Why the Medical Research Council refused Robert Edwards and Patrick Steptoe support for research on human conception in 1971

Made, Not Begotten: IVF and the Right to Life Under Conditions

In a society in which the decoupling of sexuality and human reproduction has become normal, In vitro fertilization (IVF) has mutated into a kind of standard procedure. There is little awareness of the ethical ruptures that the mechanization of human reproduction causes. The basic ethical problem with extracorporeal fertilization in a test tube is that a child is not conceived through the personal union of a man and a woman, but is "produced" in a laboratory. In the context of human creation, this entails a series of ethical problems. The technique does not merely offer another possible option for action, but it leads to a fundamental change in the attitude towards human life as such. A look at the history of assisted reproductive technology (ART) since the 1970s reveals that ethical problems, eugenic visions as well as medical experiments on humans have been inherent to the method from the very beginning. Considering that eugenic thinking has been a driving force from the very beginning it astonishes that this delicate point has hardly been recognized and highlighted so far. Robert Edwards' (1925-2013) vision went far beyond the mere treatment of infertility through the use of IVF, which he saw as enabling the selection of so-called "unhealthy life." The article considers the risks of IVF and includes recent studies by physicians involved in reproductive medicine who are increasingly critical of their industry. Furthermore it emphasizes the core ethical question on human reproductive technology, contrasting the "ethics of procreation" with the "ethics of production."

Summary

The article highlights historical aspects, considers the risks as well as the ethical questions on assisted reproductive technology.

Grant writing and grant peer review as questionable research practices

A large part of governmental research funding is currently distributed through the peer review of project proposals. In this paper, we argue that such funding systems incentivize and even force researchers to violate five moral values, each of which is central to commonly used scientific codes of conduct. Our argument complements existing epistemic arguments against peer-review project funding systems and, accordingly, strengthens the mounting calls for reform of these systems.

Grant writing and grant peer review as questionable research practices

A large part of governmental research funding is currently distributed through the peer review of project proposals. In this paper, we argue that such funding systems incentivize and even force researchers to violate five moral values, each of which is central to commonly used scientific codes of conduct. Our argument complements existing epistemic arguments against peer-review project funding systems and, accordingly, strengthens the mounting calls for reform of these systems.

Human gastrulation: The embryo and its models

Technical and ethical limitations create a challenge to study early human development, especially following the first 3 weeks of development after fertilization, when the fundamental aspects of the body plan are established through the process called gastrulation. As a consequence, our current understanding of human development is mostly based on the anatomical and histological studies on Carnegie Collection of human embryos, which were carried out more than half a century ago. Due to the 14-day rule on human embryo research, there have been no experimental studies beyond the fourteenth day of human development. Mutagenesis studies on animal models, mostly in mouse, are often extrapolated to human embryos to understand the transcriptional regulation of human development. However, due to the existence of significant differences in their morphological and molecular features as well as the time scale of their development, it is obvious that complete knowledge of human development can be achieved only by studying the human embryo. These studies require a cellular framework. Here we summarize the cellular, molecular, and temporal aspects associated with human gastrulation and discuss how they relate to existing human PSCs based models of early development.

Reconstructing Robert Edwards: biography and the history of reproduction

This commentary assesses Let There Be Life: An Intimate Portrait of Robert Edwards and His IVF Revolution by Roger Gosden (Jamestowne Bookworks, Williamsburg, VA, 2019, xxix + 359 pp., £15.99 / $19.99), an authorized biography of the IVF pioneer who founded this journal. It reflects on the challenges of placing Edwards in the history of studying reproduction, especially the rise of interest in infertility. It analyses Gosden's narrative choices and practices of reconstruction, in particular of experiences of seeing human eggs, embryos and fetuses. And it suggests that further research should explore the full spectrum of communication around Edwards with a view to illuminating the roles of scientists in transforming reproduction and to feeding back into a richer view of his life.

IVF: The women who helped make it happen

In this paper I pay tribute to four named women and 280 unidentified women patients for their essential roles in supporting Bob Edwards and Patrick Steptoe during the pioneering early days of IVF. The four named women are Jean Purdy, Muriel Harris, Lillian Lincoln Howell and Ruth Fowler.

