The Struggle With Infertility If it Pleases God to Give them Children…
When Dave and Jane were going steady, they thought a great deal about having children. During their premarital counselling sessions, the minister asked the important question, “Have you discussed having children?” He didn't ask that question out of idle curiosity, but because having children is a basic purpose of marriage. Well, Dave and Jane looked forward to sharing their life together and to starting a family. They could already see themselves enjoying the blessing of a number of children. Children are a blessing from the Lord, as it says in Psalm 127. They desired that blessing not only for the enrichment of their lives, but also for the benefit of God's kingdom and church. And they expressed that to their minister during the premarital counselling.
Two years later, however, Dave and Jane were still childless. They had almost assumed that there would come a time when they could hold a little one of their own in their arms. But no child came. After a few months of marriage, they had started to worry. They prayed intensely that Jane might conceive. But month after month it was the same. A kind of pain began to set in.
They began to feel uncomfortable whenever the conversation approached the matter of birth and children. Many of the people of the congregation seemed either suspicious or insensitive about their childlessness. At a birthday party at the house of a couple they hung around with, the conversation eventually – as it often did – turned to children. Most of Dave and Jane's friends had children. One of the men had winked at them and stated, “Waiting with kids until the mortgage is paid off, eh?” There had been a tense silence for a few moments, and neither Dave nor Jane had said anything. They were too embarrassed to talk about their childlessness. It was something intimate, something between the two of them yet, and they felt ashamed to talk about their fears and their private struggle openly.
At the last home visit, the elders had touched on the fact that they had no children yet. The matter was clumsily brought forward by the elder. Dave and Jane interpreted the statement as a veiled accusation that they were being blamed for not having children yet, and they closed right up after that. The home visit didn't go well. Afterwards Dave had stated bitterly: “Let them think what they want. I don't care.” And Jane had cried herself to sleep.
Jane had once suggested to Dave that they speak to their doctor about the fact that she wasn't conceiving, but Dave had been negative about it. He had a hard time admitting to others that there was a problem, and he didn't feel comfortable talking to a doctor about it. Dave felt they just had to accept what the Lord gave them to deal with, and that they shouldn't fool around with medical things when it came to having children. Besides, prayer should be enough, shouldn't it? Maybe they didn't have enough faith. Or maybe the Lord was punishing them for something.
Dave and Jane are an imaginary couple. Their struggle with infertility is similar to that of very many Christian couples. This is written in the hope that infertile couples may know that they're not alone, and that there are things that they can do. It is also written in the hope that others may be sensitive to that pain and offer positive advice and support.
The Pain of Infertility
As J. Douma has stated in his book De Tien Geboden III (Kampen: Vanden-Berg, 1988), marriage is conjungium (living together in love and unity), and also matrimonium (from the Latin word for mother, implying the having and raising of children). This two-fold purpose of marriage means that a childless marriage is not an unsuccessful or unfruitful marriage. If there is love and unity between husband and wife, a marriage is already a blessing for both, irrespective of whether or not they have children. However, that does not mean that a couple may therefore willfully decide to remain childless forever. No matter how happy a childless marriage can be, there is something missing. In a certain way, it is an incomplete marriage, as R. vanKooten states in his book Het Zevende Gebod II (Houten: Den Hertog, 1993).
That is why infertility is so painful for Christian couples. That pain is graphically described in the Bible in many places. We know the history of Abraham and Sarah, and Isaac and Rebecca, how they struggled with childlessness in the face of the Lord's promises. It was a test of faith.
Proverbs puts it very succinctly when it states in chapter 30:15, 16 that the barren womb is one of the things that are never satisfied. Infertility naturally causes grief and struggle.
And this pain may be intensified by the words and deeds of those around a couple. By insensitive statements such as, “So, how about it? Don't you think it's time yet?” Or excessive pity, which can also increase the pain of childlessness. When a childless woman visits after the birth of a baby, it sometimes happens that she isn't given the opportunity to hold the baby “because it might hurt her even more.”
