The Challenge of Infertility

Very few Christian couples preparing for marriage expect to have trouble conceiving and bearing children. Often in premarital counseling, couples are talking about how many children they hope to have rather than what they will do if they are unable to have any.

Sadly, about one in eight couples (12%) will deal with infertility.¹ Few will be prepared for the emotional, physical, and spiritual challenges that will accompany this trial. Christians need look no further than their Bibles to see numerous examples of the high cost of dealing with childlessness. Abraham and Sarah were driven to take drastic and damaging actions to solve their longing for a child (Gen. 16, 21). Isaac prayed in desperation for his infertile wife, Rebecca (Gen. 25). Rachel, the beloved wife of Jacob, said in exasperation to her husband, “Give me children, or I shall die” (Gen. 30:1, ESV). Hannah struggled with depression and bitterness as she wrestled year after year with her unrealized desire for a child (1 Sam. 1).

Today we do not attach the same stigma to infertility that was common in Bible times, but that does not lessen the pain of unfulfilled longing and the repeated cycles of hope and disappointment month after month. On top of all this, trying to sort through the labyrinth of potential solutions to childlessness can leave a couple bewildered and discouraged. What are the options for dealing with infertility? Can we afford them? Where and when do we start looking? What treatments, if any, are morally acceptable for a Christian?

To address important questions like these, this article will 1) examine some of the causes and potential treatments of infertility, 2) consider the ethics of infertility treatment, and 3) discuss the wisdom of pursuing some type of fertility treatment.

Infertility Treatment as Medicine

The World Health Organization (WHO) defines infertility as “a disease of the male or female reproductive system defined by the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse.”² Although infertility is officially classified as a disease, it is really more of a symptom than a disease. Conception is a complicated process and there are many, many things that can go wrong. It is estimated that around 35% of the time infertility is due to a physiological problem with the wife, while 15–20% of the time it is due to the husband. In 30% of cases, there is an issue with both partners. Surprisingly, 15–20% of the time there is no clear explanation identified. Given that, in the vast majority of cases, there is some (or multiple) physiological irregularities behind a failure to conceive, infertility should be treated like any other illness. Medical professionals should be consulted in an effort to determine the root cause.

This is especially important because medical treatment is available that can resolve many cases of infertility. This treatment could be as simple as dietary changes, hormone supplements, or minor surgery. Treatments can also be far more complex, but getting a proper diagnosis does not obligate a couple to any particular treatment. I have known infertile women who were treated for improper levels of thyroid hormone. Simply taking synthetic thyroid hormone in a pill form corrected the problem. In one case, the woman had four healthy children with no further intervention.

Given that a woman’s fertility starts to decrease rapidly after age 35, it is recommended that a couple in which the wife is 35 or older seek medical advice after 6 months of being unable to conceive. For younger couples, the standard is usually to wait at least 12 months. If there are obvious signs of a problem—things like irregular or nonexistent menstrual cycles, severe cramping or other signs of endometriosis, or a history of miscarriages—a couple should seek medical attention without delay.

Start with your family doctor, who can do routine blood work and take medical histories for both husband and wife. An analysis of basic reproductive function and normal ovulation allows the doctor to rule out some of the more obvious causes. Given that a lot of time can be wasted in hunting for an explanation, it is probably a good idea to get to a specialist if your family doctor cannot make a clear diagnosis fairly quickly.

Depending on what the underlying problem is, a specialist might recommend some version of Assisted Reproductive Technology (ART). To be considered ART, a fertility treatment has to involve the handling of both sperm and eggs in a lab setting (i.e., outside the human body). Although there are a variety of ways that this can be done, most commonly doctors would collect eggs from the wife and sperm from the husband and then allow fertilization to take place in a Petri dish. The resultant embryos would then be transferred back into the wife’s uterus through the cervix. This procedure is called in vitro fertilization (IVF) since fertilization of the egg occurs “in glass” (in vitro) instead of in the human body (in vivo).

IVF has been used in the U.S. since 1981. It is estimated that over one million children in the U.S. and over eight million children worldwide have been born via IVF procedures since the early 1980s. The most recent data we have indicates that more than 81,400 IVF babies were born in the U.S. in 2018. It is estimated that 1.9% of all children born in the U.S. today are conceived via IVF. ³

IVF has helped many couples struggling with infertility to conceive and have children. While IVF is certainly not a solution for every case of infertility, it is an effective treatment when infertility is due to problems with female ovulation or fallopian tube function. IVF can also be used effectively to overcome defects in sperm function in the husband. This is why it is important to get an accurate diagnosis of the underlying problems causing infertility before considering any particular type of treatment.

