tumors. Thus in addition to my already scheduled tests and surgeries — hysterosalpingogram, laparoscopy, transvaginal songrams, to name a few — I also had to have an MRI.

"It's no wonder you don't have kids," people would tell us. "Look at the stress you're under." As if having a good job or a book deal would result in having a baby. Sure, stress is a key factor related to infertility, but other people under stress seem to get pregnant easily. Besides, we'd enjoyed a time in our marriage when our stress levels were low. We'd also given up caffeine and alcohol; lost weight; taken Clomid; taken progesterone shots; targeted our intercourse — the list goes on and on. And still no baby.

Do we feel as if we've been handed a gift, or that any of this makes sense? Often, no. Our infertility makes no sense outside of God's plan for our lives — for us as an infertile couple. For all of us as infertile couples.

Part of the pain of being infertile lies in the struggle to understand how God can give us the desire to have children, and then prevent us from realizing this desire. Or, for those of you suffering from secondary infertility, how God can give you a baby only to take it away again. It's no wonder that, as we wrote in part one of our series, "infertile couples report equivalent levels of anxiety and depression as women with cancer, HIV status or heart disease" and that "the majority of infertile women report that infertility is the most upsetting experience of their lives."

The Gift of Faith
As if to add insult to injury, some time later we discovered that my prolactin levels had receded back to a "healthy level." Still, we were not conceiving. Just in case, our doctor ordered another semen analysis. While previous tests had come back as "essentially normal," the new specimens showed a defect with Jameson's sperm. At least three sperm tests are necessary to get an accurate picture of the health of a man's sperm. Even then, men produce new sperm every three months, so trouble can arise at any time. For us, this time came just as my own problems had apparently disappeared.

Soon after, the day came — a little more than a year ago — when our doctor told us he couldn't do anymore for us. "I have no other means of helping you. I've consulted all the experts. I don't know what to tell you," he whispered. The finality of it all was numbing. After a moment, our doctor continued, "I'm praying through this book. It's changed my life. It's called The Gift of Faith, by Father Tadeusz Dajczer. This is not a book you read. It's a book you pray — one you have to go over little by little because it's so tough."

We didn't read the book right away (as if a book could console our pain). For his part, Jameson felt as if God had tricked him. "God's a jokester," he protested. "Before we got married, I saw my children in my prayers. God's message to me was very clear: He told me I was called to the vocation of marriage and that I'd have kids. He duped me!"

What's God Doing to Us?
Once we finally did read The Gift of Faith, we were inspired by what we found. According to Fr. Dajczer, God often "does just the opposite of what we would expect." In our case, we expected God to give us children because we were being faithful. The fact that God wasn't living up to His part of the bargain proved He couldn't be trusted. Our experience of infertility had thus distorted our image of God, which, as Fr. Dajczer explained, had been preventing our abandonment to Him. How could we abandon ourselves to a God who seemed so unfair? Fr. Dajczer helped us see that what we were most afraid of — was not what God was doing to us — but what he was trying to do with us. What we feared, in other words, was that our infertility might actually be part of God's plan for our lives, a gift from God necessary to the working out of our salvation.

Book in hand, Jameson rounded the corner into our office and declared, "Infertility is a gift." "I thought God was a jokester," I responded. "I do feel that way sometimes," he said, "but let's be serious for a moment. We know we're infertile. That's a fact. So, let's talk about what we're going to do about it now that we've been told there's nothing we can do about it."

Our choice was to give up hope or abandon ourselves to God, trusting Him completely. Sadly, many couples reject God's gift of infertility and turn instead to the world of artificial reproductive technologies. Others abandon themselves to their own suffering, becoming enmeshed in their pain. We wanted neither, so we decided to write, with the hope of understanding what God wanted from us. "You need to give God everything," counsels Fr. Dajczer. "You need to know how to give Him, that which is His; that is the program of our conversion." So it was. We had to give God ourselves — and our infertility.

Not long after, we had coffee with Fr. Mitch Pacwa of EWTN. While discussing our infertility, he told us that it seems as if God is asking infertile couples to do penance for the sins against life committed by others. "It's a sort of divine fasting," he said. "Would I fast if God asked me to?" I wondered. "God isn't a God of imposition — He created us with free will — so why didn't He ask me?" Without realizing it, I answered out loud, "He's trusting you." The choice comes in how we respond to God's offer.

The Gift of Infertility
As the mystery of the gift of our infertility has begun to unfold before us, we have come to see that children are not the only gift of marriage. Infertility, too, is a great and mysterious blessing. Just as much as fertility, infertility is a gift husband and wife can give one another. It is an affirmation that: "I still love you. I love all of you. And I refuse to allow anything to come between this love, whether it be fertility or infertility." Infertility is also a gift couples can give to God and to the world. Like Christ's crucifixion, infertility is a sign of contradiction in a culture in which human life has lost its value.

Instead of giving children to God, infertile families can give their suffering to Him, their unfulfilled longing to conceive a baby. God will use this suffering to glorify His name and bring about the salvation of souls (cf. Jn. 9:1-3). Likewise, infertility is the gift God gives couples for the salvation of their own souls, as well as the souls of any children they might eventually adopt. To reject this gift is to reject the specific means by which God wills to lead us to Heaven.

Of course, this is not to say that infertile couples shouldn't use every licit means they can to conceive a child or bring a baby to term. We also do not mean to imply that every infertile couple is called to adopt. Adoption is not a "cure" for infertility because even after you adopt you remain infertile. Each of us, however, is called to "give everything to God," and to serve Him, even in the weakness of infertility.

Given that children are the "supreme gift of marriage," it might seem strange to think of infertility as a blessing. No doubt, infertility contradicts nature's intention. The gift of infertility, however, is one that transcends the natural order. It is a sign of divinity, of God's power to bring life out of a situation where nature is powerless. In this way, infertile spouses are like empty vessels, vessels that can be filled only by the intangible gift of grace. Even more so than those who can have biological children, the infertile couple is called by God to be a channel of spiritual fecundity (CCC 2379). As such, these couples are a sign to the world that the fullness of life is found in the gift of love, rather than mere physical existence.

This is not to demean in any way the generosity of large families. Although their sacrifices generally go unappreciated, these families are nonetheless a tangible manifestation of love. Part of the pain of infertility, however, is that it is an invisible sign. In our culture, most people assume that if you don't have kids you're contracepting. If you're infertile, they suppose you can easily correct the problem through artificial means. The physical and spiritual suffering caused by infertility is usually hidden. To use an analogy, the generosity of the couple who chooses to have a large family is like a brightly burning sun whose beams produce beautiful flowers that everyone can see and admire. While their love might shine just as brightly, the infertile family has no flowers of its own. Yet, as Fulton Sheen perceives: "There is no sign unless something happens contrary to nature. The brightness of the sun is no sign, but an eclipse is."

