1993 / 11月
Chang Chung-fang /photos courtesy of Hsueh Chi-kuang /tr. by Brent Heinrich
In the past, many people traveled to Taiwan from foreign lands in order to see a dentist or have a physical examination. Today, many people come to Taiwan in search of offspring.
Right before Christmas of last year, Mrs. Li came with her husband to Taiwan from Hong Kong. This visit was not for business nor was it for a holiday; it was especially to receive a "test-tube baby" operation. She explains that in Hong Kong to have the operation requires HK$100,000 (more than NT$300,000); in Taiwan it costs a third of the amount. "The price is cheap and the technology is good. Of course, we came to Taiwan to have it done!" she says.
Her husband left early to return to Hong Kong, and Mrs. Li stayed at the house of a Taiwan friend for a month and a half. After the operation was confirmed a success, she joyously return to Hong Kong, carrying in her tummy a little Christmas gift. She added that next year she would come again to conceive her second child.Seeking a child in the motherland:
Mrs. Li is anything but unique. Chang Sheng-ping, Director of Obstetrics and Gynecology at Taiwan Veteran's General Hospital, points out that Veteran's General averages 500 patients undergoing in vitro fertilization (popularly known as "test-tube baby" operations) every year, more than 50 of whom are overseas Chinese. The heavy seasons are summer vacation and around Christmas, at which time overseas Chinese from all sorts of countries--the United States, Japan, Hong Kong, and Southeast Asia--arrive in large numbers.
According to the analysis of Chang Sheng-ping and Associate Professor at National Cheng Kung University Hospital College of Medicine Liu Chi-hung, the reasons for overseas Chinese' traveling large distances to receive test-tube babies usual ly are low cost, ease in communication, and advanced technology.
Because artificial reproductive technology is not covered by health insurance, the price for the complicated in vitro fertilization procedure is exorbitant. For example, in the United States, the cost of one cycle of treatment (whether it succeeds or fails) is approximately US$10,000. In England the price of one cycle of treatment is about £10,000 (more than NT$400,000). By comparison, the fees in Taiwan of NT$70,000 to NT$80,000 are quite reasonable.
Furthermore, the problems of communication also lead many overseas Chinese to return home for medical help. Liu Chi-hung explains that the in vitro fertilization procedures are delicate and complex. They require detailed communication, and medical explanations are not easy to understand. With a common cultural background and language, communication is much smoother.High technology, low, low price:
Chang Sheng-ping observes that many countries such as the US, Australia, England and Belgium have already developed good skills in the science of making test tube babies, and in the last two or three years, Taiwan has attained an international standard in this area, as well.
For example, at Veteran's General Hospital, the success rate for each cycle of in vitro fertilization is about three out of ten. According to a report in the US journal Fertility and Sterility, the success rate for test-tube babies in America in 1991 was 25% .
In terms of volume, the United States has 175 in vitro fertilization centers; only 16 of these centers treat more than 200 patients a year. Chang Sheng-ping points out that last year Veteran's General treated more than 500 patients. "It easily ranks number five or six in the world."
Approximately 20 medical centers or clinics are currently engaged in in vitro fertilization treatment. Among these, Veteran's General, National Taiwan University Hospital, Chang Gung Memorial Hospital, and Chungshan Hospital take the lion's share of patients.
Liu Chi-hung, who did research and treatment in the area of test-tube babies first at the National Taiwan University Hospital, then at Cheng Kung University, and who entered into private practice last year, asserts that all the physicians working with in vitro fertilization are of the younger generation, and they often cooperate with each other. When new technology appears in other countries, Taiwan quickly follows suit.
In 1989, Liu Chi-hung set a record by being the first physician in Asia to successfully complete in vitro fertilization using frozen embryos ("Cryopreservation of Embryos"). Already there are two or three medical centers performing the latest techniques, such as "Micromanipulation of Sperm and Eggs" and "Assisted Hatching."Where the problem comes from:
In reality, there is a close connection between advances in test-tube baby technology and the high demand.
