This is about medicine, not theology | Mark Sant

FULL INTERVIEW • The ongoing IVF debate has sparked a wave of pro-life concern; but for obstetrician Mark Sant, that is a case of missing the baby for the test-tube. Infertility is a medical condition, he argues... and should be approached as such

Mark Sant
Mark Sant

There has been a lot of controversy surrounding the proposed amendments to IVF legislation. First off, however: is it necessary to amend this law in the first place? What needs to be changed?

It is necessary, and how. The aim behind IVF Is that infertile women will go home [after treatment] and have a baby. But the law that we have now is extremely restrictive, and in quite a few cases does not allow us to reach our aim. The current law allows us to attempt to fertilise two eggs; which is very different from having two embryos. In exceptional circumstances, the law allows us to apply for a concession to try to fertilise three eggs. Now: what happens in the rest of Europe? Usually, you collect all the eggs – in a normal cycle, between eight and 15 – and attempt to fertilise them all. Why? Because when you attempt to fertilise 15 eggs, you will get 10 to 12 that will actually fertilise; and these will then have to develop. Also, abroad they are allowed to go up to five days [before implantation] instead of only three [as is the case here]. By the end of that process, from 15 eggs, you will end up with five or six. One will be implanted, and the rest are frozen. But what are we doing [in Malta]? We are attempting to fertilise only two eggs – which sometimes gives you two embryos – and we have to [implant] them both by the third day. We don’t allow them to go up to the fifth day...

What is significant in the difference between implanting after three or five days?

By the fifth day, the embryo will have shifted from its mother’s infrastructure, to its own. This gives more opportunity to identify genetically abnormal embryos – and by ‘genetic abnormalities’, I’m not referring to Down’s Syndrome, or abnormalities that will still give rise to a live birth. I’m talking about problems that will lead to failed implantation, or miscarriages. So, by leaving implantation to the fifth day, it will give you a way to at least try to weed out the really bad ones. Those will not be replaced [back in the womb]... what’s the point of replacing an embryo that is destined to fail? In our case, however, if we had to wait until day five, in many cases we will not be implanting anything at all. [...] in reality, we are very often replacing embryos that are destined to fail. Is that right? Is that going to help us achieve our objective?

And yet, the law as it stands is called the ‘Embryo Protection Act’...

It’s a very big misnomer...

... so it seems, as from what you’re saying it doesn’t seem to be offering much protection to embryos at all...

It’s even worse. What I’ve been talking about so far are embryos that are destined to fail... which haven’t really had anything done to them. But we are in a worse situation than that. Today, we know that, if you measure one of the hormones at the time of actually triggering ovulation... basically, if the progesterone level is over 1.5 – that reduces the chances of an embryo implanting by around 20%. Abroad, in those cases they would freeze the embryo, and replace it later [when the hormone levels are lower]. What do we do? We put it in anyway. So what are we doing? We’re sending at least one fifth of our embryos to certain death, if you want to look at it that way. You call that embryo protection? It’s embryo destruction...

We’re sending at least one fifth of our embryos to certain death, if you want to look at it that way. You call that embryo protection? It’s embryo destruction...

Another effect is to raise the hopes of expectant mothers, in cases where chances of success are minimal. Do you encounter cases like that?

Unfortunately, as I tell my patients all the time: we are going to do our best, you are doing your best... but this is like a lottery. When you buy a lottery ticket, you don’t commit yourself to buying a new house or car... because, in most cases, you are not going to win the lottery. With IVF, it’s the same. Even in the best scenarios, two-thirds of the people we are going to start the process on, are going to remain empty-handed...

Is this because our law is faulty... or is it a statistic about IVF in general?

If you take IVF in general: on the first cycle – what we call the ‘fresh’ cycle – without subdividing by age, or any other factor... you are looking at a 33-35% chance of [success]. Abroad, it is slightly different... they can freeze embryos, and can attempt to fertilise all a woman’s eggs... so if you have four or five embryos, you will implant one to begin with; and if it doesn’t work, then you take one of the remaining [frozen] embryos, thaw it, and put it back in. That process is much, much simpler: you do not have to stimulate the woman with all those injections; you don’t have to give her anaesthetic to collect her eggs... because everything’s already been done. So then, there is what we call the cumulative success rate, per cycle that you have stimulated. With freezing, one stimulation gives you four, five chances. That pushes up the cumulative successive rate to between 60 and 70%. In our case, without freezing... you only have one chance. If that fails, you have to start the process again. Basically, you have to stimulate the patient every time...

One aspect that is rarely discussed is how all this affects the patient. What does a woman undergoing IVF treatment actually go through?

When we do IVF, we take over the cycle. We shut down her own cycle, and stimulate everything afresh. [...] The process involves two weeks of multiple injections; and when the eggs have matured enough, we administer a light anaesthetic to retrieve those eggs, using a trans-vaginal ultrasound with a needle on it. We puncture the ovaries, and aspirate those eggs. The eggs are then sent to the lab, where, currently, any two are taken for an attempt at fertilisation. The rest are frozen, using oocyte vitrification...

And the success rate is not satisfactory...

No. [...] The latest European statistics show that for a woman aged 35 or younger, you need eight eggs to get one good embryo. In women aged 36 and older, you need 25 eggs. So basically it’s lottery. That’s why the success rate with frozen oocytes is dismal...

