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Tribute to Georgeanna and Howard Jones
This tribute is divided into three sections. The first of these is a description of six weeks of research involving Georgeanna and Howard Jones and me over a few weeks in Johns Hopkins in 1965. Initially, it describes details of preliminary work and then completion of the maturation programme of the mature human oocyte and the first serious attempts at IVF. Scientific discoveries in those exciting weeks contributed to the earliest beginnings of IVF. A second section on knowledge of the human preimplantation embryo today concentrates on the problem of poor-quality embryos and how to overcome it, and on new knowledge on the regulation of human embryonic development. Lastly, the ethics of assisted conception are debated in relation to early practice and to some international features of modern ethical adjudication. A brief conclusion describes some of the friendships initiated in Johns Hopkins and still intact today. [locator:abslogo] (link type not set)
Keywords: Georgeanna and Howard Jones, history, human embryo, IVF, tribute.
Having celebrated on many occasions with Georgeanna and Howard, it is my immense pleasure today to salute these two wonderful Americans again. They first graced the field of IVF in 1965, then fully entered the fray in the early 1980s. Since then, they have been among the major leaders in the field, travelling as man and wife and as colleagues to endless international conferences. They are welcome everywhere, a very fine American couple, clearly dedicated to each other and to their field for many years. They have set the highest lifetime standards of care in their laboratory and clinic, and in clinical and scientific debate, while remaining a lively, social couple who enjoy welcoming people to their home or meeting them abroad. Howard paid me a fine tribute for my 75th birthday two years ago (Jones, 2002). I wish to respond by detailing some of the extraordinary times spent with him and Georgeanna in Baltimore in 1965, and to outline some of the consequences of those times.
2. A memorable visit to Johns Hopkins
I met Georgeanna and Howard in 1965, at the onset of six wonderful weeks working in Johns Hopkins Hospital, Baltimore. What a six weeks that was! I arrived from Cambridge in the UK, searching for slivers of ovaries (e.g. taken from Stein-Leventhal patients) as a source of human oocytes. I needed them in order to complete my study on the maturation of human oocytes in vitro and hopefully also to fertilize them in vitro to produce human blastocysts and stem cells. Victor McKusick, a wonderful colleague, had organized my visit, and introduced me to the Joneses in the hospital restaurant. The introduction revealed a very charming couple. Soft-spoken yet clearly very determined, Georgeanna was a first-rate endocrinologist and made me instantly welcome. Howard was tall and direct, and clearly a dedicated gynaecologist. From that moment, and still today, I had a very strong impression of a very close couple.
My previous experiences in London, in the search for small pieces of ovary, had rarely been successful. A few gynaecologists did help, especially Molly Rose of the Edgware General Hospital, who had sent several pieces of ovary to enable me to collect between three and 10 oocytes from most samples. After several years testing out various media and other factors, successive stages of maturation from the human germinal vesicle, through diakinesis to metaphase II and extrusion of the first polar body, had been identified and timed. While it was clear that 37 h were needed for the full process, numbers were still too small. Trying to persuade other UK gynaecologists to donate similar pieces of ovary removed for surgical reasons had usually been a dismal failure. Those consultants had narrowed their eyes, withdrew instinctively when the word embryo was mentioned, then suddenly discovered an urgent appointment that demanded their immediate departure. How would Georgeanna and Howard respond? After explaining my programme, I watched Howard closely. Would his eyes narrow too? Would he find another appointment, leaving me in the lurch? His eyes did narrow when my explanation included stimulating several follicles to grow and replacing human blastocysts to cure infertility and genetic disorders. This lasted a second or so, then he squared up, like the military man he was, and said‘Let's get started!’Exactly the same response was to come five years later when I telephoned Patrick Steptoe about aspirating ripe human oocytes from their follicles.
