Time lapse imaging of embryos – exciting breakthrough or just eugenics by another name?

Various media outlets (including The Times (£), The Telegraph, BBC, The Independent and The Guardian) have published articles reporting on how fertility specialists from Nottingham have developed a radical technique that will ‘dramatically improve’ the chances of IVF couples having a baby.

The original research appears in Reproductive BioMedicine Online.

About one in eight couples have trouble having children through natural conception and around 48,000 women currently undergo IVF treatment each year resulting in about 12,200 IVF births, an overall success rate of 25%.

This failure rate of 75% causes immense emotional upset to affected couples, many of whom have paid between £5,000 and £10,000 for each treatment cycle.

However the new  procedure, which uses ‘time-lapse imaging’ to monitor the health of embryos by taking thousands of digital pictures to identify ones that are developing well, could raise the chance of a live birth to 78%, about three times the national average.

The new technique identifies the ‘best embryos’ to be implanted into the womb based on the time it has taken to develop between two key stages in the early life-cycle of the embryo.

Thousands of time-lapse pictures taken during the first few days of an IVF embryo's life are used to identify the time between the first appearance of the fluid-filled cavity, called the blastula (normally 97 hours), and the full blastocyst (122 hours).

In embryos at high risk of aneuploidy (extra chromosomes) these steps occurred about 6 hours later on average. Aneuploidy is the single biggest cause of IVF failure.

To test the system, the doctors ran the program on time-lapse images of 88 embryos that had been recorded previously for 69 couples at the clinic. Some 61% of the embryos ranked as low risk for abnormal chromosomes led to live births, compared with none of those ranked as high risk.

Around a dozen private and NHS clinics are currently using time-lapse embryo imaging. It costs around £750 in addition to about £3,000 for IVF.

The £750 cost compares favourably with the current cost of £2,500 for Pre-implantation Genetic Screening, an invasive test which removes cells from the early embryo for analysis.

If the new imaging test proves to be effective in larger trials it seems likely that it will be used much more widely.

What is singularly lacking from any media coverage of this research however is any discussion of the ethics.

Not only does it seem to be taken for granted that the improved success rates override any ethical objection. There is simply no ethical objection even considered.

But let’s think about what is actually happening here.

Embryos are being created in a laboratory and those with aneuploidy are being identified and discarded.

Some of these will have the commoner trisomies (three rather than two copies of a particular chromosome) – Down’s syndrome (trisomy 21), Edward’s syndrome (18) and Patau’s syndrome (13) – where affected babies are often born alive.

Some will have other trisomies (like trisomy 15, 16 and 22) and inevitably will either fail to implant or result in miscarriages.

So is it right to implant those embryos more likely to survive and throw away the others?

Well that surely depends on what these tiny organisms actually are.

They are undoubtedly individual human lives, but what status do they have? Are they potential human beings or are they human beings with potential?

Philosophers like Singer, Glover and Harris will tell you that they are alive but non-persons because they do not yet have functioning nervous systems.

But others, who would argue that human life from the time of fertilisation should be shown the utmost respect and afforded protection would say that every living human organism – no matter how young, old or disabled and regardless of its intellectual capacity – is also a human person with rights.

I know what I think, but what do you think and why? They are either persons or not persons. Which is it?

Is this new technique the 'most exciting breakthrough in IVF treatment in 30 years'? Or is it just eugenics by another name?

It makes all the difference in the world.

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IVF for gay couples financed by the tax payer is actually the next logical step

The Telegraph this morning reports that more gay couples and women over the age of 40 are to be given fertility treatment on the NHS, despite claims that the health service cannot afford it (See BBC report here)

According to the Telegraph, under an expansion of NHS-funded fertility treatment, the National Institute for Health and Clinical Excellence (NICE) will recommend that lesbian couples be offered six cycles of artificial insemination and, if that fails, IVF.

There were just over 1,000 cycles of insemination performed for women in same-sex relationships in 2010, resulting in 152 babies. The number of cycles of IVF for this group rose from under 100 in 2009 to 561 in 2010, resulting in 215 babies. Most of these couples however paid for treatment privately, where a cycle of IVF can cost them £8,000.

