Getting Pregnant in the 1980s: New Advances in Infertility Treatment and Sex Preselection

By Robert H. Glass and Ronald J. Ericsson

This title is part of UC Press's Voices Revived program, which commemorates University of California Press’s mission to seek out and cultivate the brightest minds and give them voice, reach, and impact. Drawing on a backlist dating to 1893, Voices Revived makes high-quality, peer-reviewed scholarship accessible once again using print-on-demand technology. This title was originally published in 1982.

• Language: English
• Publisher: University of California Press
• Release date: Nov 10, 2023
• ISBN: 9780520312982

Robert H. Glass

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Getting Pregnant in the 1980s

GETTING PREGNANT

IN THE 1980s

New Advances in Infertility Treatment

and Sex Preselection

Robert H. Glass, M.D.

Ronald J. Ericsson, Ph.D.

UNIVERSITY OF CALIFORNIA PRESS

Berkeley Los Angeles London

University of California Press

Berkeley and Los Angeles, California

University of California Press, Ltd.

London, England

Copyright © 1982 by The Regents of the University of California

Library of Congress Cataloging in Publication Data

Glass, Robert H.

Getting pregnant in the 1980s.

Includes index.

1. Infertility. 2. Fertility, Human. 3. Sex—Cause and determination. I. Ericsson, Ronald L. II. Title. [DNLM: 1. Sterility—Therapy. 2. Pregnancy complications. 3. Genetic intervention. WP 570 G549g] RC889.G58 1982 618.2 82-11074

ISBN 0-520-04828-8

Printed in the United States of America

123456789

For

Pat and Jean

Contents

Contents

Preface

1. Infertility

2. The Male Factor in Infertility

3. Recurrent Spontaneous Abortion (Miscarriage)

4. Pregnancy After Thirty-five

5. Tubal Surgery and Ectopic Pregnancy

6. In Vitro Fertilization, Surrogate Mothers, and Embryo Transfer

7. Drugs and Pregnancy

8. Sex Preselection

9. Questions and Answers

Appendix: Human Reproduction

Index

Preface

Articles on aspects of human reproduction are found in almost every issue of women’s magazines. Infertility, sex preselection, surrogate mothers, fertility after thirty-five, miscarriage, test tube babies, drugs in pregnancy, have all received extensive attention. There are, in addition, recently published books on each of these subjects. Why, with the extensive amount of information already in print, have we chosen to write about these topics? The information currently available is distributed among many different articles and books, and we see an advantage in having all the newest developments in the field of human reproduction in one volume. We also bring a collaboration to this book that is unique. One of us is a physician specializing in infertility who also does basic research. The other is a research scientist who in the past decade has formed a company to market two products that he developed in the laboratory: a method for sex preselection, and a rat steri- lant. Our backgrounds in research enable us to evaluate more critically what is fact and what is fantasy in medical care. In this book, and especially in the sections on infertil- ity, medical treatment is presented not as dogma but as an educated guess. Becoming aware of the gaps in medical theory and practice will help the recipient of health care to feel more confident in participating with the physician in choosing appropriate treatment. Because there are uncertainties in many areas of the medical treatment of reproductive problems, we do not take a cookbook approach. This means that the reader must not be merely a passive recipient of instructions but must do some work to evaluate the choices presented.

We have deliberately chosen not to include case histories, which are so popular in both magazines and books. Case histories are fun to read and, at times, informative, but they also can perpetuate some of the misconceptions that surround infertility. It is very common for an infertile woman to be told by friends that another woman became pregnant after a certain treatment. Never mind that the second woman’s problem may bear absolutely no relationship to that of the first woman. The friends question the competence of the physician who has not tried the favored treatment. In a similar vein, anecdotal case histories in books and articles often leave the impression that the treatment or course of events described are applicable to all. We thought this sufficient cause to avoid the use of case histories in this book.

Chapter 1 deals with the clinical problem of infertility. It presupposes some knowledge of how the reproductive system works. For those without that knowledge, and for those who are not confident of their knowledge in this area, we suggest first reading the short segment in the appendix that details the physical and hormonal events involved in reproduction. The appendix also contains drawings of the reproductive tracts of the male and female, which can be referred to throughout the reading of this book.

