Gary and Jackie came to me following a morning worship service and asked for an appointment.  By the look on their face, it was obvious that they had a serious concern.  I took them aside for a moment and asked if there was anything I could do for them, and though they said we could discuss the details later, they informed me that they were having trouble getting pregnant and were now considering an attempt at in vitro fertilization. 

     I was aware that Gary and Jackie were trying to get pregnant for several years. They had spoken to me about adoption at one point seeking a referral to a reputable Christian agency.  However, their physician had recently explained in vitro fertilization and said that they would be strong candidates for the procedure. Given the doctor’s explanation, the couple suspected that there were some moral implications and they wanted to seek my opinion before proceeding. 

In just a few days, we would meet and they would need to hear what God would say about the option based on His word.  Helping them with their decision would require that they understand the steps involved in the procedure, the risks and probability of success, and the biblical teaching on life and reproduction.

The Issue of Infertility

Medical experts categorize a couple as infertile if they have been trying to get pregnant for at least twelve months.  Based on that definition, there are as many as 2.5 million infertile couples in America .  About 15% of married couples experience infertility, and present figures show that up to 75% of infertile couples have been to a physician or clinic to seek treatment (Albrecht and Schiff 1994, 516).

Couples seeking to get pregnant need first of all to understand that even under the best of circumstances there is a 15% to 20% chance of getting pregnant in a particular month.  Medical experts predict that 85% to 95% of healthy couples should be able to get pregnant after one year.  Therefore, failure to get pregnant in less than one year should not necessarily cause alarm (Albrecht and Schiff 1994, 515).

However, once a couple reaches the one year mark, there are a variety of treatments available to improve their chances of pregnancy.  These treatments include simple, non-invasive methods such as attempting to predict ovulation and planning sexual intercourse during the appropriate time frame.  Men should also realize their role in getting pregnant.  About 30% of all infertility is due to male factors alone. (Albrecht and Schiff 1994, 516).  Thus, men will likely be asked to provide a semen sample for analysis.

If simpler methods and tests do not help, there are more high-tech methods to which couples may resort in an attempt to get pregnant.  These methods include the use of infertility drugs such as Clomid or Perganol to stimulate increased ovulation, artificial insemination (AIH, AID), surrogacy, egg donation, in vitro fertilization (IVF) and its related procedures called GIFT and ZIFT, along with a variety of other treatments.  In all, it is estimated that there are about 38 ways to get pregnant (Mitchell and Buckley, 2).

With advancements in medical technology and increased availability of infertility treatment, a remarkable number of births have come as a result of less than natural means.  In the United States, the total number of births resulting from all forms of assisted reproductive technology (ART) amount to 0.7% of the 3.9 million total births.  Likewise, in the US, the total number of ART procedures increased from 64,725 in 1996 to 81,899 in 1998 (JAMA 2002, 1521). 

The In Vitro Fertilization Procedure

     One of the high-tech options included in the ART count noted above is in vitro fertilization (IVF).  IVF was introduced in 1978, and since that time more than one million babies have been born worldwide using the procedure.   In order to evaluate the ethical implications of such a procedure, one must first understand the steps taken to accomplish a successful IVF.  The medical process is described in Carla Harkness’s book The Infertility Book and Mitchell and Buckley’s pamphlet on “Infertility and the New Reproductive Technologies” (Harkness 1987, 173-177; Mitchell and Buckley, 5-6). 

The first step in the procedure is to give the woman a follicle stimulating hormone (FSH).  Though a woman normally produces one egg (ovum) per month, this medication causes the woman’s ovary to superovulate, that is, produce several follicles each containing an egg ready for fertilization.  The follicles are then removed from the woman and prepared for fertilization.

     The next step is to fertilize the ova by taking sperm from a donor and manually, using microscopic instruments, inserting one sperm into the egg to fertilize it.  In order to increase the probability of success, several eggs are fertilized and allowed to start the process of cell multiplication.  The fertilized eggs, called zygotes, are then observed and some may be discarded if they appear to be less healthy or underdeveloped. 

