In Vitro Fertilization Comes to America by Howard W. Jones, Jr. M.D.

I am proud to announce that Jamestowne Bookworks will publish this month In Vitro Fertilization Comes to America by Dr. Howard W. Jones, Jr. of the Jones Institute in Norfolk, Virginia. His memoir describes the ordeals of leading a medical breakthrough, which was most signally marked by the birth of Elizabeth Carr, America’s first IVF baby. IVF and assisted reproductive technologies (ARTs) occupy such a central place in fertility treatment today that it is, perhaps, hard for a younger generation to imagine the hostility of years gone by, even from doctors and scientists in the same field.

Some objections were professional arguments in favor of a surgical option for repairing blocked fallopian tubes, although that procedure was never very effective and never offered the opportunity to overcome male infertility (by ICSI) or diagnose dire genetic abnormalities in embryos (by PGD), as IVF techniques can. Other objectors—some were Nobel prizewinners—feared that babies conceived in the Petri dish would be born with abnormalities, but in fact they are just as healthy as others. And there were also protests that IVF perverted God’s will.

This book is a personal view by a medical pioneer of how a controversial technology became orthodox practice. Dr. Jones interweaves memories of patients, clinicians, scientists, and opponents into a remarkable story of achievement. Yet, this medical revolution will not be complete while infertility treatment remains unavailable in some countries and officially denied to Roman Catholics.

In 1984, Dr. Howard was invited with his wife, Georgeanna Seegar Jones (1912-2005), to join a small working party of distinguished doctors and theologians in the Vatican City to advise Pope John Paul II whether IVF was ‘licit’ for practicing Roman Catholics. Their report was never published. It was probably quashed because the Holy Office had already made up its mind, and IVF remains forbidden in the church to this day, although as widely ignored as the doctrine against contraception. Official censure of IVF was publicized in a Papal Instruction, Donum Vitae (1987).

Dr. Howard Jones and IVF
Published by Jamestowne Bookworks (2014)

Dr. Georgeanna was one of the most outstanding clinician scientists of her generation. She cared for patients with infertility and hormonal problems throughout a long career at Johns Hopkins Medical School, from which she graduated in 1936. As a Christian doctor, she felt incensed not only because the Church was denying people a safe and effective remedy for family building, which is one of the greatest of human hopes, but also because the arguments were false.

She wrote an open letter to the Vatican which Dr. Howard has included in his book. I have reproduced it below in full because her arguments are so powerful and gracious. It is one of most memorable letters I have ever read, and is as valid today as when it was written in 1987.

“I write in response to the Vatican ‘Instruction on . . . Procreation’ as a member of the large majority of the non-Roman Catholic religious community, Christian and Jewish. I write as a practicing gynecologist with a long record of investigative work in reproductive physiology and endocrinology. Perhaps even more importantly, I speak as a wife of 46 years and the mother of three children with successful marriages of 19, 15, and 14 years, respectively.

In 1984, my husband Dr. Howard W. Jones, Jr., and I were invited to the Pontifical Academy of Science at the Vatican for the purpose of explaining the technical and scientific aspects of in vitro fertilization (IVF). We were delighted to participate—as non-Catholics. We acknowledge the Catholic Church as the largest organization for potential good in the world. We regarded the invitation as an expression of openness and genuine interest in the science of reproduction.

Two years earlier we had participated in an IVF symposium in Bari, Italy, at which the five major Italian universities had joined efforts to gain support for IVF from the Vatican and from the Italian Ministry of Health. There we had had the opportunity to discuss the ethical issues with Monsignor Carlo Caffarra, one of the very conservative theologians of the Vatican, and were amazed to learn that his ethical objection to IVF had nothing to do with abortion, which was the issue often raised in the United States. Rather, the ethical problem, as he saw it, was that IVF “is outside the bonds of conjugal love.” My query was, “Do I understand this that conjugal love is defined as intercourse?” The answer was, “Yes.” My response was then as it is now: “Monsignor Caffarra, in this Twentieth Century you must change your definition of conjugal love.”