As Confucius declared, "There are three great unfilial acts, and the worst of these is not bearing offspring." It seems that no matter where you live, if you are Chinese you are not exempt from the responsibility and mission of carrying on the family line. Unfortunately, there tend to be more and more couples who face problems in child bearing. According to a study taken on behalf of the Chinese Fertility Society by Liu Chi-hung, former director of Obstetrics and Gynecology at Cheng Kung University College of Medicine, currently one out of every seven married couples can not achieve pregnancy. Overall, approximately 470,000 couples face some form of disturbance in giving birth.
Compared to ten years ago, when only one in ten couples could not achieve pregnancy, the rapid increase in the number of cases of infertility today is startling. Having researched the causes, Liu Chi-hung points out that modern people are increasingly getting married at a later time in life, and after marriage they put off bearing children even further. This increases the rate of infertility. Moreover, with social liberalizations, sexual relationships have become more complex. With increased work pressure and the ill effects of environmental pollution, the reproductive systems of both men and women have sustained direct damage. The capabilities of the ovary and the potency of the sperm have gotten worse, and the likelihood of childbirth has naturally diminished.Last chance to board the childbirth train:
Fortunately, the development of in vitro fertilization has solved some of the problems of infertility.
In July of this year, a married couple who had suffered the torment of infertility received the assistance of in vitro fertilization technology and smoothly gave birth to a baby girl. They were so happy that they both burst into tears. This couple had been married six years. The husband was an only son, and his mother had been widowed for nearly 30 years. When faced with his mother's nervous expectations, the anxious enquiries of close friends and the well-meaning concern of neighbors, their sense of great pressure could be easily understood. They had gone through all kinds of examinations and undergone in vitro fertilization seven times at four different hospitals. They had even traveled to the United States to attend the hospital with the highest success rate for in vitro fertilization, and returned disappointed.
Having exhausted all possibility and finding themselves in a hopeless predicament, they had considered adoption, finding a mistress, or going to mainland China to hire a woman to bear them a child. They had even begun to entertain thoughts of divorce. Fortunately, their perseverance finally won the pity of heaven, and with the encouragement and treatment of Doctor Liu Chi-hung, they finally succeeded in bearing a child.
This father who now knew joy after so much pain wrote a thank you note to the doctor, in which he described his sensation upon receiving the good news: "After work one day ten months ago, I was stuck at an intersection in a traffic jam, and you telephoned to inform me that my wife was pregnant. At that moment I was so excited and joyful that for a long time I couldn't contain myself. For as long as five or six minutes I couldn't control the steering wheel, and I caused a great mess in traffic . . . ."The process of creation is not simple:
Most in vitro fertilization operations proceed in the following manner. The process of test-tube baby creation is divided into two stages: external fertilization and implantation of the fertilized embryo.
Firstly, the patient undergoing treatment must receive medicine to stimulate ovulation, so that the ovaries produce more follicles. The follicles' growth is observed with ultrasound until the eggs have matured, at which time laparoscopy or ultrasound is used to precisely extract the eggs ("Transvaginal Ultrasound-Guided Ovum Pickup").
The extracted eggs and cleanly processed sperm cells are placed in a petri dish for fertilization. They must be cultivated for 48 hours in a petri dish that is perfectly compatible with the internal environment of the human body (37℃, 5% CO2, 100% humidity). After two to four eggs are fertilized, the embryos are implanted in the mother's womb and allowed to stabilize and grow. After they are returned to the mother's body, they must enter the mother's uterus, in the same manner as any other pregnancy.
This kind of circulation is called a "cycle." Some women meet with success on the first cycle; others go through several cycles with no favorable outcome. Chang Sheng-ping observes that patients who have already gone through six cycles without becoming pregnant have a very slim chance of a positive result. Liu Chi-hung also estimates that 10% of the patients will not meet with success no matter what methods are used, and the reasons remain unclear.
Chang Sheng-ping points out that during the process of natural pregnancy, fertilized eggs that result in pregnancy usually leave the fallopian tube and enter the uterus within 72 hours. Test-tube babies only have the three days spent in the external fertilization process to substitute for the passage through the fallopian tube.
It is evident, therefore, that the test tube will not eventually replace the womb. The popular term "test-tube baby" only indicates the place where insemination occurs; pregnancy can never be accomplished in a test tube. In vitro fertilization techniques can only increase the chances of pregnancy for those with few other alternatives. We are still a great long way from "creating human life."Natural mother becomes foster mother:
Not every infertile woman can receive treatment through in vitro fertilization. Neither can everyone who seeks help through this procedure necessarily gain the child they long for.