This lack of proper sensitivity on the part of others is compounded by extra sensitivity on the part of the couple. It can then become difficult to socialize. The conversation at get-togethers with peers often leads to talk about children. “Hey, did you know that they're expecting another one too?” There is often commiseration about the busyness of a family with children, and the difficulty of getting away for a break. Then someone may turn to the childless couple and say, “You don't have any problem with that, do you? You can come and go whenever you want. Must be nice!” That hurts.
And the pain is long-lasting. Think of the worship services in which children are baptized – prayer for the child and afterwards congratulations for the happy parents. It's often assumed that the pain of infertility disappears over time. But while there are different phases of dealing with infertility over time, the pain doesn't completely fade away. The couples see the children of their friends marry. They have no children who will marry and visit no grandchildren to enjoy. The questions return over and over again. “What are we living for?”
Of course, the pain can become neurotic, as if having children is the only point of life. Remember what Rachel said to Jacob in Genesis 30:1, “Give me children, or I shall die!” Rachel became overwhelmed by her desire for children. Her grief and also her jealousy dragged her down to the point where she became unreasonable towards her husband and also towards God. The pain of infertility may not take over so that there is no enjoyment of any of God's many other blessings anymore.
The pain of infertility, though, is deep and lasting. It can include emotions such as grief, depression, shock, shame, frustration, anger, loss of self-esteem, and feelings of vulnerability. For Christian couples, a major portion of grief occurs because the image of a God who blesses and gives joy is damaged. Infertility forces, to some extent, a re-evaluation of one's relationship with God.
Christian childless couples struggle with the why-question. “Why does the Lord withhold children here while there are so many unwanted children in the world, fetuses which are aborted and children who are abandoned? Are we being punished for something we did? There are couples who are less capable than we are and who have numerous children. Why us, Lord? Why?”
There is no simple answer to the why-question. The full answer will be manifest after the last day. But what we can say on the basis of God's Word is that there is a purpose and a reason for everything, also for infertility. Believing that opens the eyes to God's work in these circumstances too.
God still works good for the couple. In wrestling with their infertility and God's promises in faith, a couple will experience that “testing of faith produces steadfastness” (James 1). Prayer-life and scripture meditation take on special significance as couples work through the acceptance of their infertility.
And infertility doesn't only affect the couple. Family and friends and congregation are confronted with it too. Through this infertility of one couple, the Lord teaches other couples with children that they are a blessing from the Lord, and to be treated as such. The childless couple is, you could say, the conscience of family and church and friends and even society in general. Positively, their childlessness is a constant reminder to others not to regard children as a burden, but as a blessing from the Lord. Negatively, their childlessness confronts all with the awfulness of abortion as well as child neglect and abuse.
In faith an infertile couple may know, as the apostle Paul wrote in Romans 8:28, “that in everything God works for good with those who love Him.” And comforted by that faith, a childless couple can find great purpose and fulfillment in being a blessing to others.
How can a couple deal with childlessness? So many conflicting and differing emotions arise, that it's important to realize that this needs dealing with. It has been compared to a grieving process, similar to the kind that takes place when dealing with the death of a child. Infertility, especially when it has been diagnosed as permanent, is a loss that requires a grieving process in which husband and wife need to support each other.
Communication between husband and wife is extremely important. Expressing the thoughts and feelings each struggles with and discussing and working through them prayerfully together is a great help. One may feel a sense of embarrassment or failure, even resulting in a tendency to withdraw from one's partner. But the avenues of communication need to remain open, especially communication with the Lord.
Being active in the church community as well as in the broader community is also useful. Volunteering is welcomed by all sorts of organizations and institutions. A childless couple can find great fulfillment in giving assistance in programs for the elderly or disabled. Inviting a student or a single over on a regular basis is also a very useful and rewarding way to reach out.
