Does IVF increase risk of abnormal children?

Various opinions have recently been aired about human assisted fertility and embryonal stem cell research by various contributors, including doctors, social workers and clergymen. One of the points of contention has been whether or not some of the techniques of assisted fertility (IVF) are associated with significantly increased risk of abnormal children. Experts in this area seemed to disagree about this claimed increased risk.

Furthermore, some leading local pharmacies sell Family Doctor Series booklets, published by the British Medical Association, detailing common ailments, and one such booklet covers infertility. This booklet explains the main types of assisted fertility procedures, but does not mention this claimed increased risk of abnormal offspring.

Perhaps our social workers and medical experts, claiming a significantly increased risk of abnormal children with IVF, should put right the authors of this BMA publication. What I also find a little contradictory is that the local experts apparently advising against IVF on the grounds of this claimed increased risk of abnormal offspring, have not advocated that people with a family history of, say, diabetes type 2 should not have children, this diabetes being one of the commonest partly inherited abnormalities with significant morbidity and mortality consequences in people of Maltese descent.

A more ethically fundamental point of discussion has been, "when exactly is a human embryo a person with a soul", and not just a small lump of undifferentiated cells? We Catholics have been brought up with some religious "certainties" which most of us are not inclined to question. Our Church (or many senior clergy representing it) has, especially in recent years, stressed that ensoulment and the human person start immediately on fertilisation of the egg.

The concept of ensoulment is not peculiar to Christianity, dating back to the Ancient Greeks and Egyptians, and possibly even earlier. In a recent issue of The Lancet (Vol. 365, March 5, 2005, pp. 837-838), this matter is debated in a form of book review, claiming that Augustine argued in the fifth century that homicide applied only to killing a formed fetus, one of 40 days gestation.

The medical feature continues that the Justinian code of the sixth century confirmed that foetuses under 40 days did not have souls, but that in 1588 Pope Sixtus V rejected this view and promulgated the Papal Bull, Effraenatum, which declared that abortion was murder whatever the stage of foetal development. In 1591, his successor, Gregory IX, rescinded that, but Pius IX reinstated Sixtus V's Bull in 1869. From then on, it is claimed, the current view has prevailed.

This Lancet article also quotes early Jewish law, which considered damaging the foetus to cause abortion (say by kicking the mother) an offence but not homicide. It was only homicide if the mother died as a result. The foetus had no legal status in Jewish law until it appeared from the mother's womb, a wholly different view from the early Christian rules that followed.

I venture to think it unlikely that ensoulment takes place immediately on fertilisation of the egg, because it is estimated that about 70-80% of embryos are spontaneously aborted in the first six-eight weeks of pregnancy because of inherent major foetal constitutional abnormalities and, in most cases, without the mother realising it. I do not understand what purpose ensoulment of these abnormal early embryos would serve. Neither do I understand what purpose ensoulment of, say, an anencephalic (without a properly formed head and brain) foetus would serve, when the prime distinguishing feature of man from animals is his mind and consciousness.

I also fail to understand, when clergymen categorically declare that the human person and ensoulment start immediately at fertilisation of the egg, why the Church does not organise baptism, christening and funeral services for miscarriages and still-births. The caring individual that recently organised the burial procedure (in conjunction with our Pathology department and the Attorney General) for Maltese aborted formed foetuses in a common grave (rather than incineration with other hospital waste), is a St Luke's Hospital health worker and not a clergyman.

The Lancet article concludes: "Our ideas about life, ensoulment, birth, personhood, and the value of the pre-human being are shaped by various religious and philosophical influences. Within faith communities there are differences. What matters is that scientists cannot solve the moral questions, and theologians and philosophers cannot argue without the latest scientific knowledge. The goal of those working in bioethics should be to stop any single view prevailing. There is no absolute truth here. If views have changed for 2,500 years, they will continue to change. A calm watching brief is what is needed, not a shrill condemnation by one interest group of another. So it is time for less certainty from scientists that their research will bring forth human benefit, and a groping, uncertain cross-disciplinary study of philosophy, theology, and science together. That might lead to some conclusions about what can be allowed in our time, not in the future."

A good medical example of changing views over the centuries, is the medieval Anatomy lecture theatre in the medical school in Padua, north-east Italy, one of the oldest schools in Europe. Dissection of human bodies was carried out in this lecture theatre at a time when this was considered a desecration of the human body and therefore a crime.

The dissecting table in the centre of the lecture theatre had a trap-door which, when opened, would drop the body into a canal flowing beneath it (to get rid of the evidence), in case police threatened to burst into the lecture theatre. This is just one small example of the religious and secular opposition the advancement of medical science has had to put up with. Fortunately, the liberal North European countries have had a significant influence in freeing mankind (and particularly women) from various taboos restricting their mental and physical freedom.

Embryonal stem cell research is the other hot topic. I personally welcome the British Parliament's decision to grant a small number of respected British medical researchers a licence to conduct stem cell research on very early human embryos, in an effort to investigate some important diseases whose mechanism we do not presently fully understand. Dolly the sheep, which was not cloned from an embryonal stem cell, seemed to initially develop normally but aged very rapidly, suggesting that not all stem cells have the same potential.

Stem cell research promises to elucidate some of the fundamental mechanisms of life, aging and cancer, the latter being a disease derived from stem cells. The local press recently possibly misreported a London-based cancer specialist as saying that the mechanism of cancer development is now well understood. Unfortunately for all of us, this is not quite so. Our present understanding of how cancer starts and progresses is only the tip of an iceberg.

Finally, another negative view expressed about assisted fertility (IVF) is that it is unnatural. So is injecting someone else's blood into your veins (in fact some religious sects remain adamant that blood transfusion is wicked). Having your belly cut open to remove your inflamed appendix with knives and scissors, to prevent you from dying from natural causes, is also unnatural. So is replacing your kidney or heart with someone else's, because yours have conked up due to natural causes. We could go on and on mentioning all the unnatural treatments modern medicine has contrived to help us live better and longer.

IVF is just another set of medical interventions to deal with a medical problem, infertility. It is estimated that within the next 20 years, the infertility rate may go up to as much as one in three couples, due to women's increasing delay to start a family, increasing female infertility-causing sexually-transmitted infections due to increasing promiscuity, and to increasing female obesity. The rationale and demand for IVF is therefore bound to increase.

Having said all that, the call for local regulation of IVF procedures is, not only justified, but essential. Not only medical, but also laboratory procedures need to be regulated. To highlight the need for regulation, I will recall some details of a local medico-legal non-IVF case. A young woman had gone to have a cervical smear test (a screening test for uterine cervical cancer) to her doctor. She was told it had been reported normal, but was not given a copy of the laboratory report.

A few months later she noticed some unusual bleeding and consulted a gynaecologist who, on examining her, immediately suspected a cervical cancer, admitted her to hospital for biopsy and the cancer was confirmed. Her tumour was unusually aggressive and, in spite of treatment, she died about a year later.

Her husband initiated court and Medical Council proceedings. It was claimed that no laboratory in Malta had received the patient's cervical smear test, while the patient's doctor was adamant that she had carried out the smear test, sent it to a laboratory, had got a "normal" result back, but had lost her copy of this result. Obviously, a laboratory or the doctor had been economic with the truth. The case was never fully elucidated. Furthermore, it needs to be borne in mind that non-medical laboratory personnel are not under scrutiny and risk of censure by the Medical Council.

Professor Cilia-Vincenti is Deputy Dean of the Medical School, Guardamangia