The Ethics of ART

Just because in vitro fertilization and other forms of assisted reproductive technology are available does not mean they are ethical. How should Christians evaluate this type of technology? My personal opinion is that we should view ART (including IVF) as gifts of God’s common grace that have been developed as part of the creation mandate (Gen. 1:28). In principle, ART is the application of medical technology to overcome physiological problems that afflict many people because of the curse that came upon the earth in the wake of the Fall (Gen. 3:16–19).

Because we live in a broken world, we suffer from all kinds of physical (and other) maladies that make human flourishing difficult. God has graciously allowed us to make a variety of medical discoveries that have improved both the quality and length of human life. Antibiotics and vaccines have reduced death rates from infectious disease. Advances in surgical procedures have saved many lives. New cancer treatments have extended survival rates significantly. Similarly, developments in ART options have enabled many couples struggling to conceive to have children.

In all that Christians pursue, however, we should not blindly follow the ways of the world–even if a good end might result. We must put God’s authority and God’s Word first in all things. While I believe ART can be used without compromise of truth, I also believe that there are forms of ART that involve compromise and should not be used by Christians. This view is shared by a number of Presbyterian/Reformed sources (see sidebar article).

Some have argued that IVF, in particular, should be rejected by Christians by virtue of the fact that it separates sexual intimacy from procreation. Since fertilization is happening outside of the body, IVF is considered unnatural and inappropriate. God certainly intended procreation to flow out of sexual intimacy in marriage, but I do not believe that a married couple using IVF is violating this principle. The use of medical technology to help a married couple conceive is happening within the context of a Christian marriage in which ongoing sexual intimacy is occurring. While this argument does not mitigate against IVF in general, I do believe it argues against any kind of IVF arrangement that involves more than two partners (so-called “three-parent embryos”) or in which one of the participants is not one of the spouses (sperm or egg donation or surrogacy). Involving people who are not a part of the marriage in the process of procreation is fraught with complications and violates a primary biblical principle that “marriage is honorable among all, and the bed undefiled” (Heb. 13:4, NKJ).

Another significant ethical issue in the way that IVF is done today is the creation of excess embryos that are never returned to the wife for implantation. Typically, a clinic will want to harvest as many eggs as possible from the wife. A woman undergoing IVF is treated with hormones that stimulate ovulation at the same time she is treated with a hormone that will prevent her from releasing her eggs. This regimen results in the production of many egg follicles that can be harvested for fertilization. Since the process of stimulating ovulation is expensive, uncomfortable, and potentially dangerous, most clinics want to harvest as many eggs as possible and then fertilize all of them. Ordinarily, only one or two embryos per cycle of IVF is delivered to the woman in the hopes of achieving a pregnancy (but not multiple pregnancies), so the excess embryos are frozen and stored for possible use in future IVF cycles.

The big problem with this situation is that it has created over a million human embryos that are being stored in freezers across the country. Given the Bible’s (and science’s) teaching that human life begins at conception (Ps. 139), the very real possibility of creating children, who are then trapped in “suspended animation” indefinitely, is intolerable. There is a sort of foreswearing that happens when embryos are frozen. Without knowing what will happen in the future, a couple is committing themselves to using every embryo; but there is no way to know if a woman’s health or family circumstances will allow this.

Related to the issue of embryo freezing is a process called preimplantation genetic screening of embryos (PGS). Doctors using PGS fertilize embryos and allow them to develop for a few days, after which they extract cells from the embryo for genetic analysis. This can be done to test for genetic abnormalities, the sex of the baby, or other qualities. The fertility clinic would test all of the embryos and then select those most desirable for implantation. Those embryos with “defects” would be discarded and those without defects would remain frozen for future use. This puts the parents and doctors in the position of deciding who will live and who will die. This kind of testing is itself dangerous to the embryos, and recent studies have shown that embryos with genetic defects in the early stages are often able to repair themselves as they proceed through development.⁴

For a Christian couple to use IVF ethically, they would need to commit to finding a clinic that will respect their religious beliefs and allow them to proceed in a manner consistent with their faith. That would mean refusing to create excess embryos. They would fertilize only the number of eggs they are willing to put into the wife for implantation. Some clinics will allow couples to freeze a woman’s eggs, which do not survive freezing and thawing as well as embryos do. Egg freezing makes sense given the expense and discomfort of the egg collecting process, and there is evidence that it works. There is no ethical dilemma with discarding unused eggs, but having them would create the possibility of doing multiple IVF cycles if needed.