Like an eclipse, the sign of infertility is incomprehensible without the gift of faith. It is a sign that is usually missed because it is veiled by disappointment and failure. God, however, is the master of bringing success out of failure and life out of death. If we allow God to reveal Himself in the poverty of our infertility, He will give us a harvest of flowers more beautiful than we could sow on our own. Oftentimes these flowers are not meant for us to keep, but to give to others. For the unwed mother, infertile couples impart the gift of hope. For the couple delaying childbirth, infertile families provide motivation. For the orphan, infertile couples present the chance of new life. Recommends the Church: "Spouses who still suffer from infertility after exhausting legitimate medical procedures should unite themselves with the Lord's Cross, the source of all spiritual fecundity. They can give expression to their generosity by adopting abandoned children or performing demanding services for others" (CCC 2379).

Just as with physical fertility, spiritual fecundity requires the elimination of any barriers of bitterness, resentment and discouragement that might be obstructing your relationship with God. Although it's okay to be angry with God, at some point it's necessary to "forgive" Him. Ultimately this "forgiveness" rests in realizing that God has not committed an offense against us in allowing us to be infertile. The fruit of such forgiveness is trust.

God will forgive you, too, for not trusting Him — whether by using contraception, or in vitro fertilization, or, as is easy to do, letting the desire to have a child become a god in itself.

Forgiveness is the fruit of prayer, which is also a gift of infertility. Without prayer, the heart will never be able to discover, as one anonymous infertile woman puts it, that God is enough to love. Because we can't understand why God doesn't give us what we want, we often go in search of it on our own. By doing so, we risk overlooking the shocking truth that the gift of infertility is God Himself.

Infertility Terms You Need to Know

(Primary) Infertility: The standard medical definition of infertility is the inability to conceive after 12 months of noncontraceptive, targeted intercourse, but for couples who are charting (or women over 35) the time frame is 6 months. The definition should also include mothers unable to carry any pregnancy to term.

Secondary Infertility: The inability to conceive and/or carry a baby to term after doing so at least once before.

Sterility: A permanent condition inhibiting conception.

Zygote: A fertilized egg in the single-cell phase — i.e., an undivided fertilized egg.

Embryo: A fertilized egg that has begun the division process that will result in a fully formed person; used by scientists to refer to a baby until it reaches the fetal stage.

Fetus: Term used by the scientific community to refer to a preborn child 8 weeks or older.

ART (Assisted Reproductive Technologies): Any procedure in which both eggs and semen are extracted from a woman and a man and manipulated with the intention of producing a baby.

IVF (In Vitro Fertilization): From the Latin, "in glass," the fertilization of an egg with a sperm in an artificial environment, namely a petri dish, and the subsequent implantation of the embryo in the uterus.

AIH (Homologous Artificial Insemination): Injection of a husband's processed semen into his wife's genital tract.

AID (Heterologous Artificial Insemination): Injection of a donor's (not the husband) processed semen into a married woman's genital tract.

IUI (Intrauterine Insemination): Technique by which processed sperm are injected into the uterus with a catheter.

Multifetal Pregnancy Reduction: A euphemism used to describe the abortion of one or more children (at 8 to 12 weeks) sharing the same womb. Unlike most abortions, the dead baby's body is resorbed by the mother's body.

Embryo Cryopreservation: The freezing of leftover embryos produced via IVF.

Assisted Hatching: An IVF technique of micromanipulation that uses an acidic solution to dissolve the shell around a 2- to 3-day-old embryo to improve chances of implantation.

ICSI (Intracytoplasmic Sperm Injection): A technique by which a single sperm is injected in vitro into an extracted egg; used in cases of acute male infertility.

GIFT (Gamete Intrafallopian Transfer): An ART procedure in which multiple eggs and processed semen are placed into a catheter and then injected into the fallopian tubes so that fertilization may occur.

ZIFT (Zygote Intrafallopian Transfer): An ART procedure in which multiple eggs are actually fertilized in the laboratory with processed semen; the resulting zygotes are then injected into the fallopian tubes. Also known as PROST, pronuclear stage transfer.

TOTS (Tubal Ovum Transfer with Sperm): An ART procedure in which semen is collected from a perforated condom (rather than masturbation) and placed with one or more eggs into a tube where they are kept separate from one another by an air bubble. The semen and eggs are then injected into the fallopian tubes. This technique is rarely performed anymore.

Where to Turn for Help

Natural Family Planning Techniques

The Creighton Model System (NaProTechnology)

Pope Paul VI Institute for the Study of Human Reproduction

Phone: (402) 390-6600

Email: popepaul@popepaulvi.com

Web: http://www.naprotechnology.com/; http://www.popepaulvi.com/

The Couple to Couple League International, Inc. (Sympto-Thermal Method)

Phone: (513) 471-2000 or (800) 745-8252

Web: http://www.ccli.org/

Billings Ovulation Method Association (BOMA-USA)

Phone: (651) 699-8139

Email: info@boma-usa.org

Web: http://www.boma-usa.org/

Locate an NFP Center or Teacher Near You

One More Soul

Phone: (800) 307-7685

Email: omsoul@omsoul.com

Web: http://www.omsoul.com/

Further Reading

The Bible and Birth Control, Charles D. Provan

Donum Vitae, Congregation for the Doctrine of the Faith

Empty Womb, Aching Heart, Marlo Schalesky (While some couples profiled in this book have used artificial technologies, reading their personal struggles with infertility might prove helpful.)

Fertility Cycles and Nutrition, Marilyn M. Shannon

Full of Grace: Women and the Abundant Life, Johnnette S. Benkovic

Humanae Vitae, Pope Paul VI

Ethical Answers to Infertility 4

The Gift of Infertility Part 3

Dr. Jameson and Jennifer Taylor

Catholic Exchange
August 12, 2007

While natural family planning (NFP) is not always effective for couples (like us) who are trying to conceive naturally (see part one of this series), the Church has good reasons for its teaching on human sexuality (see part two and our "Response to Readers"). Nevertheless, many couples believe they can use intrauterine insemination (IUI) and in vitro fertilization (IVF) without violating their consciences or their faith, because, after all, such techniques create life, not destroy it.

Flirting with Danger
Proponents of artificial reproductive technologies (ART) often argue that IUI and IVF are actually "pro-life." The thinking behind this assertion is that every endeavor aimed at bringing forth new life promotes the dignity of life. Of course, all orthodox Christians, both Catholic and Protestant, agree life begins at conception. For this reason, Dr. Dobson recommends that couples using IVF fertilize and insert only as many eggs as they are willing to keep, and no more than three. "To fertilize and implant more than three," reckons Dobson, "would unacceptably increase the risk of pregnancies of quadruplets or more, pregnancies which carry high risk for both mother and babies."

