Technologies of Procreation

Kinship in the Age of Assisted Conception

Jeanette Edwards, Sarah Franklin, Eric Hirsch, Frances Price, Marilyn Strathern

• Publisher: Routledge
• Year: 2005
• Print ISBN: 9780415170567
• eBook ISBN: 9781134698073
• Edition: 2
• Topic: Social Sciences
• Subtopic: Health Care Delivery
• Index: Social Sciences

Technologies of Procreation bridges the gap between medical technology and cultural values. It looks at the ways in which the 'technologies of procreation' affect society from an anthropological perspective.

1
Beyond expectation
Clinical practices and clinical concerns
Frances Price

Previously intractable causes of both female and male infertility can now be circumvented. The escalation of technologies to assist conception in the past decade has been accompanied by an expansion of what the Human Fertilisation and Embryology Act 1990 refers to as ‘treatment services’ to couples, very largely in the private sector of medicine. One commentator has portrayed the developments in this field of medicine as ‘reproduction without sex but with the doctor’ (Brody 1987). Another cautioned, ‘The issues are so new that there isn’t an agreed ethical tradition and so there’s a danger that whatever practices doctors drift into become the norm.’¹ But the doctor who practises in this area of medicine is not the doctor of old.

Infertility clinics offering assisted conception hold out the prospect of a solution for problems which people are willing to pay considerable sums of money to address. Those women and men who seek such ‘treatment services’ by and large become consumers in a competitive market in which a’good enough’ pregnancy rate looms large. But there are crucial differences in the mode of delivery of these services, compared to that in other medical specialties. In ways which have yet to be explored systematically, doctor-patient relationships have been transformed: the classic (textbook) doctor-patient format is compromised. Not only does the focus on ‘the couple’ fundamentally change the one-to-one relationship presumed between doctor and patient, but ‘the doctor’ is ‘partnered’ also. Typically, the clinician (as the medical practitioners specialising in the technique of in vitro fertilisation and embryo transfer [IVF] and its analogues will be called in this chapter) is paired with a scientist (an embryologist). And there is a division of labour between them. The clinician who pioneered IVF, Patrick Steptoe, and the scientist Robert Edwards, published their account of their collaboration in A Matter of Life: The Story of a Medical Breakthrough in 1980 (Edwards and Steptoe 1980).

Working together in teams, then, clinicians and embryologists have developed techniques such as IVF, and analogues such as gamete intrafallopian transfer (GIFT), to provide new clinical services. An array of further options includes the micro-manipulation of gametes and embryos, the use of donor gametes, and the search for ‘host-mother’ or IVF surrogates. This chapter charts some of the expressed concerns of those who are developing and providing treatment services. The context of such developments is briefly outlined.

The politicians and policy-makers who were involved in drafting the legislation which culminated in the Human Fertilisation and Embryology Act 1990 sought scientific legitimacy for their decisions. This thrust the medical and scientific communities working in this field into a new, high-profile and political role. It was expected that they would provide a firm and authoritative input, the expert evidence. Yet the crafting of policy has been and remains a more elusive process than this implies. It turns not only on who is expected to make the decisions but also on what is to count as evidence when decisions are being made. There is social limitation on room for debate. As one sociologist of science has pointed out, the very development and not just the application of scientific knowledge is increasingly tied to policy situations in which incomplete knowledge is pressed into policy use (Wynne 1991).

Despite the passage of the Act, however, recent developments in the field of assisted conception have reaffirmed the crucial role of the clinician in both decision-making and as gatekeeper to the delivery of services. Their decisions gain authority emanating from a medical setting and may prove difficult to challenge (Price 1992). As they seek medical assistance and ‘treatment services’, couples can generally expect that their plans for pregnancy will be greeted as proper and respectable. Nevertheless, such plans may become transformed, and have unforeseen consequences, in a context in which clinicians are encouraged to provide whatever services are deemed to be within the ambit of medical competence. In some licensed centres, egg or embryo donation prior to IVF can now be offered as such a service.

Far more than the facilitation of pregnancy is at issue. The significance of assisted conception extends beyond the prospect of pregnancy, birth and associated clinical risks and uncertainties. Women and men shoulder new kinds of risk and uncertainty concerning their future relationships, particularly if there has been a donation or a multiple pregnancy. I focus on two areas of decision-making: the first is that of multiple embryo/egg transfer in IVF and GIFT procedures; the second is that of egg donation. The chapter draws from interviews with clinicians and embryologists working in the field of IVF undertaken between 1990 and 1991 in the course of a research project which focused on women and men attending infertility clinics (Price 1991).