Given that the NHS is having to find £20 billion of efficiency savings over four years because flat-rate budget increases are not enough to cope with increasing demand, this means that local clinical commissioning groups, which make the final decision on fertility provision in hospitals, will be unable to afford the extra treatment without making drastic cuts to other services.

Does it strike you as odd that in a time of economic recession NICE is recommending that our tax money through the National Health Service, pays for a lesbian woman, who is suffering from no illness, is not infertile and wants to become pregnant but does not wish to have sex with a man, to have artificial insemination or IVF?

This latest move has, perhaps understandably, generated a lot of controversy, but in fact is the next logical step following from presuppositions that we have already accepted as a society.

Having turned our backs on the Judeo-Christian worldview and ethical framework, decisions in healthcare are increasingly now taking place in an ethical vacuum where the principle drivers are autonomy, technology, commerce and relativism.

Autonomy says ‘we want it’. Technology says ‘we can do it’. Commerce says ‘there are purchasers and providers’ and relativism says ‘why not?’

The Human Fertilisation and Embryology Act 1990 started from two ethical presuppositions.

First there was the assumption that human embryos are not human beings and so can be used as a means to an end – meaning that they can be experimented upon, frozen or destroyed.

Second was the belief that gametes (egg and sperm) need not be used only within the marriage bond but can be bought, sold, shared with and given to others.

If we combine these ethical starting points with the beliefs that marriage, gender and reproduction are simply arbitrary social constructs which can be reshaped and redefined by social consensus then human demand, economics and technology become the only limitations on what can be done in human reproduction.

Equality law will then ensure that everyone who wants a given technology, regardless of marital status, gender or even degree of infertility, must be treated equally.

If married women whose husbands are infertile can use donated sperm then why can’t single women or lesbians? If married women who can’t produce their own eggs (for whatever reason) can used donated eggs then why can’t single women or lesbians? Similarly why can’t gay men use both donated eggs and a surrogate to carry the baby? 

And if lesbian women, who are fertile, choose to use donated eggs and IVF, then what is to stop single and married women, who wish to avoid either sex or pregnancy from dong the same? And if married couples can have a certain ‘treatment’ funded by the taxpayer, isn’t it discriminatory to bar others, whether gay or straight?

As technology develops further, and egg and sperm can be artificially manufactured from ordinary body cells, it will be possible for lesbian couples to generate their own sperm and eggs and produce babies that are genetically related to their parents. And gay couples will be able to do the same with the help of a surrogate, or perhaps even transplanted, uterus. We should expect these extensions of practice now and not be surprised when they occur.

If these things alarm us, then rather than simply reacting to the latest developments we should be going back to examine the set of presuppositions that brought us to this point and examining those.

In this connection I have previously put forward a Christian framework for infertility treatment which I believe respects both the sanctity of human life and the integrity of the marriage bond.

But the other real questions we should be asking are about the real drivers of this new technology. 

Why are levels of infertility increasing so dramatically and why there are so few babies available to adopt? It's not rocket science.

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Three parent embryos for mitochondrial disease – more media hype than real hope

The BBC reports this morning that a controversial fertility treatment which creates embryos from two women and one man to prevent life-threatening disorders is ethical. Children born through 'three-person IVF' would contain some genetic material from three people.

The UK's Nuffield Council on Bioethics has said the technique could free children from 'very severe and debilitating disorders'.

There are about 50 known mitochondrial diseases, which are passed on in genes coded by mitochondrial (as opposed to nuclear) DNA. They range hugely in severity, but for most there is presently no cure and little other than supportive treatment.

It is therefore understandable that scientists and affected families want research into these two related ‘three-parent embryo’ techniques (pronuclear transfer and maternal spindle transfer) to go ahead. But there are good reasons for caution.

This is not about finding a cure. It is about preventing people with MCD being born. We need first to be clear that these new technologies, even if they are eventually shown to work, will do nothing for the thousands of people already suffering from mitochondrial disease or for those who will be born with it in the future.