Liu Chi-hung notes that the test tube can not take the place of the womb. But surrogate motherhood is also in conflict with the law, and it has consistently been unable to be legalized. Civil law in the Republic of China stipulates that the woman who physically gives birth to a child is that child's legal mother. In this way, the surrogate mother becomes the legal mother; conversely, the real mother becomes the adoptive mother. Because of these problems, no matter how much in vitro fertilization techniques improve, they will be of no help at all to women with injured wombs or those who have previously received a hysterectomy.
Those whom it helps the most are patients with diseases of the fallopian tubes. Liu Chi-hung notes that in the past women with severely blocked fallopian tubes had nearly no hope of bearing children. In vitro fertilization greatly increases the chances of pregnancy for these kinds of patients.
According to Chang Sheng-ping's estimate, 80% of patients receiving the aid of in vitro fertilization suffer from blocked fallopian tubes. Ten percent suffer adverse troubles in the membrane wall of the uterus. The remaining patients seek help because of reproductive problems of the male partner, uneasily determined pregnancy problems, etc.
Besides this, to undergo in vitro fertilization, one still must fulfill several basic conditions. As Chang Sheng-ping explains, the first condition is that both the husband and wife be healthy both physically and mentally. They must have no other medical problems. In this regard, there is also a limit in age. As a rule, men must be under 55 years; women must be under 45.Are manufactured children different?
This year in July and September Tri Service General Hospital and Chang Gung Memorial Hospital independently discovered cases of test-tube babies with Down's Syndrome. This hardly alleviates the suspicions that people have about in vitro fertilization. Many people can not comprehend the cause of these problems: since the embryo has undergone screening beforehand, how can they not perform "quality control"?
Actually, the screening involved in the in vitro fertilization process has nothing to do with the good or bad properties of the genes. Liu Chi-hung explains that the purpose of the screening process is to increase the likelihood of pregnancy. Sperm cells with the soundest forms and the most powerful motion will have the most successful fortunes. In terms of the embryos, those which are round, transparent, uniform, and have no jagged imperfections are most likely to do well. Liu Chi-hung emphasizes, "The success of an embryo doesn't necessarily have any relationship with its genetic makeup."
Therefore, any disease or impairment that a naturally fertilized embryo may fall ill to, an artificially ferilized embryo may, as well. This includes Down's Syndrome, which is brought about by mutation in the chromosomes. Liu Chi-hung believes that test-tube babies with Down's Syndrome should be attributed to inadequate testing during pregnancy; it has no connection to the in vitro fertilization process. According to estimates, the rate of abnormality among test-tube babies is about the same as that among naturally conceived children, approximately 2-3%.Specially gifted test-tube children?
How test-tube babies grow in body and mind is also the focus of many people's attention. In the past Veteran's General carried out a follow up investigation of some test-tube babies born in the hospital. They discovered that the physiques of test-tube babies are about the same as any other children; in the realm of intelligence, they tend to be slightly higher. Chen Shu-chen, director of pediatrics at Veteran's General, notes that follow up investigation only includes fifty children, so the results can only be used as a reference and are not necessarily representative.
Liu Chi-hung points out that France carried out follow up research on several thousand test-tube children and found them to differ in no way from naturally conceived children. He feels that the reason that some test-tube babies have a higher IQ is that after birth the home environment is better. With the price of one cycle of in vitro fertilization standing at NT$70,000 to NT$80,000, any family that can afford the operation is at least in the upper middle class. In addition, the child was not easily brought into the world, and it is natural that it receive better care and attention.
The first test-tube baby born in Taiwan--a little boy surnamed Chang--is a good example. Master Chang is eight years old this year. Currently in the third grade, he is considered a gifted student. Mrs. Chang believes that today the boy "is pretty good," and this is probably due to the good effects of his home environment. Judging only from the many after-school lessons he is made to take--piano, English, painting, math and logic, natural science--it is not difficult to realize that his family spares no effort in grooming the child.
Furthermore, the education level of the Parents is another factor for reference. According to a survey by Veteran's General Hospital, 70% of parents with test-tube children have educations at a college level or higher, 30% have educations at the high school or junior high level.Technology's bottleneck:
Although Taiwan's technology has reached a certain level, in vitro fertilization technology is still meeting two kinds of difficulties. The first is the age barrier. The second is that embryos do not easily affix themselves in the womb. These two problems have made the success rate of in vitro fertilization not as high as it could be.