THE CONTEXT: TIME PASSING, TIMES PAST

Most women who attempt to do so conceive within one year. However, increasing numbers of women are delaying attempts to become pregnant until their thirties. Their chances by then are demonstrably less favourable, as fertility in women is generally acknowledged to decrease with increasing age.² Older women may experience great distress when they confront difficulties with conception:

You realise you’re in your mid-thirties and all these books are around you telling you that your chances of pregnancy are diminished as each year goes by. I hated birthdays. I loathed birthdays. I was coming up to my 39th birthday. Each time you have a birthday, time is churning on. And there is nothing you can do. You just grasp all the time at straws and they just give way.³

Clinicians are well aware of the pressure of time passing on their patients and perceive urgency in the expression of their desire to remedy their situation. One IVF clinician remarked to me⁴ that in his experience infertile women were ‘some of the most impatient patients in the world’. He added that he found his infertility clinic ‘much more stressful’ than his general gynaecological clinic. He elaborated further:

The infertility patient puts you under a lot of pressure. Their attitude—I mean I’ll give you an example. There is one question you ask of all women first, or one of the early questions you ask of her. How old are you? And the woman will look at you and she’ll give you an age. And you write down her date of birth and then you look at it. Before you finish she says, ‘Well I’m 34 on my next birthday.’ Now that is against women’s basic make-up. What do they do? They try to keep their age down. The truthful answer to the question is ‘I’m 33.’ But they always say —they will always add a year on…Now that is an interesting point. And it starts, it is the tone of the whole interview. The tone of the interview being the fact that they are really saying to you, look, you know, I’m losing an egg every month, you know. I’m going to stop one of these days. For goodness sake get on and do something about it.

Between one in seven and one in ten couples in the reproductive population seek help in their efforts to conceive (Hull et al. 1985; Mathieson 1986). Among these couples are those whose inability to conceive remains unexplained after all the standard diagnostic tests. The incidence of such ‘unexplained’ infertility is unknown. No physiological or pathological cause can be found for their childlessness: it is a symptom, not a diagnosis. Moreover, there is some support for the idea that psychological stress factors introduce or exacerbate difficulties with conception (Edelmann and Golombok 1989). Systematic research into the psychosocial aspects of failure to conceive is comparatively recent (Morse and Van Hall. 1987).

Historically, both the investigation and management of infertility have been accorded a low status in medicine (Pfeffer 1992). In the United Kingdom, criticism of the poor provision and coordination of services is coupled with evidence of inadequate financial planning by health managers. Where services are provided, they have been reported to be of limited effectiveness (Mathieson 1986; Pfeffer 1987; Lilford and Dalton 1987; Winston 1991). However, public expectations and professional perceptions concerning the management of infertility have been transformed since the introduction of IVF and the proliferation of clinical services.

The pressure on IVF clinicians arises not only from the demand for the new array of services arising from technological developments in the field but also from an attenuated time frame for decision-making. One clinician explained:

You see, in the old days, it [time] didn’t really matter. Because you sat back and the attitude was, well, if you give nothing to the patient they’ll probably get pregnant anyway…But now that you’ve got all this advanced technology, you’re under pressure to get it under investigation fairly rapidly, come up with answers and tell the patient the answers, discuss what they mean, and take serious decisions about what you’re going to do.

Decision-making, he said, used to take ‘as long as a year, from question to answer’. Now ‘it’s all go up front’. He added:

[P]atients who attend the infertility clinics generally are much better informed, very much better informed. They’re sharper…so that’s the pressure that is on.

The history of the science of this field indicates the extent to which the early pioneers of IVF foresaw what a demand there would be if their researches into the fertilisation of human eggs bore fruit. But many years of intermittently controversial animal research by a handful of pioneers preceded work on human IVF (Rock and Menkin 1944; Edwards 1985). The idea of assisting fertilisation by extracting and fertilising a woman’s egg with sperm and then transferring it to her uterus was the subject of animated discussion following publication in the 1930s of work on the fertilisation of rabbit eggs in the laboratory (Westmore 1984). In 1937, an anonymous editorial in the New England Journal of Medicine entitled ‘Conception in a Watchglass’ speculated that the profession would be ‘going places’ were such to be achieved in a woman. The editorial concluded, ‘What a boon for the barren woman with closed tubes!’ Nor were the early pioneers of human IVF hesitant to promote conceptions of need.