The last decade has seen major advances in research and in treatment of reproductive problems. The coming decade promises even more exciting changes. This book will tell the reader what is currently available and what may become available in this decade to help people who want to become pregnant or who want to influence the type of pregnancy that they will have. The ways in which individuals can influence reproduction range from a simple consultation with the physician to determine the optimal time in the cycle to have intercourse, to the technological breakthrough of in vitro fertilization. Not everyone will need, or want, to take advantage of all the opportunities currently available. Moreover, others will oppose any manipulation of the reproductive process because they see such manipulations as unnatural or even immoral. Because the future holds promise for even greater advances—for example, women now are being outfitted with portable pumps that automatically inject them with releasing hormones to induce ovulation—it is important to consider some of the questions that have arisen over the use of technology in reproduction.

Controversy in this field is not new. It is hard to believe that as recently as twenty-five years ago it was illegal to prescribe birth control methods in the state of Connecticut. Women who wanted to use a diaphragm were referred to a clinic across the border in Port Chester, New York. The law forbidding the use of contraceptives by married couples, even in the privacy of their homes, was overturned by the Supreme Court in a 1965 decision (Griswold v. Connecticut), If prescribing contraception was illegal in Connecticut until the early 1960s, imagine the opposition generated by Margaret Sanger’s attempts, early in this century, to make contraception readily available to all women.

Use of donor insemination has enabled many otherwise infertile couples to achieve pregnancy. It is still condemned, however, by a number of religious groups because it does not involve coitus and it utilizes sperm of a man other than the husband. As we will discuss later, another concern is that children conceived from the sperm of the same donor, unaware of their genetic origins, could meet in the future and marry. This would be an unlikely happening in all but a small town where the choice of available donors might be limited. Couples who obtain sperm from sperm banks or from physicians in larger cities have reasonable assurance that their offspring are unlikely to meet a child of the same donor. As an added precaution it has been suggested that no donor be used for more than ten pregnancies. An interesting sidelight is that based on genetic studies more than 10 percent of children could not be the product of their putative father’s sperm. Thus many individuals have an uncertain genetic heritage and they, too, have the potential for marrying blood relatives without knowing that they are related.

Prenatal diagnosis by amniocentesis provides the ability to diagnose chromosomal abnormalities and malformations of the spinal column. Widespread use of amniocentesis is dependent upon the availability of legal therapeutic abortion. Without the option of being able to terminate a pregnancy that would result in an abnormal child, there is little sense for a woman to desire amniocentesis. The linkage of prenatal diagnosis and abortion has generated attacks on prenatal diagnosis by right-to-life groups. Currently amniocentesis is utilized by less than 50 percent of women eligible for it on the basis of age. In all likelihood, this is due more to lack of information and lack of proximity to a center performing amniocentesis than it is to the efforts of those who oppose prenatal diagnosis.

Groups organized to promote the use of surrogate mothering are springing up in a number of areas in this country.

No sooner had we written in chapter 6 that the procedure could be exploited for unconscionable financial gain (and we mentioned $10,000 as a possible fee), than an associate of ours received a phone call from an individual representing a group doing surrogate mothering. Their fee— $25,000. If that isn’t enough of a problem, one court in California ruled in favor of a surrogate mother who decided to keep her child instead of giving the baby to the wife whose husband had supplied the sperm for the insemination.

In vitro fertilization has been opposed by some because of concerns that it interferes with natural processes and that embryos not developing normally will be discarded. There is additional concern that extra embryos will be retrieved at the time of a laparoscopy and fertilized but not used. Whereas each in vitro fertilization clinic will set its own protocol for handling extra or abnormal embryos, some will implant the abnormal embryos into the woman to avoid criticism that they are destroying life, secure in the knowledge that grossly abnormal embryos have little chance for survival in the uterus. Others will implant more than one embryo at one time in the hope that one will survive. The risk of this practice is the possibility of multiple births. Animal embryos can be frozen and stored, then thawed and transferred to an animal. This technique could be used in conjunction with in vitro fertilization when more than two or three embryos are retrieved during a cycle. The excess embryos could be fertilized, stored frozen and kept available for a subsequent menstrual cycle. However, what if the first implantation is successful and the excess fertilized eggs are never needed? What would be the response to their remaining forever in a deep freeze? A reaction against this alternative might be less severe if the egg were stored prior to fertilization.