The healthiest zygotes are retained and prepared to be placed in the female’s uterus.  One or more of the zygotes are placed in the woman’s uterus with the hope that at least one of them will successfully implant in the uterine wall and fully develop.  Keep in mind that if more than one zygote is placed in the uterus, more than one may implant and develop resulting in a multiple pregnancy.  If that happens, the couple may be given the option to reduce the number of embryos by a selective abortion procedure.  This may be done by personal choice or to protect the life of the mother by reducing the possibility of complications related to multiple pregnancies.

Two slight variations on the IVF procedure include GIFT and ZIFT.  GIFT (gamete intrafallopian transfer), is performed just like IVF except that the sperm and unfertilized egg are transferred into a woman’s fallopian tube instead of being fertilized in a dish and introduced directly into the uterus.  GIFT has some advantages over IVF in that it is successful up to 40% of the time, while IVF is successful about 20% of the time (Mitchell and Buckley, 5).  ZIFT (zygote intrafallopian transfer) allows fertilization to take place in a Petri dish and the fertilized embryo is transferred to the fallopian tube.

Other important variations on the IVF procedure include sperm and egg donation and surrogacy.  These options are considered when one or both parties have a substantial infertility problem wherein they cannot produce an adequate sperm or egg or when the female cannot adequately carry a child to term.

Regarding the success rates and risks of IVF, the American Society for Reproductive Medicine reports that the success rate of IVF is 22.8% live births per egg retrieval.  They also note that this success rate is similar to the 20% chance that a healthy, reproductively normal couple has of achieving a pregnancy that results in a live born baby in any given month (ASRM 1996-98).  IVF also increases the chance of multiple pregnancies.  Usually, two to four embryos are transferred with each IVF cycle.  Of all the pregnancies that result from IVF and end in a live birth, about 50% are singletons, 24% are twins and 5% are triplets or more (ASRM 1996-98).  Put another way, about 30% of all IVF deliveries were multiple births, more then ten times the rate in the general population (JAMA 2001, 874).

A Theology of Infertility

Infertility can be a very troubling experience. Couples face a variety of thoughts and emotions related to their inability to conceive.  Men and women are likely to experience feelings of guilt, inadequacy, fear, anger and grief similar to reactions to the death of a loved one (Worthington 1987, 226-228).  Couples and individuals respond differently to the problem, but it is important for family and friends to be sensitive to the struggling couple especially around holidays such as Mother’s Day or during the celebration of the birth of another person’s child.

     An important way for couples to cope with infertility is to see how the scripture speaks to the issue.  First, the Bible tells us the bearing of children is good, and parenthood, when possible, is to be celebrated.  Starting with the story of creation, God has indicated that procreation is a blessing.  In Genesis 1:28, Adam and Eve are given the command to “be fruitful and multiply.”  The Psalmist reminds us that children are a blessing from God when he states: “Behold, children are a heritage from the Lord, the fruit of the womb is His reward.  Like arrows in the hand of a warrior, So are the children of one’s youth.  Happy is the man who has his quiver full of them” (Psalm 127:3-5a, NKJV).  Children even had a special place in the ministry of Jesus (Matt. 18:1-6; Mark 10:13 -16).  Clearly, one of God’s purposes for his created beings was for them to have children. (Mitchell and Buckley, 7-8)

     However, it is equally clear in scripture that the sovereign Lord is the one who opens and shuts the womb (Mitchell and Buckley, 8).  In I Samuel 1:5, we are told that “the Lord had closed [Hannah’s] womb.”  For reasons that are not always clear, God wills many events to take place in our lives that remind us of our frailty and his sovereignty.  While children are a blessing from the Lord, the ability to bear children is subject to the mystery of God’s providence.  Therefore, we must submit all our desires, even the desire of bearing children, to the will of God.  James cautioned us that instead of brazenly following our own wills, we should say, “’If the Lord wills, we shall live and do this or that’” (James 4:15 KJV).