Jones Institute, Norfolk, Virginia
Portrait of the Drs. Jones at the Jones Institute, Norfolk, Virginia

Pope Paul VI in the encyclical letter Humana Vitae (1968) sought to enlarge the definition of conjugal love as intercourse-for-reproduction by adding to the reproductive function the function of “unity.” This is defined by one theologian as “love union” and presumably means love or bonding between couples, but it still makes the conjugal act and conjugal love inseparable. The unitive and procreative functions of the conjugal act are not permitted to be separated (“Instruction,” Part 2B, Sec.4). Therefore, procreating without intercourse is illicit, and intercourse without the possibility of reproduction is illicit. In the Vatican document, the definition of conjugal love as intercourse unifies the ethical discussions of all topics related to reproduction. Contraception is prohibited because the act is no longer expressive of the procreative function. Artificial insemination and IVF are prohibited because the procreative function is not by the physical union of the husband and wife.

To me, this reasoning dehumanizes the definition of conjugal love—intercourse, if you will—by insisting that the physical and biological aspects of intercourse must be absolute. It is physiologically possible—and to me ethically permissible—in true conjugal love to separate the function of unity (I call it loving pleasure) from the procreative function, as in the postpartum lactation phase or in the menopause. It is certainly possible physiologically to separate the procreative function from intercourse either by artificial insemination or by IVF. But to me it is never ethical to separate the procreative function between two people from conjugal love. The strongest bonds of conjugal love are those between two loving individuals who are able to make responsible judgments in relation to family formation.

A definition which implies that intercourse is conjugal love, and that the sole function of intercourse is reproduction, does not differentiate between human beings and animals. It is unjust to burden Catholic couples with such a medieval definition. Conjugal love between two human beings should first be a bond of admiration, respect, and mutual interests that produces a lasting spiritual union usually consummated in the physical union of the conjugal act, intercourse.

Reproduction with family formation is surely one of the great pleasures and benefits resulting from the commitment made between two individuals joined in conjugal love and the act of intercourse is physically designed to assure successful culmination of the reproductive process. Because human reproduction is notoriously inefficient, the repetitiveness of the act must be ensured.

This link is made by enkephalin, a natural morphine secreted by the nervous system during intercourse, thereby rewarding us with a feeling of well-being and pleasure, and making intercourse addictive. If the process were otherwise, humanity would not have survived and flourished. This habit formation ensures us that intercourse will occur repetitively enough, in a species without a built-in ovulation signal, so that one intercourse during a month may be successfully timed, and often enough during a year so that one of the successfully timed ovulations will become fertile.

More importantly, in mature conjugal love, the physical act should be inseparable from the spiritual love and respect associated with one special individual in the marriage bond. The union of the pleasurable with the reproductive aspect of the conjugal act provides not only for successful reproduction but also for the stable family formation, which, in human beings as in the primates, is vital to the survival of the young.

The relative importance of these various aspects of intercourse changes as the individuals in a marriage grow older. When age prevents reproduction and when childrearing is completed, intercourse still furnishes—without the possibility of reproduction—its natural function of pleasure. So it is that intercourse from a scientific point of view has not one function but three: (1) reproduction in the early years, (2) a bond to maintain the family formation as childrearing becomes important, and finally, (3) solace to the elderly.

This returns us to the Vatican viewpoint that intercourse is licit only for the purpose of reproduction and that every intercourse must be open to the possibility of reproduction. If one carries this viewpoint to its extreme conclusion, no sterile man or woman should have intercourse. This would include the postmenopausal woman who, presumably with her spouse, would be condemned to abstinence. As this is so obviously impossible and illogical, exceptions have been made to include “unity,” for example, the menopause and known medical factors which interrupt fertility—excluding, of course, sterilization procedures. The necessity for the exceptions makes the fallacy of the premise apparent.

 If then, the premise—that reproduction without intercourse is illicit or intercourse without reproduction is illicit—is incorrect, Vatican pronouncements against contraception should be reviewed and revised. Although the Vatican has precluded contraception because it induces a condition in which intercourse is not open for reproduction, yet it has made an exception for rhythm contraception. Such an exception is a scientific fallacy and a contrivance, for it is a well-established fact that intercourse after ovulation has occurred—which is the only effective rhythm method—is never open to reproduction. What is the difference between this form of contraception and taking a pill to ensure a cycle “never open to reproduction?” The answer is that the pill is “unnatural,” therefore alien to God’s laws. But certainly prohibiting intercourse in a marriage blessed by true conjugal love is unnatural.