Concern has been expressed that in vitro fertilization will be only a first step in a process that inevitably leads to experimentation on human embryos. One procedure has already been mentioned—the freezing of embryos. Another could involve the insertion of new genetic material into the embryo to overcome the effects of some hereditary diseases. Manipulation of human embryos outside the body might also allow for fusing the egg with other cells in order to study what factors influence normal development. Many feel that experiments of this type would violate the essentially human nature of a fertilized egg. In our view the concerns over potential abuse of in vitro fertilization seem of less import than the positive effect of helping some couples to overcome their infertility.

There has been a longstanding moratorium on government funding of any work relating to human embryos. In 1979 the Ethics Advisory Board of the Department of Health, Education and Welfare found no ethical problems with in vitro fertilization, but this did not halt the freeze on government support. The initiation of the moratorium was politically motivated, and once in place it was easier for politicians to do nothing than to change course and stir up controversy. Moreover, concern has been expressed, even by those sympathetic to in vitro fertilization, that in a time of decreasing government expenditures in the health field, government funds should not be used for a program that would help only a small number of individuals to overcome a problem that is not a threat to their physical health. Government funds could, perhaps, be better spent helping those with birth defects or, more germane to infertility, supporting research to develop methods of preventing and treating disorders that cause infertility—for example, tubal infection.

It has been suggested that the availability of successful sex preselection techniques would lead to disruptions in social patterns. If the preference for boys was translated into a higher male-to-f emale ratio, it might lead to an increased incidence of violence in society as males are placed in fierce competition for the fewer females. It also might lead to increased male homosexuality and to an increased use of prostitutes. Whereas surveys in the United States suggest that most parents would prefer an equal number of children of each sex, feminists have voiced concern that many couples would choose to have a son first. Because firstborn children seem to be high achievers, females then would be at an added disadvantage, being deprived of the firstborn position. At the present time these fears are exaggerated. Only 1 percent (13 of 980) of couples who corresponded with us concerning sex preselection were interested in influencing the sex of a firstborn child. In addition, the current method in clinical use for sex preselection (separation of sperm on an albumin column) is not 100 percent effective and although not a complicated procedure, it does require technical equipment, artificial insemination, and a fee is charged. For these reasons its use will never be sufficiently widespread to significantly affect the sex ratio.

New technology has influenced every area of reproduction, and it has enabled many couples to overcome their infertility. For others it has allowed a degree of influence on the gender of their child. Overall, the new technology has been used humanely and wisely. In the next decade we will see an increasing use of fetal surgery to save babies in the uterus from death or permanent damage. Beyond that there is the possible development of techniques to introduce new genetic material into the fetus. Only a few couples will benefit directly from these techniques once they are introduced into clinical practice, but the fallout of new knowledge gained from this type of work could lead to a greater understanding of reproductive processes. From that knowledge can come many benefits.

1.

Infertility

For most individuals, life moves in a progression that is highlighted by the events of marriage and childbirth. When this progression is interrupted by infertility, it produces an effect beyond just the physical absence of a child. A couple may, for the first time, feel they have lost control over a significant part of their lives. Their own anxieties about infertility also may be magnified by well-meaning, but unthinking, relatives and friends who continually ask about the prospects for pregnancy. When to these burdens one adds the need to have sex on schedule during the infertility investigation, it is obvious that many couples will require emotional and psychological support beyond that provided by their own resources. They will need opportunities to ventilate their concerns and to dispel their fears. Establishing a dialogue with a physician is helpful, but greater relief of anxieties can come from involvement with support groups for infertile couples organzed by RESOLVE.¹ Group meetings demonstrate to individuals that their problems are not unique; they also provide a forum for expression of concerns and for learning adaptations to the problems of infertility. Meeting with others trying to overcome infertility brings to light the statistic that 12 percent of couples are infertile.

When is it appropriate to seek help because pregnancy has not occurred? Of those couples who will become pregnant, approximately 80 percent will conceive within a year. Thus, if a year passes without conception it is reasonable to see a physician. The physician should