Looking into the Test Tube: The Birth of IVF on British Television

The birth of Louise Brown, the world's first 'test-tube baby', has come to signify the moment at which technologically assisted human reproduction became a re ality. This was a highly mediated and visible reality, as this article explores through the example of a British television documentary about Louise Brown broadcast when she was just six weeks old, 'To Mrs Brown… A Daughter' (Thames Television, 1978). In the article, I discuss the programme alongside data from an interview with its producer, Peter Williams. Williams sought to convince the public that IVF was morally acceptable and to cultivate sympathy for the infertile through this film. I will consider how he went about this by focusing on the programme's visual presentation of Louise Brown, Peter Williams' aims in making the film and his sympathetic relationship with the 'pioneers' of IVF, gynaecologist Patrick Steptoe and physiologist Robert Edwards. I will conclude with a discussion of the political implications of this film and how it contributed to the normalisation of IVF at a pivotal moment in its history.

Founding Pioneers of IVF: Independent innovative researchers generating livebirths within 4 years of the first birth

In this 40th anniversary year of the first IVF live birth, it is pertinent to look at all those teams endeavouring to generate live births from this unique technology and who succeeded within 4 years of the first. There were 9 teams who achieved this and a further 3 who were successful soon after, by the end of 1982. This historical review is compiled by 2 authors who were actively engaged in the field of IVF at the time of the first birth and who have remained active in Reproductive Medicine throughout their professional lives. They bring intimate and relevant knowledge of those pioneer researchers from the early years who can be classified as the "Founding Pioneers" of IVF.

'The men who made the breakthrough': How the British press represented Patrick Steptoe and Robert Edwards in 1978

This article examines how the British press represented Patrick Steptoe and Robert Edwards in the story of the birth of the first 'test-tube baby', Louise Brown. In 1978, the British press represented the birth of Louise Brown as both a success and a source of hope. The main pairs of protagonists in this story were Steptoe and Edwards and Lesley and John Brown, who metonymically represented British science and infertile couples, respectively. In the dominant 'success' narrative of the birth of Louise Brown as depicted in the British press in 1978, Edwards and Steptoe seemed to embody 'British' values of industriousness, perseverance, altruism, ingenuity and teamwork. Thus, their success was simultaneously a British success. With Louise Brown's birth, in-vitro fertilization came to stand for the potential happiness of infertile people and a bright future for British science and industry.

From Embryos to Adults: A DOHaD Perspective on In Vitro Fertilization and Other Assisted Reproductive Technologies

Human in vitro fertilization (IVF) as a treatment for infertility is regarded as one of the most outstanding accomplishments of the 20th century, and its use has grown dramatically since the late 1970s. Although IVF is considered safe and the majority of children appear healthy, reproductive technologies have been viewed with some skepticism since the in vitro environment deviates substantially from that in vivo. This is increasingly significant because the Developmental Origins of Health and Disease (DOHaD) hypothesis has illuminated the sensitivity of an organism to its environment at critical stages during development, including how suboptimal exposures restricted specifically to gamete maturation or the preimplantation period can affect postnatal growth, glucose metabolism, fat deposition, and vascular function. Today, some of the physiological metabolic phenotypes present in animal models of IVF have begun to emerge in human IVF children, but it remains unclear whether or not in vitro embryo manipulation will have lasting health consequences in the offspring. Our expanding knowledge of the DOHaD field is fueling a paradigm shift in how disease susceptibility is viewed across the life course, with particular emphasis on the importance of collecting detailed exposure information, identifying biomarkers of health, and performing longitudinal studies for any medical treatment occurring during a developmentally vulnerable period. As IVF use continues to rise, it will be highly valuable to incorporate DOHaD concepts into the clinical arena and future approaches to public health policy.

The birth and routinization of IVF in China

How can it be that China, with its history of restrictive family planning policies, is today home to some of the world's largest IVF clinics, carrying out as many as 30,000 cycles annually? This article addresses how IVF was developed in China during the early 1980s, becoming routinized at the same time as one of the world's most comprehensive family planning programmes aimed at preventing birth was being rolled out. IVF was not merely imported into China; rather it was experimentally developed within China into a form suitable for its restrictive family planning regulations. As a result, IVF and other procedures of assisted reproductive technology have settled alongside contraception, sterilization and abortion as yet another technology of birth control.

Introduction

The contributions to this Symposium issue of RBMS have been prepared following a unique meeting held at Yale University in April 2015 entitled IVF: Global Histories. The articles gathered here present empirical histories of the development of IVF in various countries. These are not intended to be ethnographic, or to develop major new theoretical or conceptual arguments, but rather aim to be indicative case studies situating the development of IVF in specific national contexts with an emphasis on how particular societal influences in the various countries affected the development of the IVF industries there. To date, these histories have never been documented. This Symposium issue aims to begin to rectify this deficit, and to encourage further similar studies of the global development of IVF.