     Even still, God’s plan is always for His glory and, by His grace, in our best interest.  God tells us in Romans 8:28-29 that all things work together for good for His children in order that they might become more Christ-like.  It may not be God’s will for a couple to have children; therefore, such couples should not be treated as second-class citizens.  But trials and disappointments in life can teach believers to pray, as Hannah did, or can lead couples in other directions of blessing such as adoption. 

Trials such as infertility can also expose sinful thinking or behavior.  An infertile couple will almost certainly deal with feelings of jealousy and envy of other couples.  Yet the tenth commandment warns us not to set our desire on things which are not ours. (Douma 1996, 340-341).  Coveting in such a way can lead to sinful behavior.  Just as King David’s desire for Bathsheba led him to pursue immoral means to satisfy his desires, a couple facing infertility can be faced with immoral methods to achieve their desire for a child of their own.  There is nothing inherently evil about desiring a child, but this commandment forbids us to nurse that desire and to develop and implement an immoral plan to satisfy the desire.  Drawing the line between what can morally be done to pursue a child and what is morally wrong in that pursuit takes much discernment and prayer on the part of the troubled couple.  This fact must not be overlooked.

Finally, the scripture leaves an important option open to couples who face the prospect of infertility, specifically, medical intervention.  Rae and Core note, “For the most part, technological interventions that clearly improve the lot of mankind are considered a part of God’s common grace, or his general blessings on creation. The use of medicine to alleviate infertility is parallel to the use of medicine to eliminate other physical effects of the Fall, namely disease” (Rae and Core 1994, 9-10).  Given that many causes of infertility are a result of the Fall, we should not limit couples from pursuing medical intervention in order to increase their chances of pregnancy.  Still at issue, however, is which of the medical procedures are morally permissible and which should be eliminated from consideration?  If a couple is not careful, a desire for children left unchecked for the sin of covetousness can lead them to accept immoral medical steps.  In short, medical treatment is appropriate, but it should focus on treating or correcting the medical condition of the patient and such treatments should stay within the scope of ethical limits.

A Theology of Procreation

     The task of procreation is commanded in scripture.  It is a responsibility given to man and woman as the Lord tells them to “be fruitful and multiply” (Genesis 1:28NASV).  The context of this task is further clarified in Genesis 2:24 as the Lord ordains the marriage covenant and indicates that the husband and wife will become one flesh.

The sanctity of marriage and limitations on sexual expression are prominent biblical themes found in the earliest biblical accounts of Lamech (Gen. 4:19), Abraham (Gen. 16) and Joseph (Gen. 39) and clearly stated in the eighth commandment (Ex. 20:14).  John Murray summarizes the command and its restrictions well when he states:

We discover, therefore, that the exercise of the procreative impulse and compliance with the divine command to be fruitful are not to be given unrestricted and indiscriminate scope.  The institution of procreation is circumscribed.  It is only within the marital bond that a man is to know a woman, and only his wife may he know.  And since the marital bond is monogamous, only with one wife may a man enter into conjugal intercourse (Murray 1957, 46).

Therefore, it is important for us to identify scriptural restrictions on the procreative process in order to determine the boundaries which must be set related to the IVF procedure.

The theme of scripture is that marriage is an exclusive spiritual and physical relationship between husband and wife.  This is the thrust of the seventh commandment and every related story or teaching in scripture.  For this reason Douma, in his discussion on the seventh commandment, eliminates artificial insemination with sperm from a donor (AID) as an appropriate infertility treatment. Even though we cannot speak of physical adultery, we can speak of artificial adultery since the child becomes physically that of another man.  As Douma puts it, AID “really involves a ‘someone’ and not merely a ‘something’ of that someone” (Douma 1996, 253). 

The same issue applies to egg donation or sperm donation to accomplish fertilization in a Petri dish as a part of the IVF procedure.  Though physical adultery does not occur, fertilizing a donated egg or fertilizing an egg with donated sperm constitutes a breach in the marital bond.  The result is a child that is not physically that of the husband and wife.  Though the process of fertilization does not involve physical contact between the contributors of the gametes, the psychological and emotional connection is still a factor and the end result, a child with a parent outside of the marital bond, is still the same.