So began a wonderful six weeks. Victor provided a laboratory –which was still there in 2001 –and arranged a young research student, Roger Donahue, to organize the necessary facilities. Georgeanna and Howard's daughter, Bea, liaised between the operating room and our small laboratory. Howard's colleagues, among them Ted Baramki, assisted in the operating room.
3. Exciting times in the laboratory
Soon all was ready, and the Joneses were as good as their word. Slivers of Stein-Leventhal ovaries arrived steadily –what a contrast to my experience in the UK –each providing several oocytes, immediately placed in culture. Within four weeks, sufficient numbers had accumulated on germinal vesicle breakdown, entry into diakinesis (a very essential stage), metaphase I and completion of meiosis to metaphase II and first polar body ( Figure 1 ). The timetable of maturation was fully verified as 37 h. Yet two weeks of my stay were still left –could we use it to achieve fertilization of the fully matured oocytes in vitro?
We tried really hard. One problem seemed to be capacitation, recently discovered by Chang and by Austin working independently, and apparently essential to enable spermatozoa to fertilize eggs. Simply adding washed spermatozoa to oocytes did not result in fertilization, although some spermatozoa did bind to the zona pellucida, possibly representing the first stage of attachment. Two nuclei were seen in some eggs. Several different lines of enquiry included testing different media and adding small pieces of tubal ampulla to media droplets in the hope that they would invoke sperm capacitation. Human oocytes and spermatozoa placed in rabbit oviducts unfortunately became coated in the gelatinous secretion typical of rabbit eggs. When placed in oviducts of rhesus monkeys, both oocytes and spermatozoa simply disappeared within 12 h, if I recall correctly. Closer histological examination of the eggs with two nuclei failed to reveal sperm tails in their ooplasm. Thus, any formal claim of fertilization in vitro could not be made for these nucleated eggs. Later, a friend wrote asking why acid-based fixatives had been used to prepare those human eggs for microscopic examination, because such fixatives destroy oocyte and sperm structure. Formalin would have been far preferable, especially for sperm tails, but I had become totally accustomed to using acid fixatives for staining oocyte chromosomes, and this advice came too late. Examples of the living eggs with two pronuclei were published in a joint article in the American Journal of Obstetrics and Gynecology (Edwards et al., 1966).
Inviting Howard to the laboratory to witness these living eggs with two pronuclei for himself, I watched with increasing concern as he moved the microscope objective up and down just above the coverslip. This perilous movement filled me with alarm, since I had not yet photographed those precious eggs. One millimetre more, and those eggs would have gone forever, crushed under the coverslip! Fortunately, Howard returned possession of the microscope to me, whereupon the photos were taken within 10 seconds. He told me later that he never could see anything down the microscope! Repeating these attempts at fertilization in vitro on returning to Cambridge, a few eggs with two nuclei were identified, again without evidence of sperm tails after acid fixation ( Figure ).
This brief, if exciting, description of the workload in Hopkins fails to describe adequately those six weeks in Baltimore. Kindness was everywhere, from Georgeanna and Howard, Victor, Roger, Bea, Ted and many others. Life in the Department of Obstetrics and Gynaecology was interspersed with wonderful parties, at the Jones's home or elsewhere, where many foreign graduates were welcomed. The seafood served in numerous restaurants around the bay was magnificent, the dinners superb, and time passed like lightning. My first and last period of work in the Department of Obstetrics and Gynaecology was a time to be remembered. These friendships, for example with Ted Baramki, have stood the test of time, still exist today and are still renewed at successive meetings worldwide. And when, upon their retirement from Hopkins in the 1980s, Georgeanna and Howard decided to move to Norfolk, Virginia and open an IVF clinic, our relationship began all over again.