Yet these pioneers, including Robert Edwards and Patrick Steptoe, were working in relative isolation. Yoxen surmises that they were taking a professional risk with their work:

[T]heir experiments were not thought to be in the mainstream of clinical or biological research and periodically they faced considerable public or professional hostility…. By the mid-1970s the practical goal of transferring a fertilised human embryo back to the uterus… was being attempted by several research groups around the world. Whether and in what terms these experiments had been discussed with local ethics committees, or with comparable national organisations, is unclear. But it is striking that when in 1978 the first child was born after in vitro fertilisation, the Medical Research Council in the UK let its scepticism about the value and safety of this procedure be known publicly and declined to provide any research funds. As one might expect Robert Edwards still talks about this with thinly veiled rancour. In the US a major ethical review of the field was commissioned by the Department of Health, Education and Welfare. In the event no public funds became available for this field in the US.

(Yoxen 1988:29)

Lesley Brown gave birth in 1978 to her daughter Louise, the world’s first IVF baby, after a single fertilised egg had been transferred to her uterus during a spontaneous menstrual cycle (Edwards and Steptoe 1980). The full range of instances when IVF would be proffered, and the changes in the procedure itself which were to follow, were not at that time envisaged. Robert Edwards, writing in 1980, remarked:

Patrick [Steptoe] naturally finds it painful to have to disillusion patients who have not fully understood the implications of our work. It was embarrassing, for instance, for him to have to disillusion the occasional lady several years past her menopause that there was no chance of her becoming pregnant.

(Edwards and Steptoe 1980:212)

Only a few additional IVF conceptions occurred during the next several years. A procedure which seemed to have a pregnancy rate of less than 5 per cent did not encourage potential practitioners.

It was not long before this picture changed radically. The introduction of ovulation induction to enable multiple egg recovery and multiple embryo transfer was a particularly important development and was associated with a higher chance of pregnancy (Trounson and Wood 1984). The reported pregnancy rate rose, and IVF became more desirable as an innovatory clinical service. Yoxen conveys the changed climate:

By the early 1980s it seems clear that professional attitudes were changing, and that obstetricians in many countries began to consider developing or buying in expertise in this area, in order to extend their technical repertoire. The existence of a few specialist clinics indicated a very considerable worldwide market for this service. As the success rate rose slightly, although they remain at around 10 per cent overall, so did the number of scientific publications. Furthermore in the UK several evaluations of moral issues raised by in vitro fertilisation were begun by professional bodies. All of these eventually endorsed in vitro fertilisation, including that from the Medical Research Council.

(Yoxen 1988:29)

GUIDELINES AND STANDARDS OF PRACTICE

In the absence of data from other sources about what can be realistically expected, members of the medical profession who have pioneered an innovative technology are encouraged to be at the forefront of decisions not only concerned with what constitutes ‘adequate knowledge’ about its benefits, but also with what should be promoted as good practice for its use. It is no surprise therefore that, in Britain, standards of practice that had been followed by the small handful of pioneers were taken up and became the basis of guidelines devised by the Voluntary (and then Interim) Licensing Authority (VLA; ILA). Charged with the responsibility of licensing, of constructing interim guidelines and of monitoring centres undertaking IVF, this review body was set up jointly by the Royal College of ...

Table of contents

• COVER PAGE
• TITLE PAGE
• COPYRIGHT PAGE
• CONTRIBUTORS
• PREFACE AND ACKNOWLEDGEMENTS
• INTRODUCTION TO THE SECOND EDITION
• INTRODUCTION: A QUESTION OF CONTEXT
• 1. BEYOND EXPECTATION: CLINICAL PRACTICES AND CLINICAL CONCERNS
• AFTERWORD FOR CHAPTER 1: ‘SOLUTIONS FOR LIFE AND GROWTH’? COLLABORATIVE CONCEPTIONS IN REPRODUCTIVE MEDICINE
• 2. EXPLICIT CONNECTIONS: ETHNOGRAPHIC ENQUIRY IN NORTH-WEST ENGLAND
• AFTERWORD FOR CHAPTER 2: CLONES—WHO ARE THEY?
• 3. NEGOTIATED LIMITS: INTERVIEWS IN SOUTH-EAST ENGLAND
• AFTERWORD FOR CHAPTER 3: GLIMPSES OF MOMENTS IN THE ‘CIRCUIT OF CULTURE’
• 4. MAKING REPRESENTATIONS: THE PARLIAMENTARY DEBATE ON THE HUMAN FERTILISATION AND EMBRYOLOGY ACT
• AFTERWORD FOR CHAPTER 4: ‘ORPHANED’ EMBRYOS
• 5. REGULATION, SUBSTITUTION AND POSSIBILITY
• POSTSCRIPT: A RELATIONAL VIEW
• BIBLIOGRAPHY