These dangers are significant. According to the CDC, even twins, who comprise 30 percent of ART births, "are still at substantially greater risk for illness and death than singletons." Dr. Eric Surrey, president of the Society for Assisted Reproductive Technology, cautions: "Twin pregnancies are at a three- to five-fold greater risk for pregnancy complications and perinatal mortality compared to carrying one fetus. With triplets, there is at least a seven-fold greater risk." Low-birth weights and neurological diseases, such as cerebral palsy, are also far more common in twins and other multiple-infant births. In addition, women using ART, especially when combined with drugs that cause ovarian hyperstimulation, are putting their "health and lives in jeopardy," warn Drs. Marie Anderson and John Bruchalski. "Since there is no regulatory agency to oversee the industry, women are treated as research subjects, given drugs that pose an unknown risk."

While pro-life Christians who resort to IUI or IVF would never consider having an abortion, they should keep in mind that the reproductive technology industry is institutionally dependent upon the destruction of human life. On average, women 35 and younger are impregnated with three to five embryos per cycle. Most IVF specialists discourage couples from transferring just one embryo, but approximately 66 percent of all ART births are singletons. At the same time, the overall live-birth success rate for ART is 29 percent. Hence, well over 70 percent of all embryos created through ART do not survive. Thousands more children that reach the fetal stage are killed via selective or "multifetal pregnancy" reduction, a euphemism used to refer to a first trimester abortion. Although the CDC does not disclose the exact number of multifetal reductions each year, the number of multifetal pregnancies accounting for miscarriages and induced abortions exceeds the number of multiple births by approximately 10 percent. A 1993 study found that 31 percent of multifetal pregnancies ended with miscarriage while 27 percent ended with selective reduction.

With experts complaining about an "epidemic of multiple births," physicians feel pressure to keep their multibirth rate low. As reported by the San Francisco Chronicle, "The creation and destruction of human embryos is part and parcel of modern infertility treatments, reflecting both the inherent inefficiency of human reproduction and efforts by fertility clinics to keep costs down and success rates as high as possible" (Aug. 20, 2001, A-1).

It is estimated that as many as one million embryos have been destroyed since IVF was introduced in the United States in 1981. Over 500 embryos alone lost their lives to produce the first "test tube baby," Louise Brown, in 1978. Currently, more than 400,000 embryos are frozen.

Even if a couple follows Dr. Dobson's advice and transfers only as many embryos as they are willing to carry to term, they are still unintentionally cooperating with the murder of nascent human life. To begin with, these couples are benefiting from technologies that would not exist without embryonic research, research many of these same couples oppose. Additionally, they are lending financial and social support to a system that dishonors life by encouraging such practices as selective reduction (i.e., abortion), cryopreservation and genetic selection. Finally, couples who use ART tacitly buy into the abortion-driven myth that life begins upon implantation, rather than conception. After all, no one sends out pregnancy announcements when their baby is still "in vitro." Yet the debate over when life begins — at conception or implantation — is one of the great divides that separate the culture of life from the culture of death.

I've Got the Power
Ironically, many of the couples using IUI and IVF in their late twenties and mid-thirties were contracepting earlier in their marriage. This is because IUI and IVF are the logical counterparts of the contraceptive mentality, whose fundamental tenet is that women enjoy total control over their fertility. The following comment from one infertile woman perfectly epitomizes this view: "I'm not a control freak, but it's one area of my life that I thought I'd always have control over. You know, I was on the pill for five years before we started trying to have a baby. ... Five years I thought I was in control of my fertility. When I didn't get pregnant, it came as quite a shock" (Handbook of Families & Health, SAGE Publications, 103).

Predictably, the Catholic Church is criticized from both sides: When it's convenient, couples tell the Church that they should be allowed to contracept; when they change their mind, they tell the Church that she should permit them to use IUI and IVF. Either way, the Church is accused of being archaic and narrow. Rather, it is the view that separates the procreative and unitive aspects of marital intercourse that is truly "narrow." Such a view reduces the sexual act to being either primarily for the sake of unity or primarily for the sake of reproduction. The Church alone, in her wisdom, refuses to divide the two.

The Church refuses to divide what God has joined because she does not have the power to do so (cf. Mt. 19:6). The possession of such power would enable man to become like God (cf. Gn. 3:5). In fact, this premise underlies the scientific revolution, which promises man total control over nature, even human nature and human sexuality. Some might argue that the power science gives man comes from God, but not every thing invented by man is for his own good. This does not mean that technology cannot be used to assist the reproductive process, but that such assistance must never be divorced from the recognition that all life is a gift.

In accepting the gift of life, man agrees to respect the means by which life should be transmitted. A man who gave his wife a diamond ring, for instance, would be horrified if she used it as a drill bit. Likewise, a gift should not be opened before its time; rather the gift-giver chooses when and how to give the gift. As Donum Vitae reminds us: "The child is not an object to which one has a right, nor can he be considered as an object of ownership: rather, a child is a gift, 'the supreme gift' and the most gratuitous gift of marriage" (II, 8).

If children are "the supreme gift of marriage," how are couples to understand their infertility as a gift? The fourth and final part of this series will discuss the heart of the mystery of infertility and provide additional resources for those who want more information.

Ethical Answers to Infertility 3

The Gift of Infertility … A Response to Readers

Dr. Jameson Taylor and Jennifer Taylor

Catholic Exchange
August 5, 2007

Before we turn to part three of our series, we want to respond to readers' questions concerning whether the Church has formally condemned the use of intrauterine insemination (IUI). In addition to asking about the Church's teaching on IUI, several people have wondered how we can possibly refer to infertility as a gift. Part four will discuss this issue in more detail. In the meantime, we speak to this question in the comments sections of part one and part two.

As pointed out by one reader, Dr. Peter Cataldo has claimed that Catholics are permitted to use IUI or GIFT in cases where a perforated condom has been employed to collect semen from a previous act of conjugal intercourse. Cataldo's opinion derives support from a document that appears on the U.S. bishop's (USCCB) website. This document was written, not by the bishops, but by Dr. Hanna Klaus. Klaus asserts that the following two procedures are "neither approved nor disapproved":

1) Gamete intra-fallopian transfer (GIFT). (The Sacred Congregation for the Doctrine of the Faith has not yet pronounced on the subject.)

2) Intrauterine insemination (IUI) of "licitly obtained" (normal intercourse) but technologically prepared semen sample (washed, etc.).

In light of the historical instruction of the Church that artificial insemination is always wrong, it is difficult to make sense of Dr. Cataldo and Dr. Klaus' interpretations of Church doctrine. What, then, does the Church teach? The U.S. bishops address this question in the fourth edition of the USCCB text Ethical and Religious Directives for Catholic Health Care Services:

[Directive 38]: When the marital act of sexual intercourse is not able to attain its procreative purpose, assistance that does not separate the unitive and procreative ends of the act, and does not substitute for the marital act itself, may be used to help married couples conceive.

[Directive 41]: Homologous artificial fertilization (that is, any technique used to achieve conception using the gametes of the two spouses joined in marriage) is prohibited when it separates procreation from the marital act in its unitive significance (e.g., any technique used to achieve extra-corporeal conception).