Family and friends can also help. It is already supportive to be sensitive to the fact that a childless couple's pain is deep. That leads to sensitivity in speech. If the infertility is not known but a possibility, for instance, how could you broach the subject sensitively, for instance as church elder? Well, it's more sensitive to ask “Do you hope for children?” than “When are you going to have children?” And if the infertility is known, it is better to say. “It must be difficult. I don't know what it's like,” than to say “Oh, it'll happen someday. Don't worry.” The former statement at least acknowledges the pain, whereas the latter brutally minimizes it and only brings more pain.
One thing that a partner or friend could do to help with the struggle to deal with infertility is to remember the special occasions that there are in a partner's life, or in a childless couple's life. Attention for birthdays and anniversaries is helpful. The childless person or couple are made to feel worthwhile and even needed. Another way to help is to make sure to include childless couples in social events and gatherings. Invite them specifically, and involve them. Let them feel they are valuable to the communion, and integral part of it.
What About Medical Means?
It takes time for a childless couple to accept and deal with their infertility, and so it often takes a long time before a couple visits the doctor with their concerns about not conceiving. Since conception involves sexual intimacy in all its privacy, some couples may also have difficulty building up the courage to talk to the doctor about it. There will be examinations and tests which aren't very pleasant. Others are afraid that medical testing will show who is the infertile one and that this will become a matter of negative feelings between them such as shame or blame.
Conception itself is part of the mystery of God-given life, and this can also make some apprehensive about seeking medical help. “Children are God-given, and it wouldn't be right to use other than the normal means to conceive.” Nowadays there are many medical means which are unsuitable for the Christian, and this can scare a couple away from seeking medical help. It's a lot safer not to have to deal with the ethical choices that have to be made than to have to study them and decide on them on the basis of the Bible.
God gave the means of medical technology to help us in other areas of health, and we are permitted to use this technology, as long as there is no conflict with the Bible. Why should we not make use of technology in the area of procreation? Involving the medical profession at not too late a stage can save years of frustration.
Of course, the couple needs to be careful using treatments that have even the potential to abuse life or that involve destroying life which, as Psalm 139 shows so beautifully, begins at conception. But they do not need to avoid all medical help only because of that potential. It is true that not everything that is medically possible in procreative medicine is ethically right. But as long as husband and wife are fully informed and aware of what is being done, the possibility of making use of medical technology is there.
In seeking medical help, a couple has to take into consideration that involving a doctor will mean embarking on a process that requires quite a bit of intrusion in their lives and a fair bit of effort and commitment and concentration. Maybe also money. There are infertility tests and treatments which are not covered by medical insurance.
A family doctor will usually refer to a specialist. The couple needs to be comfortable with the specialist. They should let him know that they want to deal with this as Christians. The specialist should be open and ready to explain clearly all tests and treatments. That helps with the ethical issues that may arise.
The First Tests
The first tests and treatments are basic. If tests show blocked fallopian tubes or zero sperm count, a couple knows right away what the problem is and what can or cannot be done. Most problems with fertility involve more obvious problems. Many can be dealt with and “cured.” However, there are quite a few cases of infertility where the cause is more difficult to discover, if it can be diagnosed at all. More tests and treatments are then needed, which can be quite exhaustive. In the case of the wife, the tests may include ultrasound, biopsy and laparoscopy.
It is not my purpose to explain all the possible medical procedures and terms. There are, however, some ethical issues that need to be dealt with when it comes to some tests.
A sperm analysis is a usual test for the husband. This test requires obtaining a sample of sperm. Some doctors request the husband to masturbate into a specimen container, and some provide pornographic materials to assist in this. Aside from the fact that it would be unbiblical to use pornographic materials, we would also have a problem with masturbation. In the case of testing, it may be true to some extent that this does not take place for erotic pleasure, but erotic thoughts and sexual gratification outside the actual relationship between husband and wife are involved. This means unchastity in the light of Lord's Day 41 of the Heidelberg Catechism, which includes unchaste thoughts and desires as adultery. The use of seminal collection condoms (Seminal Collection Devices) is a far more ethical alternative, and doctors can be advised of this preference.
