As we delve into the issues surrounding medical interventions to treat infertility, several moral questions arise — both when having children with one’s own gametes (sperm and eggs) and also when having children with donor gametes. Below, I note the problems and suggest my own responses.
The overall rate of miscarriage in all pregnancies is 75-80 percent, with lower probabilities among younger people without risk factors. Fertility doctors generally aim to implant three embryos in a woman using in vitrofertilization (IVF) in order to increase the chances of at least one embryo implanting in the uterine wall and ultimately becoming a baby. In order to produce more than the usual one egg per menstrual month so that several eggs can be fertilized and implanted at once, doctors will administer hormones to induce the woman to produce as many as eight or ten eggs at a time for use in the first and succeeding attempts at producing a baby. While taking high doses of hormones puts the woman at some increased risk of ovarian and cervical cancers, the risk is not so great as to make IVF unsafe for most women (hundreds of thousands of women have borne IVF babies without contracting these cancers), and it would be too costly (each attempt at IVF costs $12,000 or more) and unlikely to succeed if only the one egg the woman produces in a given month were used in IVF. If the couple succeeds in having a baby during the first IVF attempt, the remaining embryos will be frozen at about the fifth or sixth day of development for later attempts to have other children.
When doing IVF, the standard practice is to implant three embryos in the woman’s uterus — even though one, and perhaps two, will need to be “deselected” (aborted) during the pregnancy. This “deselection” is performed to reduce the risks of carrying twins or triplets for the mother and to enhance the chances of having healthy children. Such abortions are permissible and, especially if triplets implant, mandatory to preserve the health, and possibly the life, of the mother. This takes precedence over the commandment to propagate, however much the couple wants to have children. In deciding whether to deselect one or more embryos or not, the doctor must determine the level of risk involved in carrying multiple embryos to term for the particular woman involved, taking into consideration the many factors that define her state of physical health and her ability to carry more than one embryo safely. If one or more embryos are to be aborted, the selection of which embryos to abort should be random unless there is some clear indication that one or two of the embryos are less likely to survive. To avoid the necessity to deselect, some Orthodox rabbis oppose IVF altogether, but most permit both IVF and the deselection process that is sometimes necessary to preserve the woman’s life or health.
During the course of IVF treatments, some couples create multiple embryos that they ultimately choose not to use, either because they have already had as many children as they want or they have given up bearing children biologically. What should they do with their remaining embryos? Because embryos are frozen at about five or six days of development, and because within the first 40 days of gestation, embryos have the legal status of “simply liquid,” according to the Talmud (B. Yevamot 69b), the remaining embryos may be discarded. The embryos may also be donated to science for embryonic stem cell research. If a couple can produce viable gametes but the woman cannot carry a baby to term, Jewish law would allow the couple to use a gestational surrogate — but only if permitted by civil law in the jurisdiction in which the implantation and birth take place. In this last option, both couples should be counseled to ensure that they both understand and agree to the boundaries of how they will each interact with the child.
All Jews — of both Ashkenazic and Sephardic backgrounds — should be screened (through blood tests) to determine if they are carriers of the genetic diseases that affect Jews more commonly than the general population. From my family’s personal experience, they should also be tested for Fragile X syndrome, a very common genetic disease that produces both physical and mental deficits, but not one more common among Jews than among the general population. If one or both members of the couple test positive, they may and should use preimplantation genetic diagnosis (PGD), in which only embryos that lack the problematic gene are implanted in the woman. This will add some cost to the IVF procedure, but far less cost — both financially and emotionally — than bearing and then raising a child with these diseases. PGD should only be used to deselect embryos with lethal or debilitating diseases; it should not be used for gender selection or in an attempt to create “the designer child.”
Using donor sperm or eggs is permissible, but this entails a number of legal and psychological issues that couples should consider before using donated gametes. Legally, one must clarify that the donor will not have parental rights or responsibilities for any children produced. In Jewish law, the child is Jewish if born to a Jewish woman, no matter the source of the gametes, but must be converted if born to a non-Jewish surrogate, even if the gametes come from Jews. (Some Orthodox rabbis rule otherwise.) Furthermore, the family status of kohen or levi is determined by the source of the sperm used, so that can produce uncomfortable situations for men who are either a kohen or a levi, but whose son is not. Psychological issues can also arise in situations in which one member of a couple can produce viable gametes but the other cannot, and so a donor is used. In such situations, psychological counseling can help the member of the couple whose gametes were not used to accept the child fully as his or her own — even in the heat of anger (“That’s your child, not mine!”). More generally, in the use of donor gametes as in adoption, the parents raising the child will need to learn the various ways in which the biological parents have had a role in creating the child that will influence the child throughout life.
Similarly, donating one’s sperm or eggs is permissible, but that, too, requires consideration of many issues. Even if it is clear that donors have no rights or responsibilities vis-à-vis the child (and that is not always the case), they should be given to understand that their gametes have been used to produce a child, and that sometimes such children will later seek them out to learn more about their identity.
I want to point out that adoption is an honored option in our tradition. Even so, like all of the options infertile couples have, it has its challenges. Even with these challenges, it is important to know that the Talmud says that those who take children into their home and raise them are “as if they have given birth to them” (B. Megillah 13a), and they are among the few who can fulfill the injunction in Psalms106:3 to “act justly and do right at all times.” (B. Ketubbot 50a) Children of any race or age should be so considered.
Infertility has been a challenge since the time of our biblical patriarchs and matriarchs. Despite the problems associated with the technologies of enabling infertile couples to produce children, we are blessed to have these new methods and even more blessed to have the children they produce.
1 For example, see Sh’ma column
on the ethics of parenting adopted children March 2014