These two directives clearly indicate that — at least under the usual conditions — homologous artificial fertilization is prohibited by the Church. Granted, the directives do not specify what other techniques may be used to assist conception. The bishops, though, provide an indication of what they mean in the footnotes that accompany these passages. The first footnote, which cites Donum Vitae, states:

Homologous artificial insemination within marriage cannot be admitted except for those cases in which the technical means is not a substitute for the conjugal act but serves to facilitate and to help so that the act attains its natural purpose (Donum Vitae, Part II, B, no. 6; cf. also Part I, nos. 1, 6).

Likewise, the footnote to Directive 41 states:

Artificial insemination as a substitute for the conjugal act is prohibited by reason of the voluntarily achieved dissociation of the two meanings of the conjugal act. Masturbation, through which the sperm is normally obtained, is another sign of this dissociation: even when it is done for the purpose of procreation, the act remains deprived of its unitive meaning: "It lacks the sexual relationship called for by the moral order, namely, the relationship which realizes 'the full sense of mutual self-giving and human procreation in the context of true love'" (Donum Vitae, Part II, B, no. 6, emphasis added).

To begin with, let us grant that heterologous artificial insemination (AID) — or artificial insemination by donor, instead of husband — is always wrong. The question, then, remains whether IUI, when practiced as a form of homologous artificial insemination (AIH), "separates procreation from the marital act in its unitive significance." If it does, then it is illicit.

In order to answer this question, we need to clarify what Donum Vitae means when it grants that certain "technical means" that do not substitute for the conjugal act may be used to "facilitate" and "help" the sexual act attain its "natural purpose." Instead of delineating here what technical means are licit, however, we will limit our discussion to the question at hand — whether IUI, and related procedures, is permissible.

While Dr. Klaus is correct to emphasize that semen used in IUI cannot be acquired through masturbation, she obscures the real meaning of the Church's teaching by focusing on whether the semen sample has been "licitly obtained" or not. Donum Vitae, though, does not say that masturbation is the only indicator that artificial insemination causes a dissociation of the natural and personal ends of the conjugal act. Masturbation is only "another sign of this dissociation," which is to suggest that the dissociation is not essentially caused by the manner in which the sperm is collected — e.g., through a perforated condom or through masturbation. Rather, the dissociation of which Donum Vitae speaks is a result of the artificial insemination process itself, which (as explained in parts one and two of our article) disrupts the unitive aspect of the conjugal act.

Thus whether or not IUI, GIFT and TOTS (tubal ovum transfer with sperm) are licit depends, not only on how the sperm is collected, but on whether these techniques disrupt or facilitate the unitive aspect of the conjugal act. As we explain in part four of this series, GIFT is a procedure in which multiple eggs and processed semen are placed into a catheter and then injected into the fallopian tubes so that fertilization may occur. Similarly, TOTS is a procedure in which semen is collected from a perforated condom (rather than masturbation) and placed with one or more eggs into a tube where they are kept separate from one another by an air bubble. The semen and eggs are then injected into the fallopian tubes. Technically speaking, GIFT and TOTS are not the same as IUI. This is because neither GIFT nor TOTS entail intrauterine insemination, but rather, intrafallopian insemination. Our article did not specifically address whether GIFT and TOTS are permissible techniques. That being said, Donum Vitae defines artificial insemination as the "transfer into the woman's genital tracts of previously collected sperm" (DV, Part II). According to this definition, IUI, GIFT and TOTS are all forms of artificial insemination.

Following the release of Donum Vitae, then-cardinal Joseph Ratzinger seemed to leave open the possibility that GIFT and TOTS might be licit. Commented Ratzinger: "When the discussion is still open and there is not yet a decision by the magisterium, the doctor is required to stay informed, according to classic theological principles and concrete circumstances."

Understandably, Ratzinger's response led some ethicists to conclude that GIFT and TOTS — but not other forms of artificial insemination — might be permissible. This conclusion requires one to presume that "classic theological principles" allow some forms of artificial insemination. In fact, they do not.

Here, we should recall that artificial insemination is not a new process, but was being used on humans at least as early as the 1930s. Accordingly, Donum Vitae — precisely in the section quoted above that deals with artificial homologous insemination — cites two documents (notes 51-53) issued by Pope Pius XII that explicitly condemn artificial insemination of any kind. The second of these documents, the 1951 Discourse to the Italian Catholic Union of Midwives, is worth quoting at length:

To reduce the common life of husband and wife and the conjugal act to a mere organic function for the transmission of seed would be but to convert the domestic hearth, the family sanctuary, into a biological laboratory. Therefore, in Our allocution of September 29, 1949, to the International Congress of Catholic Doctors, We expressly excluded artificial insemination in marriage. The conjugal act, in its natural structure, is a personal action, a simultaneous and immediate cooperation of husband and wife, which by the very nature of the agents and the propriety of the act, is the expression of the reciprocal gift, which, according to Holy Writ, effects the union 'in one flesh.'

That is much more than the union of two genes, which can be effected even by artificial means, that is, without the natural action of husband and wife. The conjugal act, ordained and desired by nature, is a personal cooperation, to which husband and wife, when contracting marriage, exchange the right.

Pope Pius XII repeated this prohibition in even more forceful terms in a 1960 address to the Seventh Annual Hematological Congress:

The first case mentioned above envisages, as a solution to the husband's sterility, artificial insemination, which evidently presumes a donor, unknown to the couple. We have already had an opportunity to take a stand against this practice in the address delivered to the Fourth International Congress of Catholic Doctors on September 9, 1949. We absolutely condemned insemination between people who are not married to one another, and even between spouses.

We returned to this question on May 19, 1956, in Our address to the World Congress on Fertility and Sterility; We condemned once again all types of artificial insemination, on the ground that this practice is not included among the rights of married couples and because it is contrary to the natural law and Catholic morals. As for artificial insemination between unmarried persons, We declared in 1949 that this practice violates the principle of the natural law that new life may be procreated only in a valid marriage.

Given Pope Pius XII's clear censure of "all types of artificial insemination," Donum Vitae reminds us that "the teaching of the Magisterium on this point has already been stated" (II, 6). Adds the instruction, "This teaching is not just an expression of particular historical circumstances but is based on the Church's doctrine concerning the connection between the conjugal union and procreation and on a consideration of the personal nature of the conjugal act and of human procreation" (II, 6).

The Church's prohibition of "all types of artificial insemination," in other words, is based on "classic theological principles." As if to reinforce this fact, the Catechism's teaching on artificial insemination, published seven years later, is free of the apparent ambiguities arising from Donum Vitae's reference to techniques that might facilitate the conjugal act. States the Catechism:

Techniques involving only the married couple (homologous artificial insemination and fertilization) are perhaps less reprehensible, yet remain morally unacceptable. They dissociate the sexual act from the procreative act: the act which brings the child into existence is no longer an act by which two persons give themselves to one another, but one that "entrusts the life and identity of the embryo into the power of doctors and biologists and establishes the domination of technology over the origin and destiny of the human person. Such a relationship of domination is in itself contrary to the dignity and equality that must be common to parents and children." "Under the moral aspect procreation is deprived of its proper perfection when it is not willed as the fruit of the conjugal act, that is to say, of the specific act of the spouses' union. ...Only respect for the link between the meanings of the conjugal act and respect for the unity of the human being make possible procreation in conformity with the dignity of the person" (2377).