It should also be known exactly what is done with the collected samples, including the type of testing. Some tests may sound strange and unethical at first, but are not necessarily so. For instance, the hamster-egg penetration test. In this test, sperm is placed in a dish with the egg from a female hamster to see if it has the capacity to penetrate the egg's surface. This may cause ethical questions, but it cannot produce any life at all, and so I do not see a real ethical problem here. However, it shows that a couple must be watchful with testing and, if they have questions, should not be afraid to consult others.
Once the testing has been completed, treatment may be prescribed. Medications and hormones can be used to help in one or other area of the reproductive system. Again, the couple needs to know what is going on. Some fertility drugs for women can cause multiple conceptions. To counter this, doctors sometimes recommend what is called “pregnancy reduction” or “embryo reduction.” This means that when it is discovered that a woman who has been using fertility drugs has conceived and is carrying a number of fetuses, a doctor deliberately destroys one or more of the fetuses. This is abortion. One or more fetuses are killed, presumably for the health of the mother or the chance of survival of the other fetuses. But Christians take the reality of life from conception onwards very seriously. Only if the health of the mother is seriously imperiled, may we even consider an abortion. To sacrifice one or more sibling fetuses for the sake of the survival of another in this case would, I believe, be unethical.
These ethical issues that may arise when an infertile couple proceeds with testing and treatment are not meant to scare any childless couple away from pursuing medical help, but to emphasize the need for ethical caution all along the way. This means also knowing your Bible and reading up on what has been written from a Reformed perspective about similar issues. There are many books and manuals about this subject which claim to examine the issues from a Christian perspective, but not all have a truly Biblical view of life and procreation. Caution is advised, as well as consultation with officebearers or close family or friends within the communion of saints. If we struggle with an issue, Scripture directs us to the communion of saints. There the Lord provides the advice needed (1 Corinthians 12:7ff).
It also needs to be kept in mind that medical treatments do not always produce the desired results. In fact, they can heighten expectation and therefore also deepen the disappointment when no conception takes place. This, along with the strain of the tests and treatments, can make it a very trying time for couples. They need to remain sober about what is being pursued; remembering always that it is ultimately God alone who gives life. That again calls for constant prayer for His help and blessing together, also help to accept His will if there is no conception as a result of all that has been done.
Assisted Reproduction Techniques
When tests and the less invasive type of treatments prove fruitless, an infertile couple may be faced with the question of whether to stop at that point or to proceed with what are sometimes called assisted reproductive techniques. This is an ethically complex field, and no couple should step into it unless they are strong and sober in a Christian sense in their pursuit of the conception and birth of a child. Exploration of assisted reproduction requires extreme caution for Christians. It would be very understandable if a couple concluded: “We accept our status now, and we intend to concentrate on pursuing adoption or discovering other ways to be fruitful in God's church and kingdom.”
I don't pretend to be an expert in the medical procedures and terms used, but I will attempt to touch some of the basic choices which couples who may wish to pursue assisted reproduction techniques could be offered by doctors.
Artificial insemination (AI) is a common technique today. It is not new, and there are records of it being used already in the 18th century. It can be defined as attempting to bring about conception by the placing of male sperm into the female reproductive system outside of normal sexual intercourse between husband and wife. There are two main kinds of AI: AI using husband sperm (AIH) and AI using donor sperm (AID).
As far as AID is concerned, I agree with J. Douma when he says that it would be wrong for conception to take place outside the context of the sacred union of a husband and a wife. A third party would be involved, and even though he may remain anonymous, the fact remains that this is a far-reaching intrusion into the sacred marriage bond which is unacceptable for Christians. Some have compared AID to adoption of a child. An adopted child is not biologically related to either of the adoptive parents. A child conceived through AID is at least half biologically related. So what could be wrong with AID?