Not only at issue is the prohibition to commit adultery, but also the injunction that believers live life within the confines of God’s covenants and commands and that we trust God for the results.  The story of Abraham and Hagar is an ancient illustration of this principle.  When Abram and Sarai were unable to conceive a child, Sarai told her husband to take her maid and have a child through her.  Abram and Sarai jumped ahead of God’s plan to provide a child for them.  One consequence of this action which must not be overlooked is the subsequent resentment Sarai had toward Hagar which lasted a lifetime (Gen. 16:4-6).  Thus, issues of procreation are not just physical; they are very emotional, psychological and spiritual.

A Theology of Life

     The most critical question to be answered in evaluating the morality of the IVF process itself is, “When does life begin?”  The sixth commandment clearly commands that we are not to kill another human, but with scientific advances that now allow us to fertilize human eggs in a Petri dish and view the first multiplication of the tiny embryonic cells, the theologian is asked to insightfully tell the scientist when the cells have a soul or at least have the full value of a human being.

     The importance of this issue cannot be understated.  One can argue about a mother’s rights or the fetus’ rights.  He can argue about the social, psychological, political or legal implications of allowing women to terminate a pregnancy.  But the overriding issue is when the cell or group of cells becomes a life.  If agreement were ever reached on this issue, many other arguments would fall by the wayside.

     For the Christian, the answer to this question cannot be found in philosophical discussion, but in the Bible.  And plentiful discussion about abortion has left us with ample material about it.  This discussion will serve as a starting point for evaluating the issues related to IVF.

     The Christian church has always stood firmly against abortion and affirmed the value of a fetus.  Only in the past few decades have Christian ethicists turned from condemning abortion to defending it.  Regarding the early church’s beliefs on abortion, Douma notes that Turtullian, referring to the fetus, considered something in the process of becoming a human being as already a human being.  And prior to Turtullian, Christian authors had branded abortionists as “destroyers of God’s image” (Douma 1996, 218).  Likewise, Calvin, commenting on Exodus 21:22, stated:

...for the foetus, though enclosed in the womb of the mother, is already a human being, (homo), and it is almost a monstrous crime to rob it of the life which it has not yet begun to enjoy.  If it seems more horrible to kill a man in his own house than in a field, because a man’s house is his place of most secure refuge, it ought surely to be deemed more atrocious to destroy a foetus in the womb before it has come to light (Calvin, quoted in Douma 1996, 218).

Thus, the early church and the Reformers as well as the Roman-Catholic Churchcondemned abortion with equal severity.

     The Bible passages commonly referred to in defense of this view are found in Psalm 139 and Job 10:8-12.  These two passages speak of God’s intimate involvement in the development of a fetus and, most importantly, His knowledge of us in the womb before we are born.  Such intimacy presumes that God values the unborn child like He values the person he ultimately becomes.  If God values the unborn child, then we too must value it and thus protect it.

     However, even with these arguments in mind, IVF takes us to a specificity of fetal development that Tertullian, Calvin and other theologians may not have imagined we would go.  With every stage of fetal development from fertilization to birth distinctly defined, we must now move from general statements about the value of a fetus and speak to the value of a gamete, zygote, implanted zygote and so forth. 

     In the IVF procedure there are three specific stages at which one could attempt to make a determination about the start of life in the eyes of God.  The first stage is with the removal of the ovum from the woman’s ovary and the acquisition of sperm from the man.  These two cells each contain half of the genetic information for life and independently cannot produce a living being.  Scripture does not directly state or allude to placing a value on these cells like that of a human, so the destruction of these cells alone would not constitute a violation of the sixth commandment which prohibits killing unlawfully.