Moreover, several pronouncements by John Paul II explicitly condemn artificial insemination as "morally unacceptable." These include the 1993 encyclical Veritatis splendor and the 2002 address to the bishops of Brazil. Likewise, the Pontifical Council for the Family interprets Donum Vitae as denouncing artificial insemination. Finally, a document written by Dr. Jerôme Lejeune for the Pontifical Academy of Sciences refers to the Church's prohibition of "artificial insemination by syringe."

In light of the Church's past and present statements regarding artificial insemination, it is clear that Donum Vitae does not permit IUI — the most widely practiced form of artificial insemination. Indeed, following the 1987 release of the instruction, numerous ethicists and journalists (and even a cardinal or two) bemoaned the fact that the Church had upheld its condemnation of artificial insemination — even when performed using the husband's sperm.

Thus while it may remain an open question among some Catholic ethicists as to whether procedures like IUI, GIFT and TOTS are morally permissible, the Church's constant teaching on this matter is and has been that all forms of artificial insemination, including IUI, are illicit.

For some couples, the Church's teaching on IUI seems to be insensitive, with the result that it is often said that the Church lacks compassion for infertile couples. As we explain in parts three and four (forthcoming) of this series, however, it is precisely out of Her deep love and respect for the human person — including the infertile couple and the unborn child — that the Church does not permit the use of such techniques.

Ethical Answers to Infertility 2

The Gift of Infertility Part 2

Dr. Jameson and Jennifer Taylor

Catholic Exchange
July 22, 2007

As we saw in part one of this series, couples who have learned to chart effectively have a 76 percent chance of conceiving during their first cycle of use and a 98 percent pregnancy rate by their sixth cycle. Still, even if natural family planning (NFP) does not work for everyone (us included), artificial reproductive technologies (ART), such as intrauterine insemination (IUI) and in vitro fertilization (IVF), are contrary to the Church's teaching on human sexuality. Not only do IUI and IVF frustrate the unitive aspect of lovemaking, they violate the baby's right to be conceived through a person-to-person, body-to-body communion of husband and wife.

Person to (Doctor to) Person
Just as the person is an integration of the physical and the spiritual, every act of lovemaking should be ordered to the physical and spiritual good of each spouse. The physical goods of intercourse — pleasure and reproduction — need little explanation. The spiritual goods — primarily joy and gratitude — are derived from knowing that your spouse accepts and embraces all that you are. In this acceptance, the person is treated as an end in himself rather than a means to an end.

Couples struggling with infertility often experience an intense bond that comes from enduring the crisis of infertility together. Such intimacy, however, is distinct from the personal communion that only occurs in the conjugal act. Perhaps more than others, infertile couples can appreciate the spiritual benefits of lovemaking. When you are infertile, every act of intercourse is pregnant with the hope that God will work a miracle.

By contrast, techniques such as IUI and IVF entail an intentional decision to bypass the unitive aspect of the marital act. The use of these procedures transforms what is supposed to be a spiritual union between two persons into a merely biological process. Unlike intercourse between animals, though, the marital act requires that husband and wife surrender their entire selves to each other and to God.

This total gift of self, from which the spiritual goods of the conjugal act are derived, is inseparable from the act itself. For this reason, techniques such as IUI and IVF cannot bring about the spiritual goods unique to marital intercourse. Donum Vitae (The Gift of Life) explains: "The origin of the human being thus follows from a procreation that is 'linked to the union, not only biological but also spiritual, of the parents, made one by the bond of marriage.' Fertilization achieved outside of the bodies of the couple remains by this very fact deprived of the meanings and the values which are expressed in the language of the body and in the union of human persons" (II, 4).

The "meanings and values" inherent to the conjugal act are uniquely personal. That is to say, man and wife can only give themselves person to person, not person to catheter to person, or person to petri dish to person. By definition, this union is exclusive. Hence, nothing should come between the person-to-person, body-to-body communion of husband and wife. IUI and IVF are not conjugal acts because they are not extrinsically exclusive. The very possibility that these procedures can produce a baby between two people who have never even met one another indicates that IUI and IVF are not exclusive, and hence, not personal. To claim that they are is to redefine the conjugal act, much as homosexuals want to redefine marriage as a union between any two people who subjectively love one another. The wisdom of the Church's instruction is derived from the recognition that the marital act is designed by God to adhere to certain objective standards.

What About the Baby?
Most people believe that intercourse should be something more than a physical process aimed at making a baby — that the baby himself has a right to be created through the loving union of two persons. This intuition, at least, helps to explain why couples who use IUI and other reproductive technologies continue making love even after the procedure in the hope that their child might be the result of a natural conception — a conception achieved without the intervention of a third party. It also permits the couple to believe that their baby is the product of their conjugal love for one another in spite of their use of a procedure aimed at conceiving a child outside of a specific conjugal act. In effect, these couples presume IUI and IVF are personal acts because they occur within the context of ongoing marital relations. But not every sexual act that may occur within marriage — sodomy, for example — is a personal act.

As suggested above, a personal act harmonizes the spiritual and physical welfare of each spouse. This integration is what distinguishes mere reproduction from procreation — creation that seeks to imitate God in his own generosity and fecundity (cf. CCC 2335). In doing so, the couple extends God an invitation to enter into and bless their sexual union in whatever way He desires. This idea, that a child has the right to be created by God through a specific personal act, is especially stressed in Donum Vitae: "Conception in vitro is the result of the technical action which presides over fertilization. ... In homologous IVF and ET [embryo transfer], therefore, even if it is considered in the context of 'de facto' existing sexual relations, the generation of the human person is objectively deprived of its proper perfection: namely, that of being the result and fruit of a conjugal act in which the spouses can become 'cooperators with God for giving life to a new person.' These reasons enable us to understand why the act of conjugal love is ... the only setting worthy of human procreation" (II, 5).

To conceive a child through a technological process that replaces the conjugal act is to subject him to the "standards of control and dominion" inherent to the scientific method (II, 4). As such, the baby becomes an object of micromanipulation, rather than the fruit of a personal union sanctified by God.

Christians who approve of IUI and IVF maintain that these "artificial means merely assist the natural process." The Church, however, teaches that these procedures replace the conjugal act. Clarifies Donum Vitae: "A medical intervention respects the dignity of persons when it seeks to assist the conjugal act either in order to facilitate its performance or in order to enable it to achieve its objective once it has been normally performed" (II, 7). In the case of IUI, IVF, and other techniques, "The medical act is not, as it should be, at the service of conjugal union but rather appropriates to itself the procreative function and thus contradicts the dignity and the inalienable rights of the spouses and of the child to be born" (II, 7).