According to estimates, the rate of miscarriages after in vitro fertilization is as high as 25% to 30%, twice as high as natural conception. The crucial matter is the would-be mother's age. Liu Chi-hung observes that the older a woman is, the less effective are her ovaries, and the miscarriage rate is higher. For women 35 years of age, the miscarriage rate is 20%; for those 40 years of age the rate surpasses 30%; for women 45 years of age, the rate of miscarriage is already 50%.
Besides this, when embryos are being cultivated outside the body, their shells ("zona pellucida") tend to harden, which leads to the embryos not easily taking root in the womb after they are implanted. Currently, the medical world uses lasers to pierce the shell, making it easier for the embryo to break out of its shell and escape, thus affixing itself in the womb. Thus, this problem has seen some improvement. For patients who have experienced repeated failures, it can be a great help.
Besides a higher rate of miscarriages, in vitro fertilization also increases problems related to multiple embryos. The rate of multiple embryos is more than ten times higher than natural conception. Liu Chi-hung explains that at the time of embryo implantation, the more embryos implanted, the greater the likelihood of pregnancy. Because of this, most patients request that many embryos be implanted. "It is best to draw the limit at four," says Liu Chi-hung. Multiple embryos can produce complications, such as premature delivery, high blood pressure diabetes, toxemia, and so forth. It is important to cut down the number of embryos to ensure safety.Finding an heir in a test tube:
Even though Taiwan's in vitro fertilization technology has reached an international standard, Liu Chi-hung feels concern that little attention is paid within the country to basic research. "Everyone is only anxious to study the procedures, without researching the underlying reasons. They just understand the superficial results; when they run into problems, they're lost at sea."
Chang Sheng-ping notes, "Everyone started doing it at once, in a swarm. It's not a good thing." He points out that in vitro fertilization only involves one small part of the reproductive endocrine system. Everyone is at present only increasing clinical accomplishments, not engaging in basic research.
"Those who can bear children can never understand the pain of those who can not," says a barren wife who can not stand the ridicule of her neighbors. Perhaps it is a deeply rooted conviction that one must produce an heir; perhaps it is the unceasing pressure from in-laws. People deeply crave flesh-and-blood offspring, to maintain matrimonial love and to affirm the position of the household. To Chinese people, the advent of testtube babies not only relieves the troubles of women who can not conceive; it also relieves the burden of the spirit.
There is a limit, after all, to the help that science can provide. How it can help people address the failures in the affairs they pursue is perhaps closer to the heart of the question.
In vitro fertilization technology provides new hope for infertile women.
"Micromanipulation of Sperm" uses microscopic instruments to guide the sperm into the egg to increase the chances of fertilization. It is a great aid to men with a low sperm count or low virility.
With the use of "Cryopreservation," multiple embryos can be stored in liquid nitrogen at -196℃, thus avoiding the trouble of extracting eggs from the womb a number of times.
Using laparoscopy to implant embryos in the uterus takes only about 20 to 30 minutes.
The Process of Creating Test-tube Babies
1.Ovulation medicine is injected, inducing the production of surplus eggs.
2.Ultrasound is used to extract the eggs after they have matured.
3.The egg undergoes external fertilization, and the embryo is cultivated for about 48 hours. After the fertilized egg divides into two or four cells, it is implanted in the mother's body.
4.Implanting the embryo in the mother's womb can be accomplished via two different channels. Insertion through the vagina is customarily termed "In Vitro Fertilization and Embryonic Transfer (IVF/ET); insertion using laparoscopy is termed "Tubal Embryo Transfer" (TET).
Taiwan's first test-tube baby, little Master Chang, is a gifted student.
The joy of becoming a mother wiped from Lin Yueh-hui's memory all the torments of the medical process.
An overseas Chinese who succeeded in finding heirs in the motherland mailed a thank you card to the doctor on the eve of Mother's Day, pasting on it photos of her two darling children. (courtesy of Chang Sheng-ping)
Liu Chi-hung with test-tube babies and their parents. (photo courtesy of Liu Chi-hung)