The future of human uterus transplantation

The only untreatable subgroup of female infertility is absolute uterine factor infertility (AUFI), which is due to congenital or surgical absence of a uterus or presence of a nonfunctional uterus. The solitary option for a woman with AUFI to become a biological mother today is through a gestational surrogate mother, a procedure that is prohibited in Sweden and large parts of the world. Uterus transplantation (UTx) is a potential future treatment of AUFI. After extensive animal research, also involving non-human primates, a small number of human UTx cases have recently been performed. Here, we summarize the primate UTx experiments that have paved the way for the human UTx cases, which are described and analyzed in more detail. We also estimate how many women of fertile age are affected by AUFI and describe the causes. The ethics around UTx is complex and is also addressed.

Germline genome-editing research and its socioethical implications

Genetically modifying eggs, sperm, and zygotes ('germline' modification) can impact on the entire body of the resulting individual and on subsequent generations. With the advent of genome-editing technology, human germline gene modification is no longer theoretical. Owing to increasing concerns about human germline gene modification, a voluntary moratorium on human genome-editing research and/or the clinical application of human germline genome editing has recently been called for. However, whether such research should be suspended or encouraged warrants careful consideration. The present article reviews recent research on mammalian germline genome editing, discusses the importance of public dialogue on the socioethical implications of human germline genome-editing research, and considers the relevant guidelines and legislation in different countries.

The Oldham Notebooks: an analysis of the development of IVF 1969-1978. VI. Sources of support and patterns of expenditure

Three major sources of financial support for the research undertaken by Edwards, Steptoe and Purdy between 1969 and 1978 are identified: the Ford Foundation, Oldham and District General Hospital (ODGH) Management Committee, and Miss Lillian Lincoln Howell via the American Friends of Cambridge University. Significant possible financial support from the World Health Organization was also identified. In addition, evidence of support in kind from GD Searle and Co. plus staff at ODGH was found. Expenditure on salaries of staff at Oldham was negligible, as most volunteered their time outside of their official paid duties. Work in Cambridge was evidently funded largely from Ford Foundation grants, as was Edwards' salary and probably that of Purdy. Clinical costs seem to have been largely borne by ODGH. The funds from Lillian Lincoln Howell supported travel and accommodation costs plus office costs. Overall, Edwards, Steptoe and Purdy achieved reasonable support for the programme of research, despite the initial rejection of funding by the Medical Research Council. However, this was at the expense of considerable inconvenience to Purdy and Edwards, and depended upon the good will of staff led by Muriel Harris in Oldham, who donated their time and expertise. As a result of our research, we conclude that, to Edwards, Steptoe and Purdy, should be added the names of two other hitherto neglected people who were essential to the success of this pioneering research: namely Muriel Harris and Lillian Lincoln Howell.

The Oldham Notebooks: an analysis of the development of IVF 1969-1978. I. Introduction, materials and methods

In this introductory paper, we describe the primary source material studied in this Symposium, namely a set of 21 notebooks and 571 pages of loose sheets and scraps of paper, which, on cross-referencing, have allowed us to reconstruct the sequence, timing and numbers of the laparoscopic cycles planned, attempted and undertaken between 9 January 1969 and 1 August 1978 by Robert Edwards, Patrick Steptoe and Jean Purdy in Oldham, UK, as well as to identify most of the patients involved. In addition, we describe the background to the five papers that follow, and the secondary sources and recorded interviews, which have provided useful ancillary material.

The Oldham Notebooks: an analysis of the development of IVF 1969-1978. IV. Ethical aspects

Six evidential sources are examined to investigate how Edwards and Steptoe applied ethical standards to their research leading to the birth of Louise Brown: (i) Their own contemporary writings from 1970 onwards. (ii) Archival evidence from the British Medical Association (BMA), the British Association for the Advancement of Science (BAAS), and correspondence between Edwards and the Ford Foundation. (iii) Minutes of Oldham General Hospital (OGH) Ethics Committee. (iv) Letters by Edwards to prospective patients. (v) oral evidence from interviews with a patient and colleagues. (vi) Evidence from their clinical case management of patients. Taken together these sources suggest that Edwards and Steptoe demonstrated a strong awareness of the ethical issues involved, and offer evidence of honesty to patients about the realistic prospects of success and ethical practice. Nonetheless, decisive evidence that ethical aspirations were put into practice is not available.