There are also already some alternative solutions available for affected couples including adoption and egg donation.

But apart from this I’m left with four big questions.

Will it work? I am sceptical. This technology uses similar ‘nuclear transfer’ techniques to those used in ‘therapeutic cloning’ for embryonic stem cells (which has thus far failed to deliver) and animal-human cytoplasmic hybrids (‘cybrids’). The wild claims made about the therapeutic properties of ‘cybrids’ by the biotechnology industry, research scientists, patient interest groups and science journalists duped parliament into legalising and licensing animal human hybrid research in 2008. Few now will remember Gordon Brown’s empty promises in the Guardian on 18 May that year of ‘cybrids’ offering 'a profound opportunity to save and transform millions of lives' and his commitment to this research as 'an inherently moral endeavour that can save and improve the lives of thousands and over time millions of people'. That measure was supported in a heavily whipped vote as part of the Human Fertilisation and Embryology Bill, now the HFE Act. But ‘cybrids’ are now a farcical footnote in history. They have not worked and investors have voted with their feet. Ironically, it was in that same Act of Parliament, that provision for this new research was also made.

Is it safe? No, each technique involves experimental reproductive cloning techniques and germline genetic engineering, both highly controversial and potentially very dangerous. Cloning by nuclear transfer has so far proved ineffective in humans and unsafe in other mammals with a large number of cloned individuals spontaneously aborting and many others suffering from physical abnormalities or limited lifespans. Also, as the Guardian noted last week, any changes, or unpredicted genetic problems (mutations) will be passed to future generations. In general, the more manipulation needed, the higher the severity and frequency of problems in resulting embryos and fetuses.

Is it ethical? No, there are huge ethical issues. A large number of human eggs will be needed for the research, involving ‘harvesting’ that is both risky and invasive for women donors. How many debt-laden students or desperate infertile women will be exploited and incentivised by being offered money or free IVF treatment in return for their eggs? How many thousands of human embryos will be destroyed? If it ever works, what issues of identity confusion will arise in children with effectively three biological parents? What does preventing those with mitochondrial disease being born say about how we value people already living with the condition? Where will this selection end? Some mitochondrial diseases are much less serious than others. Once we have judged some affected babies not worthy of being conceived, where do we draw the line, and who should draw it?

Is the debate being handled responsibly? No. The research scientists involved have huge financial and research-based vested interests and getting the regulatory changes and research grants to continue and extend their work is dependent on them being able to sell their case to funders, the public and decision-makers. Hence their desire for attention-grabbing media headlines and heart rending (but highly extreme and unusual) human interest stories that are often selective about what facts they present.

It must be tempting for David Cameron, like Gordon Brown before him, in a week when politicians are itching for good news stories, to make promises of ‘miracle cures’ in years to come which no one may remember. But I suspect it is much more about media hype than real hope.

This is being driven as much by prestige for government, research grants for scientists and profits for biotechnology company shareholders as anything else.

Let’s keep a cool head and instead concentrate on finding real treatments and providing better support for affected individuals and their families rather than spending limited health resources on unethical, risky and highly uncertain high tech solutions that will most likely never deliver.

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Egg donation mania – probing beneath the journalistic hype

There are two stories about egg donation in the papers this week.

First is the HFEA’s drive to recruit sperm and egg donors. Apparently it is bringing together a National Donation Strategy Group to look at how to ‘raise awareness’.

The BBC gives an advertorial gloss to the story but the Daily Mail tells us that the payment to women donating their eggs for use in IVF has tripled from £250 to £750 this week and that the extra money on offer is said to have led to a five-fold increase in women approaching clinics to donate their eggs to infertile couples.

Under the change, egg donors will be given free treatment to retrieve the eggs plus a payment of £750 per cycle, no matter how many eggs are collected. Tempting during a recession and the question has to be asked, ‘how many of these women would choose not to take the risk if it were not for the money?’

It is noteworthy that the infertility industry in the United States has now grown to a multi-billion dollar business, its main commodity being human eggs. Young women all over the world are solicited by ads—via college campus bulletin boards, social media, online classifieds—offering up to $100,000 for their ‘donated’ eggs, to ‘help make someone’s dream come true.’