Divine Grace and Human Nature
What is primarily at issue here are the differing views of human nature held by Catholics and Protestants. Catholic doctrine maintains that grace builds on nature. God — and man's — action in the world must thus respect the natural order, which itself is part of the eternal order. Protestant theology believes nature is something low, something to be overcome by grace. For the Catholic, IUI and IVF are immoral because they replace the natural means by which a child should be conceived and, in so doing, subvert the natural ends of marital sexuality. For the Protestant, these natural means (and ends) are much less important than the good intentions and faithful heart that accompany the use of these techniques. As the authors of Empty Arms put it, "One can use 'unnatural' treatments and still demonstrate trust in God." What is important for the Protestant is the belief that God is working through these procedures, apart from whether or not the procedures are performed according to nature.

United in prayer and hope in God's generosity, couples who use IUI and IVF naturally feel as if their struggle with infertility has brought them closer to each other and to God. Yet these couples, albeit inadvertently, are impeding their union as man and wife by enabling a third party to intervene. The Catechism counsels: "These techniques ... betray the spouses' 'right to become a father and mother only through each other'" (CCC 2376). Some couples intuit this fact by acknowledging that masturbation is embarrassing or that choosing IVF was an extremely difficult decision. Nevertheless, these same people will maintain that they don't feel alienated from each other or God. The case is similar to those who justify their use of contraception by saying: "If God wants us to have a baby, we'll still have one." Yet, as the author of life, God "fearfully and wonderfully" begets each one of us "in secret" (Ps. 139:13-16). According to Scripture, this is His right alone (cf. Eccl. 11:5). Sure, God is acting when a man and a woman conceive a child outside of the natural order, but His hand is being forced. In such cases, God is present only permissively, rather than actively. Every baby, however, has the right to be given as a gift, a blessing bestowed according to the natural means established by God in accord with His perfect timing.

This is not to deny that babies produced through IUI and IVF are just as cute, wonderful and loved as any other children. The joy they bring to their parents is also just as real, if not more intense. This happiness, though, comes at the expense of the babies who have been denied the right to be conceived through a personal act. Needless to say, children created through artificial techniques are persons; they have immortal souls. Once conceived they also have a right to be loved and protected by their parents and society. Still, no one would admit that every act that results in the conception of a child is morally licit. Rape, for instance, may also result in the conception of a child.

Likewise, as we will see in part three of this series, not every act that creates life is "pro-life" — or even promotes the dignity of life.

Dr. Jameson Taylor is the author of America's Drug Deal: Vaccines, Abortion, Corruption (www.americasdrugdeal.com); Jennifer Taylor is a homemaker and a marriage and family therapist. Jameson and Jennifer are in the process of adopting their first baby and are currently writing The Gift of Infertility: A Guide for Catholic Couples Struggling with Infertility.

The Birth Control and Breast Cancer Connection

This is one of the more brief articles on this important issue, that pleads for the consideration of women on both ends of the life-giving spectrum.


The Pill and Breast Cancer Risk Is Anyone Listening?

Timothy P. Collins, M.D.

Ethics and Medics March 2007
Volume 32, Number 3

“An IARC Monographs Working Group has concluded that combined estrogen-progestogen oral contraceptives and combined estrogen- progestogen menopausal therapy are carcinogenic to humans, after a thorough review of the published scientific evidence.” — IARC/WHO

“In a startling turnaround, breast cancer rates in the United States dropped dramatically in 2003, and experts said they believe it is because many women stopped taking hormone pills.” —Marilyn Marchione, Associated Press

Truths converge. The Church teaches a moral truth that contraception is an intrinsically evil act, which can never be justified. This includes, of course, use of the Pill— birth control pills (BCPs). In addition, there is accumulating evidence that use of BCPs is associated with, among other dangers, an increased risk of future breast cancer. As scientific truths cannot conflict with Church teaching, this finding should not come as a surprise.

Risks and Statistics
There are many uncontroverted dangers associated with BCP use, including heart attacks (especially in obese, diabetic, or hypertensive women), blood clots, and their associated life-threatening pulmonary emboli. Less lethal, but no less obnoxious side effects include depression, headaches, and nausea. There are also some cancers associated with BCP use: liver cancer—specifically, hepatocellular carcinoma— is mentioned in standard medical textbooks. Although not terribly common, neither is it rare; the National Cancer Institute (NCI) estimates that approximately fiftythree hundred U.S. women died in 2006 of hepatocellular carcinoma. For comparison, cervical cancer, whose risk is also increased by BCP use, claimed the lives of an estimated thirty-seven hundred women in the same year.

But it is breast cancer which concerns us here. Breast cancer is the second most common form of malignancy diagnosed in U.S. women, the most common being skin cancer. For 2006, the NCI estimates over 214 thousand new breast cancer diagnoses, and approximately 41 thousand deaths. If the amount of money poured into breast cancer screening programs is any indication, it is by far the most feared, and politically volatile, of any malignancy.

Lists of breast cancer risk factors can be found in any medical textbook. Genetics plays a role, such as carrying the BRCA gene, as does a significant family history of breast cancer. Like most cancers, the risk of breast cancer increases with age. There is a group of so-called “fibrocystic changes” that breast tissue can undergo, some of which confer significantly increased risk. Finally, there is a whole list of factors related to “excess estrogen exposure,” sometimes called “unopposed estrogen exposure.” These include early onset of menstruation, late menopause, late child-bearing (first child after age thirty), decreasing parity (the fewer babies a woman carries, the greater the risk), estrogen replacement after menopause, and obesity. To understand why excess estrogen exposure is a risk factor for future breast cancer, it is necessary to look at a bit of physiology.

Physiological Background and Pathology
The breast is a modified sweat gland, and its primary purpose is to produce milk. In adolescence, a young woman’s breasts begin to grow under the influence of estrogen (and, to a lesser extent, progesterone), and the numerous ducts and lobules begin to proliferate. These tissues, known as epithelia, are the source of the vast majority of breast cancers. The epithelia proliferate under the estrogenic effect, but it is not until the breast is exposed to the hormonal symphony of the completed first full-term pregnancy (FFTP) that it becomes fully mature, differentiated, and able to produce milk. Prior to the FFTP, the breast is more or less “held” in a proliferative state.

This is important, because highly proliferative tissues are more prone to develop malignancies. Every time a cell divides, it must reproduce a complete new copy of its genetic code. Errors creep in, and the accumulation of these errors—mutations in the cell’s genetic code—underlie the development of most cancers. That is why highly proliferative tissues, such as skin and GI tract epithelia, develop cancers more frequently than tissues like fat and muscle. Thus, “excess estrogen exposure” is a risk factor because it holds the breast epithelium in a proliferative state.