The Oldham Notebooks: an analysis of the development of IVF 1969-1978. II. The treatment cycles and their outcomes

This paper reports on the numbers of treatment cycles involved in the development of IVF (1969-1978) and their outcomes. We show that between 1969 and 1978: (i) a minimum of 282 women were involved in 495 cycles of potential laparoscopic oocyte retrieval (LOR); (ii) of these cycles, 457/495 proceeded to LOR to attempt egg collection; (iii) of which an outcome was recorded in 436/457; (iv) eggs were recovered in 388/436 of these; (v) inseminations were recorded in 331/388; (vi) embryos were recorded in at least 167; (vii) a total of 112 embryo transfers were attempted; and (viii) a maximum of 11 possible biochemical/preclinical pregnancies plus five clinical pregnancies were observed; (ix) from which two healthy live births resulted.

Making birth defects 'preventable': pre-conceptional vitamin supplements and the politics of risk reduction

Since the mid-1990s, governments and health organizations around the world have adopted policies designed to increase women's intake of the B-vitamin 'folic acid' before and during the first weeks of pregnancy. Building on initial clinical research in the United Kingdom, folic acid supplementation has been shown to lower the incidence of neural tube defects (NTDs). Recent debate has focused principally on the need for mandatory fortification of grain products with this vitamin. This article takes a longer view, tracing the transformation of folic acid from a routine prenatal supplement to reduce the risk of anaemia to a routine 'pre-conceptional' supplement to 'prevent' birth defects. Understood in the 1950s in relation to social problems of poverty and malnutrition, NTDs were by the end of the century more likely to be attributed to individual failings. This transition was closely associated with a second. Folic acid supplements were initially prescribed to 'high-risk' women who had previously borne a child with a NTD. By the mid-1990s, they were recommended for all women of childbearing age. The acceptance of folic acid as a 'risk-reducing drug' both relied upon and helped to advance the development of preventive and clinical practices concerned with women's health before pregnancy.

Evidence-based medicine and the role of the National Health Service in assisted reproduction

The wholesale introduction of any new procedure to medical practice requires an acceptance based on evidence-based medicine, which is primarily acquired using prospective randomized controlled trials. However, for self-funded treatments, as are the majority of IVF cycles, this has always been very difficult to achieve. Generally, new technologies are introduced and adopted by patients who have failed in previous attempts at IVF. Urging patients to enter into a prospective randomized controlled trial is problematic, especially when they are self-funding; eagerness to conceive when time is against them, and/or having undergone previously failed treatment attempts, convince most patients to fund the new technology/opportunity rather than risk falling into the control arm and repeating their previous failure(s). The UK is uniquely placed to advance IVF medicine by helping practitioners and patients gain access to vital trials through the National Health Service.

The wobbly evidence base of reproductive medicine

In assisted reproduction, there is strong evidence for some things done, but no or only very weak evidence for others. There are several reasons for this. Most assisted reproduction procedures have small signal-to-noise ratios. This means that their treatment effect is sometimes only little better than the spontaneous conception rate, or the conception rate with traditional treatment. Hence, large trials are required. These demand complex multicentre logistics. The latter require substantial funding and funding for reproductive medicine in most countries is notoriously difficult to obtain (as opposed, for example, to oncology research or cardiovascular research). Apart from these funding issues, the creation of embryos specifically for research is only allowed in a limited number of European countries, thus tempting clinicians to skip preclinical studies altogether and go directly for clinical application in their patients, raising an ethical issue. Introducing new treatments into the clinic without proper evidence, however, is perhaps even more of an ethical issue. Subfertile couples are very vulnerable and should not be exploited.

On being a (modern) scientist: risks of public engagement in the UK interspecies embryo debate

In 2006, a small group of UK academic scientists made headlines when they proposed the creation of interspecies embryos - mixing human and animal genetic material. A public campaign was fought to mobilize support for the research. Drawing on interviews with the key scientists involved, this paper argues that engaging the public through communicating their ideas via the media can result in tensions between the necessity of, and inherent dangers in, scientists campaigning on controversial issues. Some scientists believed that communicating science had damaged their professional standing in the eyes of their peers, who, in turn, policed the boundaries around what they believed constituted a "good" scientist. Tensions between promoting "science" versus promotion of the "scientist;" engaging the public versus publishing peer-reviewed articles and winning grants; and building expectations versus overhyping the science reveal the difficult choices scientists in the modern world have to make over the potential gains and risks of communicating science. We conclude that although scientists' participation in public debates is often encouraged, the rewards of such engagement remain. Moreover, this participation can detrimentally affect scientists' careers.