Second is the news that scientists in Edinburgh are intending to seek permission from the HFEA to fertilise eggs grown in a laboratory from stem cells. The tests are understood to be aimed at eventually generating an unlimited supply of human eggs that could assist women to have babies later in life.

Stories like these of course make alluring headlines and journalists reproducing uncritical press releases from those with vested interests seldom ask questions about the deeper ethical issues around egg donation – such as the health dangers of egg harvesting, the huge numbers of human embryos destroyed in the process of refining new techniques and the problem of children with confused identities and parentage as a result.

Even less do they ask the ‘elephant in the room’ question of why there is such a huge demand for donated eggs in the first place, but it is precisely that which I want to shed some light on.

The primary problems driving egg donation are the rising incidence of infertility and the huge decrease in babies available for adoption.

Infertility is the most common reason for women aged 20–45 to see their GP, after pregnancy itself. It is estimated to affect around one in six or one in seven UK couples – approximately 3.5 million people – at some point.

Around 1.5% of all births and 1.8% of all babies born in the UK are the result of IVF and donor insemination and 45,264 women had IVF treatment in 2010. These women had 57,652 cycles of treatment, an increase of 5.9% on the previous year. There were 12,714 babies born in 2009 as a result of IVF treatment using women’s own fresh eggs.

There are of course many different treatments for infertility depending on the cause and only a small percentage of these use donated eggs but there were 1,506 treatment cycles with donated eggs in 2010 - and 593 children were born from donated eggs in 2009.

The latest figures (2009) show that 25.2% of IVF treatments using a woman's own fresh eggs resulted in a live birth but infertility in women is strongly linked to age.

The biggest decrease in fertility begins during the mid thirties. For women who are 35, 95% will get pregnant after three years of having regular unprotected sex. For women who are 38 the equivalent figure is 75%.

The following figures give the average success rate for IVF and ICSI treatment using a woman’s own fresh eggs in the UK in 2009.

•32.3% for women under 35
•27.2% for women aged 35-37
•19.2% for women aged 38-39
•12.7% for women aged 40-42
•5.1% for women aged 43-44
•1.5% for women aged 45+

Add to that the fact that women are delaying childbirth and having babies later and later and we see why there is such a high demand for IVF and donor eggs. In England and Wales, the average age at first birth was around 24 during the 1960s, compared with around 28 in 2009 (see graph of maternal age at birth in 2010).

Along with the increase in infertility there are fewer and fewer babies for adoption for two main reasons – abortion (which kills babies that might otherwise have been adopted) and state support for single parent families (which means that babies that would have previously been given up for adoption now are not).

There is currently only one baby adoption in the UK for every 2,235 abortions.

The new adoption tsar has tried so far unsuccessfully to promote adoption as an alternative to abortion but an in depth examination of UK adoption data reveals the following:

Total adoptions in England and Wales fell steadily from 22,502 in 1974 to 4,725 in 2009. Adoptions involving babies under one year fell from 5,172 in 1974 (23% of all adoptions) to just 91 in 2009 (2%). That is a huge reduction in baby adoption.

During the same period abortions on UK residents rose from 119,123 in 1974 to 203,444 in 2009.

The number of abortions on UK residents in 1968, the first full year after legalisation was 23,991. I can’t find an adoption number for that year but suspect it was considerably higher than 22,000.

There are also now three million children living in a single parent household (23% per cent of all dependent children).

Just over a quarter (26 per cent) of households with dependent children are single parent families, and there are 2 million single parents in Britain today. About half of these had their children outside marriage.

In 1971 just 8 per cent of families with children were single parent families but this had increased to 24 per cent by 1998 and 26 per cent by 2011.

So when you next read about egg donation, before jumping on the bandwagon and trumpeting it as a wonderful advance remember the deeper ethical issues (embryo destruction, health risks of harvesting, confused identities and commercial exploitation) and the societal changes (abortion, delayed childbirth and single parenthood) which have contributed to the demand.

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