     The next stage involves the laboratory assisted fertilization of the egg.  This procedure creates a viable cell which, barring any genetic abnormalities, will begin the process of cell division and lead to a fully developed human being.  This step is clearly one of the major leaps in the procreative process and is most commonly referred to the point of conception.  It is at this stage that many theologians point to as the start of life itself.  Mitchell and Buckley, two Southern Baptist ethicists, draw the line at fertilization by comparing the destruction of a newly fertilized egg with any other kind of elective abortion.  They state:

Since individual human life begins at conception, it is immoral to abort fertilized eggs or embryos.  The overwhelming majority of Southern Baptists and many other evangelical Christians, Catholics, Jews, and Muslims affirm that elective abortion is wrong.  By extension, any new reproductive technology which results in the destruction of fertilized eggs should be avoided. (Mitchell and Buckley, 11).

Such is the standard view of evangelicals on the issue of IVF and when life begins.

     A third stage one may consider as the start of life is when the fertilized egg successfully implants in to the uterine wall of the mother.  Gilbert Meilaender makes the case that we should fix the beginning of individual human life slightly later than conception:

For one thing, the fertilized ovum must successfully implant in the uterus before pregnancy is established, and research seems to indicate that as many as half of fertilized ova may fail to implant successfully.  If any figure even approaching that is accurate, and if an individual life begins at fertilization, we would be forced to conclude that half of the human race dies after a life of four to five days. Although that is logically possible, it is also rather counterintuitive (Meilaender 1996, 30-31).

The issue Meilaender raises highlights the complexity in trying to determine the exact point of life’s beginning when a greater amount of details about the reproductive process is known.  And his point is critical to those considering the IVF procedure.

     As noted above, in the IVF procedure several eggs are retrieved from the mother for fertilization in the Petri dish.  At this point, the technician can fertilize as many eggs as needed, up to the number he was able to retrieve.  Likewise, after the ova are fertilized, technicians can observe the zygotes to see which appear to be more healthy in the early stages of cell reproduction.  Those which appear to be less healthy could be discarded in order to improve the chances of implantation (pregnancy), unless the couple refuses this option and insists that all the fertilized eggs be implanted. 

The couple’s beliefs on the beginnings of life will have an impact on the freedom of the doctors and lab technicians to reduce the number of fertilized eggs to those they consider to be the most viable.  It will also impact their option to give permission for the physicians to fertilize more eggs than the couple is willing to have inserted in the uterus in any one procedure.  Extra embryos could be frozen for possible use in the future by the couple or offered to another couple like an adoption. 

The key in all of this discussion is the determination of when life begins. Since the scripture affirms the value of the fetus, we must recognize that life begins before birth and terminating the development of the fetus would be an unacceptable act.  Though the Bible does not provide scientific detail about the point a life begins, it does affirm that life exists in the womb.  Furthermore, without direct biblical evidence to the contrary, it is most reasonable to assume that life begins at conception since the newly formed embryo has all the genetic information and the biological capacity to develop into a fully functioning human.  The fact that the embryo has not implanted in the uterine wall is incidental, thus we reject the Meilaender’s notion that the embryo is not a life until is has implanted.

Conclusions and Recommendations

     Four issues underlie the decisions which must be made regarding in vitro fertilization: the validity of medical intervention, a determination of when life begins, the implications of God’s plan for marriage and family, and costs for the married couple.  With each of these issues addressed in part in the discussion above, it is time to restate those conclusions and offer our young couple recommendations regarding the IVF procedure.

     First of all, we affirm that medical treatment for infertility is a valid option as long as the treatment is designed to correct or assist the body of the husband or wife with its regular reproductive functions.  The basic purpose of the IVF procedure is to help the wife get pregnant by manually insuring the egg and sperm unite and placing the embryo in the uterus where implantation is able to occur.  Such medical intervention is comparable to assisting one’s immune system by providing a body with antibiotics or assisting one’s heart by replacing a valve.  However, overstepping the bounds of this principle would include providing a surrogate mother for the embryo’s development or providing a sperm or egg from a source outside of the husband and wife.  Both of these options do not involve directly treating the couple’s physical problems that are a result of the Fall.

