he announcement that Supreme Court Justice Anthony Kennedy will retire at the end of the month and President Trump’s nomination of Brett Kavanaugh to take his place has spurred concern over the future of women’s reproductive options. Not only is the legal status of abortion at stake, but the concept of embryos as “persons” could be decided by the next Supreme Court.
Despite the explosion of genetic technology that has revolutionized reproductive medicine over the past decade, I fear that an answer to the question of personhood based on faith rather than science could hinder our ability to improve the chance of having a healthy child.
Louise Brown, the first “test tube baby,” turns 40 this month. Since 1978, more than 8 million babies have been born using in vitro fertilization (IVF) and other assisted reproductive technologies. Couples who never would have conceived due to blocked Fallopian tubes or severely low sperm counts can now have children of their own.
Many of my patients have chosen to use preimplantation genetic testing to avoid severe, often life-threatening inherited conditions in their children. Some of these families have already suffered the loss of an affected child and want to avoid experiencing that heartbreaking situation again by selecting an embryo that does not carry a harmful genetic condition.
The process works like this: After in vitro fertilization, several embryos are grown in the laboratory for five to six days. A few cells are removed from each embryo for genetic analysis, after which the embryos are frozen. The DNA from each embryo is carefully assessed for a variety of genetic disorders. A single genetically normal embryo can then be thawed and returned to the prospective mother’s uterus.
This process is not for everyone as some women may not produce adequate numbers of eggs and embryos to select for an unaffected one; also, some do not have insurance coverage for IVF or cannot afford this costly procedure.
The goal of this process is to achieve a healthy child, which now occurs at a remarkably high rate. For specific genetic disorders, preimplantation genetic testing can reduce the odds of having a child with a lethal disorder from 25 to 50 percent to less than 1 percent.
Medicine’s ability to culture embryos and select healthy ones has improved dramatically in the last few years. A clinical trial that I led several years ago showed that transferring a single genetically tested normal embryo resulted in the same delivery rate as transferring multiple untested embryos. When genetic testing is performed, it is now standard of care to transfer just a single embryo at a time — gone are the days of risky triplet and high-order multiples after IVF. Actual babies, not embryos, are being spared from dying from the complications of genetic diseases and severe prematurity thanks to the increased use of single-embryo transfer afforded by preimplantation genetic testing.
During my training as an obstetrician/gynecologist specializing in reproductive endocrinology, I was incredibly optimistic about the future of this field. There was no doubt that we would continue to make IVF safer and more effective, helping more and more people have healthy children, one baby at a time. What could be more “pro” life than that?
But as I’ve watched what has played out in politics and society over the last few years, I’ve grown concerned about the future of reproductive medicine, and worry that doctors and prospective parents will no longer be able to improve this field and select healthy embryos.
Some disorders that individuals carry, like premutations in the long arm of the X chromosome that can cause fragile X mental retardation, do not always cause problems in their children. But the size of the premutation can increase with each ensuing generation, eventually leading to the full fragile X mutation. Children with fragile X can develop severe mental delays, autism, seizures, and other neuro-cognitive disabilities.
I used to counsel patients that by the time their (hopefully healthy) children were ready to have their own children (my patients’ grandchildren), our reproductive technologies would surely be even more precise and safer. Now I feel obliged to counsel them that there is a chance that these technologies won’t be permitted in the future if embryos are considered to be persons and that their children might not have the option to avoid passing down a severe disease trait. Should they do preimplantation genetic testing now to protect their future grandchildren, or risk a future in which their daughter may not be able to use such testing to have a healthy child?
The status of preimplantation testing of human embryos is a complex ethical and emotional issue. Some people believe that life begins at fertilization and, since every life has inherent value, we should not “play God” by choosing not to implant some embryos. Others recognize that embryos have the potential to create a child but require many more steps, and that most embryos are actually incapable of creating a baby.
I side with Dr. Richard Paulson, the former president of the American Society for Reproductive Medicine, who wrote that there is no scientific basis for the concept that life begins at fertilization. To paraphrase his argument, the egg cell and sperm cell are as alive before fertilization as the embryo that begins to form after it occurs. Melding egg and sperm does not create “new” life. I also believe that selecting a healthy embryo to place back in a woman’s uterus is preferable to possibly terminating an affected pregnancy or suffering the tragic loss of a child due to a lethal disease.
Eleven states have introduced “personhood” bills (none have passed) and more than a dozen court cases have been brought on this issue. The outcome of these cases could significantly limit the ability to practice reproductive medicine techniques such as IVF with preimplantation genetic testing.
If laws or the courts recognize embryos as people, that may restrict how many embryos may be created — if any — or women may be forced to use frozen embryos even after they have completed their desired family. The concept of preimplantation genetic testing itself may be challenged, as some embryos are discarded in the process.
Should my patients seize the opportunity now to avoid transmitting severe disease traits because their own children might not have this option? That and other reproductive issues are likely to be debated by future courts. My fervent hope is that they will be guided by science, not faith.
Eric J. Forman, M.D., is the medical and laboratory director at the Columbia University Fertility Center and assistant professor of obstetrics and gynecology at Columbia Irving University Medical Center.