This brings us to the issue of BCPs and breast cancer. BCPs are, of course, various combinations of synthetic estrogens and progestins and, in some instances, progestins only. Thus, it would seem intuitively obvious that a woman who ingests (or has implanted or injected into her body) these exogenous excess estrogens would be putting herself at risk for future breast cancer. In fact, there have been papers published for decades supporting with data a relationship between BCP use and breast cancer, as well as a few papers claiming there is no link.

Publications and Research
Chris Kahlenborn, M.D., published the book Breast Cancer: Its Link to Abortion and the Birth Control Pill in 2000. Fully half of it is devoted to BCPs, breast cancer and, in particular, the conflicts in the data and why they might exist. The author looked at twenty studies performed between 1980 and 1999, and found that eighteen of them showed that a woman who took BCPs prior to her first full-term pregnancy (FFTP) increased her risk of future breast cancer by 40 to 72 percent, depending on the length of time she took the Pill. Further, these cancers appeared earlier, and were more aggressive, than in nonusers. The implantable and injectable forms of hormonal contraception were particularly onerous in their association with breast cancer, especially as these forms tend to be used primarily by adolescent girls and young women prior to their FFTP. The author’s point is to show that (1) most well-designed studies do show an increased risk of future breast cancer with hormonal contraceptive use, and (2) those studies which do not, suffer from significant methodological flaws.

The International Agency for Research on Cancer (IARC) and the World Health Organization (WHO) came to the same conclusion, as evidenced by their 2005 press release. Now, two more major papers have been published, both in 2006. The first is a review article in the January issue of the New England Journal of Medicine titled “Estrogen Carcinogenesis in Breast Cancer.” The authors conclude, “Studies of breast cancer have consistently found an increased risk associated with ... exposure to exogenous estrogen plus progestin through hormone-replacement therapy and the use of oral contraceptives.” Further, the paper states, “The mechanisms of carcinogenesis in the breast caused by estrogen include the metabolism of estrogen to genotoxic, mutagenic metabolites and the stimulation of tissue growth.”

The second major paper was published in the October 2006 Mayo Clinic Proceedings, and its lead author is the same physician who wrote the book cited above. Titled “Oral Contraceptive Use as a Risk Factor for Premenopausal Breast Cancer: A Meta-analysis,” the authors’ conclusion is succinct: “Use of [oral contraceptives] is associated with an increased risk of premenopausal breast cancer, especially with use before FFTP.”

Is Anyone Listening?
One would think that data regarding a link between the most commonly prescribed drugs in the world, and one of the most feared cancers in the world, would receive some attention. It is easy to imagine the uproar that would ensue if we were discussing, say, appetite suppressants and breast cancer. There would be universal condemnation of the drug, rapid withdrawal from the market, massive media coverage, political posturing, and endless class action lawsuits. Yet, since the discussion is about birth control pills, the medical establishment spins the facts (“benefits outweigh the risks”) and the mainstream media is silent. Why? Because, simply, our culture is organized around contraception and its immoral counterpart, abortion. Justice Sandra Day O’Connor recognized this connection fifteen years ago when she said, “For two decades … people have organized intimate relationships and made choices … in reliance on the availability of abortion in the event that contraception should fail.” Taking away BCPs would be like taking away air.

The Catholic Church teaches a moral truth: contraception is evil. Scientific data teach a secular truth: hormonal contraception is dangerous. Truths converge, they do not contradict. Why should this be a surprise? Perhaps we will open our ears, and listen.

Timothy P. Collins, M.D.
Surgical and Clinical Pathologist
Naval Medical Center Portsmouth
Portsmouth, Virginia

Ethical Answers to Infertility

Here is the first in the series of articles to come on the issue of Catholic infertility. You can see previous notes on the subject here.

The Gift of Infertility, Part 1

Dr. Jameson and Jenifer Taylor

Catholic Exchange
July 15, 2007

Having struggled with infertility for nearly six years, we know the pain of not being able to have a baby. We're also familiar with the awkward silences — and tears — that often accompany conversations with those who have never experienced infertility. On the one hand, people tend to believe fertility is something we have perfect control over. "Just relax," we've been told. "When you settle down, I'm sure it will happen." Or, "Maybe you're just not ready yet," as if "buying a house" or "getting a better job" would make us pregnant. On the other hand, it's a mystery why so many couples like us aren't blessed with biological children. If, as Scripture tells us, "children are a gift from the Lord" (Ps. 127:3), how should couples understand their infertility? What hope is there for couples who desperately desire children, but also want to remain faithful to the Church's guidance regarding artificial reproductive technologies?

According to the Centers for Disease Control, infertility is a condition that affects 2.1 million married couples (1 in 8 of childbearing age) and 6.1 million women, aged 15 to 44. Male factor infertility accounts for 30 percent to 40 percent of all cases. These rates are increasing as more couples delay marriage and childbirth to pursue careers and educational opportunities.

But did you know that according to Harvard researcher Alice Domar, "Infertile women report equivalent levels of anxiety and depression as women with cancer, HIV status or heart disease"? Adds Domar: "The majority of infertile women report that infertility is the most upsetting experience of their lives." Such heartbreak might help explain why so many hurting couples are tempted to pursue morally questionable remedies for infertility.

Fortunately, though, most couples can conceive using natural techniques that accord with the Church's wisdom on marital sexuality. Counsels Dr. Domar: "Very few people have physical conditions that make it impossible to have a child, and in many cases simple lifestyle changes and low-tech strategies can make a decisive difference. ... Many couples can be helped by our greater knowledge of how lifestyle factors like stress, exercise, and nutrition affect conception, of better ways to regulate and target ovulation cycles, and of common medicines to avoid that can inhibit sperm and egg production." Dr. Paul Dmowski, a leading infertility specialist, estimates that "only 8-10 percent of couples in treatment need high-tech ... procedures," such as in vitro fertilization (IVF). Concludes Domar: "So much attention in the media is focused on the latest high-tech intervention that many people forget to give nature enough of a chance."

Domar's observations allude to a popular prejudice in our culture that nature and science are at odds with one another. Natural, scientifically based alternatives are thus thought to be inferior to their high-tech counterparts. In reality, scientific technologies that work in accord with nature have proven very effective in treating infertility. The Creighton System's NaProTechnology program, for instance, boasts an overall pregnancy rate of up to 50 percent for patients of all ages and diagnoses — with rates as high as 80 percent for many couples. These figures are nearly two to three times higher than results from the leading artificial technologies.

Techniques like those taught by the Pope Paul VI Institute, Couple to Couple League, and the Billings Ovulation Method Association differ from artificial technologies in that they cooperate with nature by equipping couples to listen to what their bodies are saying. For a woman, these messages can usually be discerned by charting monthly cycles and mucus patterns. According to the Pope Paul VI Institute, couples who have learned to chart effectively have a 76 percent chance of conceiving during their first cycle of use and a 98 percent pregnancy rate by their sixth cycle. Yet, because many couples assume they'll get pregnant right away, they rarely take time to explore how their fertility works. "Even sophisticated couples," relates Dr. Domar, "may not be clear about when ovulation occurs or how long sperm live."