A Christian couple would also have to resist pressure from the clinic to perform some form of PGS on the embryos. In addition to putting the embryos at greater risk, the parents would be put in the position of deciding which of their children live and die. God is the giver of life. He can do this using IVF if He chooses, but we need to honor Him in how we use this technology and resist the urge to turn our children into commodities that we treat like items we choose in a store.

Finally, if a family is in the unenviable position of having embryos frozen in a clinic, I would encourage them to aggressively work to get the embryos adopted. Organizations that promote so-called “snowflake” adoptions seek to find families willing to implant these babies into the wombs of their adoptive mothers. Embryo adoption does not violate the principle of getting people outside the family involved in procreation; it takes an already conceived child and gives that child the opportunity to live.⁵

Seeking Wisdom

Just because ART is available and can be done ethically does not mean it should be done. Pursuing this kind of treatment requires the application of wisdom. A couple experiencing infertility should get the basic medical work done to try to get an accurate diagnosis of the problem first. The solution might turn out to be fairly simple. In the event that it is not, IVF or other forms of ART might make sense, depending on the nature of the cause of the infertility and the age of the wife. The average success rate of IVF in the U.S. is around 24% live births per cycle, but those numbers vary considerably with the age of the mother. A woman who is under 35 has a much higher success rate than a woman who is over 42 (50% success rate per egg retrieval versus 3.9% success rate). Simply put, the older you are, the more likely you will need multiple cycles of IVF in order to have a child.⁶ The CDC actually offers an “IVF Success Estimator” that can estimate a couple’s likelihood of conceiving with IVF based on diagnosis, age, and other factors.⁷

A couple needs to consider seriously the fact that IVF fails to work at least as often as it works. Because of that, they need to prepare for the potential emotional challenges of expending significant effort that might go unrewarded. The average costs for a cycle of IVF are $10–15 thousand in the U.S. This may vary depending on your health insurance and where you live. Couples must consider the reality that they might spend a substantial amount of money and have it not work.

Families considering IVF should definitely evaluate the pros and cons of adoption. Adoption is a wonderful picture of God’s love for us (Eph.1:5), but it is not without its own complications, challenges, and expenses. Still, a person is less likely to pay the full price for an adoption that never happens than to pay for an IVF procedure that fails to produce a child.

In the final analysis, a couple facing infertility should prayerfully consider the options that are open to them, seeking godly counsel from those who know them well. Depending on the specifics of health, age, diagnosis, finances, and calling, pursuing some form of ART could be a wise and God-honoring decision. In some circumstances, the wisest course of action will be to pursue adoption, foster parenting, or some other means of having a godly heritage (Ps. 127:3).

The desire to have children is good. Children are a gift from the Lord. But we must refrain from making an idol of that good gift. We must resist the temptation to compromise in order to achieve a good end. There are ways to use ART that do not involve compromise, in my opinion, but there are ways that do require compromise. The couple considering using ART needs to be settled in their own minds where those lines are. No child has ever been born apart from the will of God. God might use modern medical techniques to enable a couple to conceive. He might not. Either way, we bow before His sovereignty and give Him thanks for giving His only Son for our salvation. As Paul writes in Romans 8:32 (NKJ), “He who did not spare His own Son, but delivered Him up for us all, how shall He not with Him also freely give us all things?”

Resources for further study

CDC Infertility: https://www.cdc.gov/reproductivehealth/Infertility/index.htm.

Grudem, Wayne. How IVF Can Be Morally Right posted on the Gospel Coalition’s website (https://www.thegospelcoalition.org/article/ivf-morally-right/), April 25, 2019.

Szamatowicz, Marian and Jacek. “Proven and unproven methods for diagnosis and treatment of infertility.” Advances in Medical Sciences Volume 65, Issue 1, March 2020, Pages 93-96 (https://www.sciencedirect.com/science/article/pii/S1896112619300252?via%3Dihub).

McConchie, Daniel S. An Ethical Perspective on Reproductive Technologies posted on the website of the Center for Bioethics and Human Dignity (CBHD) of Trinity International University (https://cbhd.org/content/ethical-perspectives-reproductive-technologies) posted on June 7, 1999.

VanDrunen, David. Bioethics and the Christian Life: A Guide to Making Difficult Decisions, Crossway, 2009. See especially chapters 4–6 for a somewhat different take on this issue.

Notes