Don't forget the baby

Throughout the debate on artificial reproductive therapy (ART), there has been one voice - that of the infants - that has been painfully conspicuous by its absence. While we must not underestimate the significant daily heartache that infertile couples experience and for whom ART offers a lifeline, it is the children who suffer the most when problems arise! However, I suspect that many are not aware of the potentially grave risks for the offspring of ART and this must be taken into consideration and balanced with the wishes of infertile couples. I believe that there is a middle ground that allows ART to be available but in a regulated format while not unduly jeopardising the issuing progeny.

Many forms of fertility treatments carry an inherent failure rate, namely an unsuccessful pregnancy, and compensate by "enhancing" the chances of conception by exaggerating natural processes to unnatural limits. For example, ART hyper-stimulating drugs induce the release of multiple eggs and in vitro fertilisation (IVF) may create several embryos simultaneously. If all are re-implanted into the womb simultaneously, this may result in multiple pregnancies - twins, triplets, quadruplets or more. However, all barring twins seldom occur in nature because the human uterus is not designed to accommodate many babies and multiples have very high risks of miscarriage in utero and significant morbidity and mortality to the infants thereafter. Yet, by design, unregulated ART emulates this very quirk of nature! Indeed, it is the very high risk of multiple pregnancies that imparts the greatest single risk to ART-induced babies. Some statistics:

Whereas just 5-8 per cent of single pregnancies deliver prematurely, up to 50 per cent of women carrying twins and as many as 95 per cent with triplets will deliver prematurely. Compared with babies born at nine months, the risk of cerebral palsy for these premature infants is seven times greater for twins, 18 times for triplets and more than 28 times greater for quadruplets. The overall mortality for premature singleton babies is about five per cent whereas this figure increases five-fold for twins and 11-fold for triplets, with significant neurological disability in 20-33 per cent of survivors. These figures apply to all babies born prematurely including those induced by ART and are no different in Malta as elsewhere.

These sobering statistics have led other countries to regulate ART and, for example, legally permit the implantation of just one embryo during each attempt at IVF. Others allow multiple fertilisation with embryo storage and selected re-implantation followed by elimination of those embryos that are "surplus to requirements", all of which are not acceptable to me personally nor to many Maltese citizens and institutions including the Church.

Consequently, in Malta, embryo storage is very unlikely and, without this, the fertilisation and implantation of just one embryo will significantly reduce the success rate of IVF. However, while empathising with infertile couples, I strongly believe that we should emulate what occurs naturally and certainly have a duty not to sanction a scenario that is unacceptably risky for the babies.

Therefore, where we are able to exert control, as in the case of IVF, I would support the fertilisation and implantation of two embryos: after all twins are common "events" and their risks, although greater than those for singletons, are still reasonable and considerably less than those for triplets (or greater). This proposal will, admittedly, reduce the "success rate" for each IVF procedure but grading success in terms of "creating an embryo" without due consideration for its outcome is, at best, extremely simplistic.

I believe that most infertile couples considering IVF and who have been properly counselled would agree that the argument is not about a baby at any cost (to the baby). Good practice in infertility treatment is surely about delivering a healthy infant with no/minimal risks to both mother and baby. The acceptance of any legislation that permits more than two embryos in the womb at any one time creates a serious and significant risk to all three (or more) embryos and, based on all medical and scientific evidence to-date, is unequivocally not "good practice" from the baby's viewpoint.

I am aware that the Bioethics Consultative Committee is reviewing this issue prior to formulating clear guidelines for the basis of national legislation. To this committee I would simply say: "Please don't forget the baby".

Prof. Attard Montalto is chairman, Department of Paediatrics, Mater Dei Hospital