Diet and nutrition are also crucial to achieving pregnancy. According to John Kippley, cofounder of The Couple to Couple League, "In many cases, cycle irregularities can be either eliminated or alleviated simply by better nutrition or body balance." Many other seemingly insignificant modifications — wearing boxers instead of briefs, eliminating nightlights, taking 500 mg of extended release B6, using iodized salt — can likewise aid in conception.

Shifting Trends
Despite high success rates, some couples (like us) might not be able to have a baby using natural family planning. Lured by promises frequently backed up by a "100 percent money back guarantee," more and more couples, including many Catholic couples, are resorting to artificial insemination (AI) and assisted reproductive technologies (ART) to conceive a baby. The majority of people who employ high-tech treatments turn first to intrauterine insemination (IUI), the most popular form of artificial insemination (a technique by which processed sperm are injected into the uterus with a catheter). If that fails, many couples move on to in vitro fertilization (IVF), by far the most widely used form of ART. In recent years, however, IVF has become so popular that some physicians no longer consider IUI a first-line approach.

Given that very few Christian ethicists approve of donor insemination, or heterologous artificial insemination (AID), we will limit our remarks to the homologous forms of IUI and IVF. By and large, Protestant theologians agree that infertility procedures that are homologous or exclusive, in that they use only the husband's sperm and/or his wife's eggs, are Biblically defensible. Out of her deep respect for the human person, however, the Catholic Church holds that no form of artificial insemination or ART is permissible.

The primary reason the Church opposes IUI and IVF is that these techniques frustrate the unitive aspect of the marital act. As discussed below, the unitive end of marriage encompasses the personal and spiritual good of the spouses themselves. One indication of this breach in unity is that artificial interventions (excepting a tubal ovum transfer with sperm) always require masturbation.

Until quite recently nearly all Protestant theologians disapproved of masturbation. Genesis 38:8-10, in which Onan is struck dead by God for repeatedly practicing coitus interruptus, is the locus classicus for the traditional teaching on masturbation. Commenting on this passage, Luther argued that God punished Onan because he "preferred polluting himself with a most disgraceful sin to raising up offspring for his brother." Continues Luther: "It is far more atrocious than incest or adultery. We call it unchastity, yes a Sodomitic sin." Calvin likewise declared: "The voluntary spilling of semen outside of intercourse between man and woman is a monstrous thing."

Yet most Protestant authorities no longer agree with the traditional elucidation of Genesis 38 and so do not consider masturbation a sin. James Dobson, for one, posits that Onan was killed for failing to do his "duty" to produce offspring for his brother, rather than for spilling his seed. In a similar vein, When Empty Arms Become a Heavy Burden, a "Christian guide to the practical, moral, marital, and spiritual challenges of infertility," acknowledges that while masturbation "can prove disruptive to a relationship with God as well as others, particularly in marriage," providing a semen specimen "on demand" can be a gesture of "respect for God" and love of one's spouse.

Protestant scripture scholar Charles Provan, however, demonstrates in The Bible and Birth Control that Onan was not killed for disobeying his father, Judah, or because he did not honor his brother's memory, or for anything other than spilling his seed. Citing Genesis 2:24, Provan shows that Judah's authority over his son ended when Onan got married. Provan also recalls that the punishment prescribed for failure to "raise up seed for a dead brother" is not death, but merely to have the widow publicly remove her brother-in-law's sandal and spit in his face (Dt. 25:5-10). Additionally, Provan leads us to ask why Onan — and not Adam, Eve, Cain, Jonah and countless others — merited such harsh punishment for his disobedience? Provan's conclusion, based upon a close analysis of Leviticus 20, is that God forbids all forms of intentionally sterile intercourse.

The Narrow Way

Apologists for IUI and IVF often call the Church's view on masturbation narrow, just as they call the Church's definition of conjugal love constrictive. Empty Arms offers this partially misleading analysis of Catholic teaching: "The Vatican, which interprets Scripture for members of the Roman Catholic Church, holds that sex (the unitive) must not be separated from the opportunity to reproduce (the procreative) nor vice versa. ... As a result, the Vatican prohibits birth control, D.I. [donor insemination], and even insemination using the husband's sperm. ... While we agree on the importance of Scripture, we question the specific interpretation that leads to the Vatican's viewpoint. If carried to its extreme conclusion, this view would suggest that no sterile man or woman may have sexual intercourse. It would also prohibit postmenopausal women from sexual relations. For this reason, some have suggested that the Vatican redefine conjugal love in such a way that it encompasses all forms of physical expression in marital love, rather than limiting it to sexual intercourse" (167-168).

Similarly, John and Sylvia Van Regenmorter, authors of a popular text on infertility published by Focus on the Family, contend that "numerous Roman Catholic theologians" disagree with the Church regarding infertility treatments. "Following this reasoning many Roman Catholic couples are convinced they may pursue AIH [homologous artificial insemination] without violating their consciences or their faith."

Granted, some Protestants don't approve of any form of artificial insemination or ART. But lacking doctrinal authority, most discussions about these matters are vague and unsystematic; equivocation is also common. Frequently, couples looking for specific advice are told there is no simple right or wrong answer. That's why it's so great to be Catholic. Regardless of what dissident Catholic theologians claim, the Church offers concrete guidance for couples struggling with infertility. This guidance is grounded in the Church's longstanding teaching on human sexuality. As reaffirmed in Humanae Vitae (Of Human Life): "There is an unbreakable connection between the unitive meaning and the procreative meaning [of the conjugal act], and both are inherent in the conjugal act. This connection was established by God, and man is not permitted to break it through his own volition (12)." These last four words — "through his own volition" — are essential to understanding the Church's position. Contrary to what the authors of Empty Arms say, the Church does not prohibit sterile (impotency is another matter, cf. Can. 1084) or postmenopausal couples from having intercourse. These couples are not choosing to disconnect the procreative and unitive aspects of their lovemaking; rather, they are letting nature take its course while continuing to come together as man and wife in the way nature ordains.

But the main point here is that the unitive aspect of the marital act does not consist merely of sex, as asserted above. Rather, as the Catechism teaches, its end is the "good of the spouses themselves" (CCC 2363). This good is such that it can only come about through the mutual surrender of one spouse to another: a self-donation that must be both personal and exclusive.

Contrary to what many couples may believe, IUI and IVF are neither exclusive nor personal acts. As we shall see in part two of this series, IUI and IVF thus violate both the baby's right to be created through a specific personal act and the mother and father's right to become parents only through each other (CCC 2376).

Dr. Jameson Taylor is the author of America's Drug Deal: Vaccines, Abortion, Corruption (http://www.americasdrugdeal.com/); Jennifer Taylor is a homemaker and a marriage and family therapist. Jameson and Jennifer are in the process of adopting their first baby and are currently writing The Gift of Infertility: a guide for Catholic couples struggling with infertility.