But adopting a child in need of loving parents is something different from desiring a child and causing one to be conceived with the sperm donated by a third party. The biological aspect cannot be ignored or minimized when it comes to being involved in the actual conception of a child. A donor “parents” a child without bothering with that child and its mother. This is clearly wrong when you consider the way God is pleased to work through the generations in the covenant, and requires of parents that they promise to raise their children in the fear of His Name. Adoptive parents would not wish to be regarded as encouraging biological parents to abandon their children so they can be adopted. So we may not encourage men to play a role in the conception of a child which they will never take responsibility for.
Besides the ethical wrong, AID also means entering a minefield of possible psychological and legal problems. The shadow of an anonymous third party who played a role in the conception of a child can cast a dark cloud over a family with an AID child. Donor, child and non-biological father may all have to deal with long term consequences, it has been discovered in recent years. There is a book by A. Baran and R. Pannor which has a telling title: Lethal Secrets: The Shocking Consequences and Unsolved Problems of Artificial Insemination (New York: Warner Books, 1989). The authors have documented many psychological problems that occur as a result of anonymous AID, and propose that it would be better to reveal the biological connections. This, in my opinion, would not solve but multiply the problems, and it does not right the ethical wrong here in any way.
I would argue against surrogate motherhood in similar vein. The surrogate mother may not be biologically related to the embryo placed in her womb and carried to birth by her, but this is a radical intrusion into the sacred unity of marriage which cannot be acceptable to Christians. The womb of another woman is more than simply a temporary incubator or residence for a child. It is a place where the child develops and where a woman actually becomes a mother. This is not something that can simply be ignored. There are cases in which surrogate mothers refused to give up to biological parents the children they carried to birth.
AIH (Artificial Insemination with Husband's Sperm), however, is a method of assisted reproduction that could possibly be used by Christian couples, but with extreme caution. Though sexual intercourse is separated from procreation in the actual procedure, the bond of husband and wife is maintained. The husband's sperm can be collected, concentrated or “washed” and introduced into the wife's reproductive system.
One serious issue that arises here, however, is that because the sperm has to be processed in a lab, there is the possibility of a mix-up of sperm. Recently cases of mix-up have come to light in California and the Netherlands. Eggs were fertilized by sperm from someone who was not the biological father, and I shudder to think of the ramifications of such a discovery. The doctor and lab must be professional and the couple ought to insist on being involved in the processing and procedures as much as possible if this procedure is to be even considered.
There is also a variation of AIH which is called “Gamete Intrafallopian Transfer” (GIFT). This technique is used when the cause of infertility is unknown, when the husband has low sperm count or when the wife has ovulation problems. In this procedure eggs and sperm are both collected, placed together, and immediately transferred into the fallopian tubes of the wife in the hope that fertilization will occur there. This procedure is apparently not unethical itself, as long as it involves husband and wife. However, the drug use required and the retrieval procedure for the wife can be emotionally and physically demanding, and this needs to be considered. The possibility of multiple conception is also present, with all the ramifications as touched on above.
There is a variation of this procedure called “Zygote Intrafallopian Transfer” (ZIFT). In this procedure the sperm and eggs are combined outside the body, but allowed to come to fertilization. A zygote is a fertilized egg which has not yet begun to grow by division. After 24 hours these zygotes are then transferred to the wife's fallopian tubes in the hope that they will continue to develop there. I do not see too much problem in the fact that fertilization of the eggs takes place outside the body itself. However, there is increased ethical risk, if I may call it that. How many of the zygotes are placed back into the fallopian tubes? If some of them are disposed of, the destruction of life takes place. A zygote may be an early stage of conception, but the fact is that we have to do with a human life. And we believe that the destruction of this life is wrong.