The majority opinion of the theologians attending the symposium of the Pontifical Academy to investigate the scientific and ethical aspects of IVF was that basic IVF is an ethical consensus. Monsignor Caffarra was the sole dissenter from this consensus. His final statement was that accepting the IVF procedure as ethical would demand reconsideration of all past pronouncements on the subject of reproduction. The next theologian to speak pointed out that if accepting IVF as ethical meant that the Vatican needed to review and possibly revise all former pronouncements on reproduction, perhaps the time had arrived to do just that.

Those in attendance were to receive the final draft of the scientific and ethical discussions for their review and, if necessary, corrections prior to presentation of the document to the Pope for his enlightenment. But no such document was circulated. We therefore conclude that His Holiness is not acquainted with the scientific discussions by the physicians or the ethical judgments of the theologians convened for the express purpose of evaluating the scientific and ethical considerations of IVF. The recent Vatican publication therefore seems to make a mockery of this activity of the Pontifical Academy, which was established during the Renaissance to preclude another Galileo affair.

The Vatican would be well advised, as the twentieth century draws to close, to listen to the collective wisdom of the many dedicated and brilliant ethicists and scientists available within its walls. The Vatican should redefine conjugal love between human beings in terms that emphasize all-encompassing love instead of limiting it to sexual intercourse. The Vatican should realize the scientific factualness—naturalness if you will, God’s law as I prefer—of the two-fold function of intercourse reproduction, and pleasure, and the changing importance of the two functions in the lives of two individuals joined in conjugal love.

The pronouncements of natural law were expounded by the early pagan philosophers; in the Judeo-Christian ethic, the laws of nature were regarded as God’s laws. We seek to determine the scientific and logical explanation for all of these wonderful and beautiful examples of God’s laws. When our investigations indicate either additional functions, such as pleasure in intercourse, or additional therapeutic measures for correction of defects, such as IVF for the treatment of infertility, we should accept these findings as further evidence of God’s will for us to be inquisitive and rational. For this is a world of reason that God in His mercy has provided for us. When we know the fact, we must sometimes change our definitions—and even our minds.”

If the Pope ever read the letter it has made no difference to church doctrine, though that will surely change one day. Perhaps the subject will come up during the current synod on family life, and if so maybe Pope Francis will prove more progressive about contraception and fertility treatment than his predecessors.

Next Post: Ghost story from West Virginia

Room for a Womb – a transplant story

It seems particularly fitting to congratulate a Swedish colleague who announced the world’s first successful uterine transplant the same week that the Nobel Prize for Physiology and Medicine is announced from Stockholm. Not that the transplant will earn him the Prize one day, which is awarded for a scientific breakthrough rather than a technical tour de force. Surgeons have long known how to hook up blood vessels, but have balked at challenges about transplant safety, longevity, and ethics.

Sherman Silber, M.D.
Roger Gosden discussing an experiment with Sherman Silber after a lecture

Mats Brannström has been working on the project for about fifteen years, or as long as I have known him. We used to chat at fertility preservation conferences when I was working on ovarian transplants. My goal was frozen-preservation of ovaries for young cancer patients who were likely to be sterilized by chemotherapy or radiation: when they were clear of disease we would transplant the thawed organs back to restore natural menstrual cycles and fertility. Around the globe, over thirty patients have conceived healthy children after an ovarian transplant. I also worked with the brilliant surgeon, Sherman Silber of St. Louis, who restored years of menstrual cyclicity and fertility to women who had an ovary donated by their genetically-identical twin sister. There is no greater satisfaction for a researcher than to witness their work leaping from the laboratory to the clinic.

uteru,s ovarian and fallopian tubes
Human female reproductive organs

But transplanting reproductive tissue can be troubling, if not actually controversial. For us, it was the question of whether an ovary that was removed for storage before the disease was cured might seed cancer cells in the patient as a transplant? For womb transplanters, the major question they face is, “Why do it, when it is so risky?”