Meanwhile, the discussion has also been characterised by concerns with abortion: there have been highly emotive public protests against ‘freezing babies’, making no distinction between a human embryo, and a foetus. From a medical perspective... what is the difference, anyway?

It is a continuum: you stick labels as you go along. When a baby is born, we call it a newborn baby... then we call it a toddler when it starts to walk a bit; then a child, then an adolescent, then an adult... there aren’t clear definitions: it’s a continuum...

By that argument, the protestors may have a point. If the definitions aren’t clear, they can be stretched backwards as much as forwards...

But then, science does give definitions. An adolescent, for example, is going to go through puberty. A baby has to have been born; before that, it’s a foetus... which is not the same thing as an embryo. But you can take the argument back even further. Before you were an embryo, you were a sperm and an egg. And if we were to go on ethical issues: contraception was ‘not right’ because it stopped the potential for that life. Even a sperm and egg, lying next to each other, can give rise to life. But what is an embryo? By day three, it will consist of about seven to eight cells. Those cells are all identical, and have the potential [to become an individual]; but they still have to give rise to a placenta... to membranes... eventually, to a foetus. Potentially, they could give rise to three foetuses. So how can you call that an ‘individual’, with its own identity? It could become three people...

Fr Peter Serracino Inglott had made a similar argument some years ago: we cannot talk of an individual ‘soul’ for the same reason. But that’s a case of applying theological reasoning to scientific issues. Is that a good way to approach this issue?

No, I think it’s very unfortunate. But one finds oneself compelled to do it, because these are the arguments being thrown at us all the time. I have been compelled to look things up, and – in a similar, in my opinion, ridiculous fashion – I have had to come up with comparisons. Muslims, for instance, believe that the soul starts at 40 days [from conception]; in Judaism, it’s when the organs start to form. I think it’s useless to go down this route... but I feel I have to, because these are the arguments we face all the time...

Nonetheless, there are other arguments which are less emotive. If the success rate with frozen embryos is high, we could end up with a surplus of viable frozen embryos: raising questions as to what to do with them in the long run...

I think we have reached a point in this interview where I can say that I don’t like the proposed amended law. It is still too restrictive, and I really don’t see why our citizens with fertility issues have to be second-class. The proposed amendment says that we will be able to attempt to fertilise five eggs... but not even the first time round. For the first time, you will only be allowed to attempt to fertilise three. I think that’s incredibly ridiculous. So, if I have a situation which is dismal – I can tell straight away that it’s a hopeless situation – they’re telling me that I have to subject that patient to a whole cycle of IVF, to fertilise three eggs... just so that she might qualify for a slightly better chance with five. Why? [pause]. Even if we are to going to go with this super-restrictive idea, at least it should be the Embryo Authority to decide: I present the case, and they decide if it’s a genuine case that can go straight for five embryos. Why should I have to compel somebody to go through all the hardships of a full IVF cycle, so that they can qualify for another chance?

It seems to me that the reason for these restrictions is to appease the general public. Would you agree?

Not even the general public. I would say it’s to appease the objections of certain individuals. Unfortunately, the people who are really going to need this therapy are not being consulted. The infertile population we have right now is not being consulted... and please note: it is at least one in six people... and expected to increase. One in six is not a small number. But they are not being consulted, mainly because they are not coming forward. The stigma is still there. We think of Third World countries where infertile women are cast out of communities, as something disgusting – and it is – but we do the same thing here. A woman who is infertile still feels the taboo. And even more than that, they are scared to come forward because, if they eventually do have a child through IVF, and people get to know about it... they are afraid that even their children will be stigmatised. That is why very few come out in public. But the ones who are really going to need it are not voicing their opinion. I think it’s ridiculous that people who have had four, five, nine children feel empowered enough to impose on the childless, and tell them: ‘Lump it. You’re not going to have babies...’

I think it’s ridiculous that people who have had four, five, nine children feel empowered enough to impose on the childless, and tell them: ‘Lump it. You’re not going to have babies...’

This seems to echo arguments made in Parliament recently, to the effect that legislators should not grant rights that have been ‘denied by God and nature’. What is your answer to that?

That argument throws away medicine in general. Let’s say I have a strong family history of heart disease – my father died at 40, his brother died at 42... and I’m next in line. So I go and have an angiogram done, and find that my veins are a bit tight. So we put stints in them, and I end up living till I’m 70 or 80. I was not meant to live that long. My genes were meant for me to snuff it when I was 40... but medicine intervened. We do the same thing with disabled people. Do we throw them away? No. We care for them, medicine tries its best, etc. Same with renal failure. We don’t give up on those cases: we try to obtain organs and transplant them. This is about medicine.  And this concept, that infertility is ‘just a luxury’, is wrong. In Europe, infertility is a medical condition. If you have a right to medicine, you have a right to medical treatment for infertility. [...] The idea that this is just about women being capricious... wanting to have a child, because she ‘would like to have one’... is wrong. That woman has a very basic, instinctive need to procreate; and the inability to do so is a medical condition, and that is how it has to be treated. I really hate it when people talk about a woman ‘desiring to have a child’. No. She might ‘desire’ to have a nice set of curtains... not to have a baby. The baby is an instinctive need, not a desire.

 

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