In Vitro Fertilization (IVF) is another technique which is commonly suggested by doctors to possibly overcome infertility. It was first successfully used in 1978 in England, but is now a common technique worldwide. In this procedure the wife is usually given fertility drugs, and then mature eggs are “harvested.” These eggs are placed with the husband's sperm in a special solution. After between 48 and 72 hours the eggs are checked to see if they have fertilized. The fertilized eggs are then placed in the wife's uterus where they develop further.
I see no great problem for Christians with the principle of this procedure. That everything is clinical, medical techniques are used and fertilization takes part outside the body cannot be regarded as arguments which make this unethical, as long as the procedure involves husband and wife. However, I would again be concerned with an ethical minefield here.
The Issues at Stake
In the book From Infertility to In Vitro Fertilization (New York: McGraw-Hill, 1988), written by G. Sher, A. Virginia and J. Stoess, the authors list some of the issues couples considering the IVF process have to face. They include:
- how many eggs they wish to have fertilized;
- what should be done with excess eggs;
- how many embryos to have transferred into the uterus;
- how excess embryos are to be disposed of;
- how to deal with large multiple pregnancy (quadruplets or larger).
The authors also state that if a couple wish to be sure of having only one child, they would have to ask for only one embryo to be transferred. But then there is only 8 per cent chance of conception.
What is to be done if not all embryos are implanted into the womb? This is a major ethical issue. The authors above suggest freezing extra embryos for later transfer. While this may appear to be very unethical in itself, the problem is that many – up to 50 per cent – of the embryos are destroyed in the freezing process. I see this then as a process which lets human life perish, after deliberately causing conditions which promote the conception of that life. Then there are also the legalities surrounding the frozen embryos. What is to happen with them if couple's divorce or die in an accident? Even now there are custody battles in courts over frozen embryos. And simply letting the embryos die would represent disregard for human life too.
Dr. J. Douma, in his Tien Geboden III, states that IVF does not need to be rejected by Christian couples as long as certain stringent conditions are met. That means as long as all fertilized eggs are used by the couple and then as soon as possible, in case the wife suddenly loses her life, for instance in an accident. However, I then also agree with R. vanKooten in Gij Zult Niet Echtbreken II that setting such stringent conditions is unrealistic and makes IVF quite an unattractive option for infertile couples to pursue. It's possible for a Reformed couple to use it, but then there must be extensive knowledge of what the doctors are saying and doing, and extreme control over what happens with every fertilized egg. The ethical concentration and concern seem quite overwhelming.
A Family of Three…
Much of the above also applies to couples who deal with what is known as “secondary infertility.” This refers to couples who are unable to conceive or carry a child to term following the birth of one or more children. Couples with secondary infertility experience similar emotions and pain as couples with primary infertility. Although there may be problems unique only to secondary infertility, the types of tests and treatments are similar, as are the ethical issues. The struggle of couples with secondary infertility also needs to be recognized, by both couple and family and friends, as well as officebearers.
A Family of Two…
After all ethical medical treatments and procedures have been followed, it may be that the Lord in His wisdom still does not grant a couple biological children. That is a possibility that must be kept in mind all through the treatments, and a reality that must be prayerfully accepted if it is so. We can make our plans, but the outcome is in the Lord's hands (Proverbs 16:1). That still doesn't mean that a couple must remain childless, however. There is also the possibility of adoption. I hope to return to that topic later in this magazine.
If a couple decides not to pursue medical means any longer at a certain point, and they accept their childlessness, they should not be pressured by others to still pursue every means to have children. Having children may not become an end in itself. The purpose of life and marriage is also to serve and glorify God in whatever state or circumstances He places us. There is ample opportunity for a childless couple to do so, beginning in the communion of saints but also looking beyond. There is much to be done for the kingdom of God. And His promises are sure. A childless couple may in all their struggles and painful moments hold on to God's covenant promise in Psalm 103:5 where He says that He will “satisfy you with good as long as you live.”