Mats explained that the idea didn’t come out of the blue: one of his patients asked if it could be done. She was having a hysterectomy and desperately wanted the experience of gestating a baby. Her inquiring mind set him on a journey to help women like herself. For women who still have ovaries, they can have in vitro fertilization (IVF) before surgery to store embryos in the freezer until they are ready for transfer to the transplant. But, unlike our identical twins, they need constant treatment with drugs to suppress the immune system that naturally tries to reject the foreign organ.

Objectors point out the alternatives for women who lack a uterus. First, there is child adoption, although not such an easy option as in the past. Second, there is surrogacy in which a “tummy mummy” is commissioned to carry the baby. This can be arranged either by conception in her own body, using sperm from the patient’s husband or a donor, or by IVF in which embryos from the commissioning couple are transferred to the third party, so the child is genetically related to them. But surrogacy is outlawed in some countries, including Sweden, as it is in some U.S. states and for Muslims.

Medical practitioners are less paternalistic than they used to be. In the past, they were more comfortable proscribing (as well as prescribing) treatment if it made them uneasy or in their clinical wisdom it did not seem to be in the best interests of their patient. Nowadays, as we come to our doctors after consulting other specialists and surfing the Internet for the latest medical research, we are increasingly telling them what we think they should do! In the parlance of bioethics, the Autonomy/ Beneficence pendulum is swinging from right to left, from B to A, which can take a doctor on a hike into swampy ethical territory. I sympathize with them for wondering why a hazardous uterine transplant should be attempted if it is not life-saving but, on the other hand, I think we ‘fertiles’ can too easily underestimate the grief of childlessness and the lengths that people will go to achieve one of the greatest joys in life—parenthood.

Queen Amalia, Mullerian agenesis
Beautiful Queen Amalia of Greece (1818-1875) by Stieler

Most women who seek a transplant have had a hysterectomy to treat cancer or another medical condition. Some were born without a uterus because of a genetic abnormality with a name that can throw a student at exam time—Mayer-Rokitansky-Küster-Hauser syndrome. This was the condition that Queen Amalia of Oldenburg (1818-1875) had, and her inability to give King Otto an heir caused their expulsion from Greece. Perhaps a transplant would have saved the monarchy.

I don’t know who should take credit for the original idea of uterine transplantation. I don’t think I deserve that honor (if it is such), but exactly thirty years ago I mentioned it at a conference in another Nordic state, Finland. My suggestion didn’t cause any rumbles, as I expected, perhaps because the audience was too polite to pronounce me ‘off the wall.’ When I returned home to the Edinburgh Medical School, I took the opportunity one day to ask senior colleagues in the common room what they thought of the idea. The gray silence that followed spoke more than anything they might have uttered.

I never thought any more about it until I moved to McGill University and collaborated with a skillful Chinese microsurgeon. We transplanted ovaries, fallopian tubes, and segments of uterus en bloc from donor rats to sterile recipients. Treated with immunosuppressive drugs, the transplants survived and gestated healthy pups. But those were rats. Nobody talked about transplanting a human womb.

The first clinical case was reported in 2000 from Saudi Arabia. It ended in disaster. A blood clotting problem necessitated emergency removal of the womb, amid international criticism. The bad news did not deter a Turkish surgeon, who had famously performed the first full face transplant in his country. In 2013, all was going well when the 22 year-old patient conceived after embryo transfer, but when her fetus was scanned at 8 weeks it was found to have no beating heart and, sadly, had to be terminated.

Meanwhile, Professor Brannström was cautiously honing techniques, testing them in monkeys, and assembling a multidisciplinary team. Patients were carefully selected for the best chance of success, and most had recruited a relative or friend as a donor. Mats deserves credit for not rushing to be first, which is a great accolade in medicine and science.

Seven of the first nine transplants survived. It did not matter that some donors were postmenopausal, because the uterus ages far more slowly than the ovaries. The successful patient did, however, develop pre-eclampsia which forced an early delivery by Caesarean section. But mother and baby boy are doing well and I salute them and my old chum.

Next Post: Rehabbing Peter Rabbit