IVF and embryo transfer: historical origin and development

IVF and embryo transfer for the treatment of human infertility has now resulted in the birth of over 4 million babies. The technique did not arise as a quantum event but was built on the efforts of many earlier workers in the fields of reproductive endocrinology and development. One should remember the famous saying of Isaac Newton: 'If I have seen further than most, it is because I have stood on the shoulder's of giants'. Ethical and moral issues have always arisen when investigators study early mammalian development, particularly human development. This paper documents these earlier studies and also draws attention to the ethical and moral arguments that inevitably arose.

Robert Edwards: the path to IVF

The early influences on Robert Edwards’ approach to the scientific research that led to human IVF are described. His interest as a graduate student in the genetics of early mammalian development stimulated him later to investigate whether the origins of human genetic diseases such as Down, Klinefelter and Turner syndromes might be explained by events during egg maturation. This clinical problem provided the most powerful stimulus to achieve both oocyte maturation and fertilization in vitro in humans. Indeed,preimplantation genetic diagnosis was his main goal until he met Patrick Steptoe in 1968. A re-evaluation of his meeting with Steptoe suggests that initially Steptoe’s laparoscopic skill was of interest for its potential to solve the sperm capacitation problem. Steptoe’simpact on Edwards was twofold. First, Steptoe’s long-held interest in infertility raised this application of IVF higher in Edwards’priorities. Second, Steptoe offered a long-term partnership, in which oocyte collection without in-vitro maturation was a possibility.The professional criticism generated by their work together encouraged Edwards to pursue a deliberate programme of public education about the issues raised and to challenge and develop professional bioethical thought and discourse about reproduction.

Innovative reproductive technologies: risks and responsibilities

In view of the global burden of subfertility, efforts are required to make assisted reproduction more effective, less burdensome and more equally accessible. New reproductive technologies are frequently introduced in clinical practice without a sound evaluation of their efficacy, effectiveness and/or safety. Safety issues in this context refer both to patients (mostly women) undergoing the relevant medical procedures, and to the health of children born as a result. Responsible innovation requires making potentially risky reproductive technologies the subject of research, ideally proceeding through the steps of preclinical investigations, clinical trials and (long-term) follow-up studies. The European Society of Human Reproduction and Embryology is especially equipped to take the lead here.

The politics of human embryo research and the motivation to achieve PGD

This article reports a historical study of factors influencing the achievement of clinical preimplantation genetic diagnosis (PGD) in 1990, 22 years after its first demonstration in animals. During the 1970s, research on PGD continued in large farm animals, but serious interest in human PGD was not evident until 1986. First, interest in PGD during the 1970s waned with the advent of prenatal testing, which for gynaecologists was clinically more familiar, technically simpler and ethically less challenging than IVF. Indeed, IVF was viewed with widespread suspicion until the first IVF births in 1978. Second, interest in clinical PGD was stimulated by the UK Parliamentary reaction against human embryo research that greeted the Warnock Report in 1984. This hostility led scientists to initiate a pro-research campaign, further galvanized in 1985 by MP Enoch Powell’s bid to ban such research. However, while Powell abhorred embryo research, he approved of PGD, a stance that divided the anti-research lobby. Accordingly, the campaigners for research emphasized that it was needed to achieve PGD. Powell demanded evidence of such projects and PGD research increased from 1986. It is concluded that UK political debates on embryo research played a critical role in stimulating the achievement of clinical PGD.

Human pregnancies following preimplantation genetic diagnosis (PGD) for embryo sex were announced in 1990, 22 years after the technique was pioneered in animals. PGD in humans required not only technological advances, such as IVF and sensitive diagnostic tests, but also the motivation to develop and apply them. Our historical analysis shows that, although research on PGD continued in large farm animals during the 1970s, and techniques of the required sensitivity were developed on mouse embryo models, interest in clinical PGD was not evident until 1986. Two factors stimulated this sudden change in motivation. First, interest in PGD was depressed during the 1970s by the advent of prenatal diagnostic techniques, which for gynaecologists were clinically, technically and ethically less challenging than IVF. IVF was then regarded with a suspicion that only started to wane in the early 1980s following the first IVF births. Second, the UK Parliamentary reaction against human embryo research that greeted the Warnock Report in 1984 provided a positive stimulus to clinical PGD by prompting scientists to form a pro-research lobby, which was further galvanized in early 1985 by MP Enoch Powell’s almost-successful bid to ban human embryo research. We show that while Powell abhorred embryo research, he approved of PGD, a stance that fractured the unity of the anti-research lobby. Accordingly, the pro-research lobby emphasized that embryo research was needed to achieve PGD. Powell demanded evidence of such projects, thereby, we argue, stimulating PGD research from 1986. Our evidence shows that UK political debates about PGD played a critical role in stimulating the achievement of PGD clinically.