     Secondly, life begins at conception, or in the case of IVF, at the point the egg and sperm are united in the laboratory setting.  This conclusion has several implications for the couple considering IVF.  First, the couple should limit the number of eggs fertilized to the number they would be willing to implant in the uterus.  They should not allow the technicians to fertilize extra eggs in order to discard embryos they feel are not as healthy.  Likewise, the fertilized eggs should be implanted immediately, that is, the couple should not plan to freeze or donate extra embryos for adoption or research.  That which God considers to be a life should not be held in limbo or given an uncertain future and donating an embryo for research almost always ends in destruction of the embryo.  Furthermore, God did not intend for us to create a life in order that it may be adopted.  The adoption process exists for a living person who has lost his parents through a tragedy. Families are encouraged to consider adoption of a child, but not to create an embryo for implantation into a different mother.

     Thirdly, God’s plan for marriage and family and the scriptural injunctions against adultery strongly imply that the procreative process should be an activity exclusively carried out between a husband and wife.  Once again, but on this separate basis, there should be no donation of an egg or sperm from an outside individual.  Such donation leads to a child that is not an offspring of one of the married couple, which is the same result as if one partner participated in marital infidelity.  On a related matter, couples should also request that when sperm donation by the husband is necessary, the wife be permitted to assist in the retrieval process.  Men are generally instructed to donate their sperm by masturbation.  They may be given pornography for sexual stimulation, but this provides an occasion for lust and it separates the husband and wife from the reproductive process.  It is more natural and consistent with scripture to allow the wife to assist in the retrieval process (Mitchell and Buckley, 12-13).

     Finally, a couple should consider the costs of attempting in vitro fertilization. The financial costs are definitely a factor since researchers calculate the average cost per successful IVF delivery at $66,667 to $114,286 (Neumann, Gharib and Weinstein 1994, 239-243).  But there are also other costs.  As noted previously, only around 20% of IVF procedures result in a child carried to term.  The investments of time and emotional energy can strain a marriage significantly.  Other options should be considered and couples should seek God’s will as they consider this form of medical treatment. 

BIBLIOGRAPHY

Albrecht, Bruce M.D. and Isaac Schiff, M.D., “The Infertile Couple.” The Office Practice of Medicine, 3^rd edition by William T. Branch, M.D., editor. Philadelphia: W. B. Saunders, 1994.

ASRM, American Society of Reproductive Medicine, FACT SHEET: In Vitro Fertilization (IVF), (1996-98); available from http://www.asrm.org/Patients/FactSheets/invitro.html.

Douma, Jochem.  The Ten Commandments: Manual for the Christian Life. Translated by Nelson D. Kloosterman.  Phillipsburg, New Jersey: P & R Publishing, 1996.

Harkness, Carla.  The Infertility Book.  San Francisco: Volcano Press, 1987.

JAMA, The Journal of the American Medical Association, “Use of Assisted Reproductive Technology—United States, 1996 and 1998.” (March 27, 2002): v287, i12, p1521(2).

JAMA, The Journal of the American Medical Association, “Fertility Treatment Statistics.”  (February 21, 2001): v285, i7, p874.

Meilaender, Gilbert.  Bioethics: A Primer for Christians.  Grand Rapids: William B. Eerdmans, 1996.

Mitchell, C. Ben and Don W. Buckley, M.D., Infertility and the New Reproductive Technologies.  Critical Issues.  Nashville, Tennessee: The Christian Life Commission.

Murray, John.  Principles of Conduct: Aspects of Biblical Ethics.  Grand Rapids: William B. Eerdmans, 1957.

Neumann, P. J., S. D. Gharib and M. C. Weinstein, “The Cost of a Successful Delivery with In Vitro Fertilization.”  New England Journal of Medicine 331 (July 28, 1994): 239-243.

Rae, Scott B. and John H. Core, “Reproductive Technologies and the Theology of the Family.” Ethics & Medicine 10 (Spring 1994): 12.

Worthington, Everett L.  Counseling for Unplanned Pregnancy and Infertility.  Waco, Texas: Word Books, 1987.