4. The early development of IVF
In the meantime, Patrick Steptoe and I had begun our collaboration in 1968–1969 using human menopausal gonadotrophin/human chorionic gonadotrophin (HMG/HCG) to stimulate several follicles, which were aspirated by laparoscopy. Cleaving embryos and blastocysts were produced in vitro within two years, despite the geographical distance between us. Transfers of blastocysts began in 1971–1972, to begin a horrendous time for us, largely due to the choice of Primulot depot as a luteotrophin, when it is actually an abortifacient. After many failures in establishing pregnancy, the first clinical IVF pregnancy occurred in 1976 after the transfer of a single blastocyst with HCG and progesterone luteal phase support. It ended in a tubal ectopic. Louise Brown and two other IVF babies were conceived in Oldham just as Patrick left the National Health Service. Throughout these 10 years, I often wondered if new studies on IVF would first be reported from Johns Hopkins or Chapel Hill, North Carolina where I worked in the summer of 1966. On my departure from Hopkins a complete laboratory, with trained staff in gynaecology and embryology, had been established. Yet no data came from either source, and precious little from elsewhere as we pursued our clinical and laboratory work, facing immense ethical pressures.
On leaving Oldham, we no longer had any facilities, having received a completely inadequate offer of help from the National Health Service in Cambridge. One or two other groups had begun IVF. Alex Lopata and Ian Johnston now conceived two children in Australia using natural cycle IVF, and others reported occasional pregnancies. At last, in 1980, Bourn Hall opened after venture capital was raised following 2 years frustrating delay since Louise's birth. Other clinics opened in Europe and Australia as the whole world joined in, with different laboratories utilizing their own chosen methods ( Table 1 ). Alan Trounson and Carl Wood had decided to use clomiphene and had established several pregnancies. In Bourn Hall, we had restarted using natural cycle IVF and had 20 or more pregnancies. We were now planning to use clomiphene/HMG, which in Oldham had produced good ovarian stimulation and a complete and normal luteal phase without any need for support. By 1986, Bourn Hall had delivered 649 babies from 531 deliveries, which was 30% of the world total (somewhat overestimated as 2140) ( Table 2 ) (Steptoe and Edwards, 1986). Scandinavian and Austrian groups introduced ultrasound-guided oocyte aspiration in the early 1980s, and had used it to establish many pregnancies. Howard and Georgeanna had joined in with full enthusiasm. Moving to Norfolk, they recruited staff who are still totally loyal, even if they had to leave the Jones Institute to develop careers elsewhere. Pregnancies accumulated very fast in Bourn Hall throughout the 1980s, including the first, and possibly the second, US IVF babies. I believe the next were conceived in the Jones Institute, in advance of any other US clinic. Georgeanna and Howard were clearly leading the field in the USA, facing tough ethical decisions and numerous demonstrations, yet standing firm on their intention to proceed.
|Zeilmaker et al.||4–16 cell||−||3||3|
|Trounson et al.||3–12 cell||144||16||8|
|Quinn and Kerin||blastocysts||7||3||0|
|Lassalle et al.||1–8 cell||65||11||1|
|Total (%)||324||55 (17)||21(6.5)|
They decided to use HMG and HCG as a form of ovarian stimulation. This approach had drastically shortened luteal phases in Oldham, giving us major problems with luteal phase weakness. These problems had been solved by stronger forms of luteal phase support, which sustained the first pregnancy ending in the tubal ectopic mentioned above. We did not intend to use this form of stimulation in Bourn Hall after our experience in Oldham. Georgeanna felt she knew HMG and HCG best, and decided to apply it in Norfolk. So as we improved natural cycle IVF and planned for clomiphene and HMG, the Jones Institute began a huge trial on HMG and HCG, based on 19 different sessions of treatment, each with its own characteristics. One session of the 19 gave slightly better results than the others, at a low P = 0.05 level, if I recall correctly. I could not agree with Georgeanna that this result was anything other than random, i.e. 1 in 19, which is a P = 0.05 chance at best, and that HMG and HCG were too chancy because new forms of stimulation were being introduced. They persevered with HMG and HCG, I believe, until the gonadotrophin-releasing hormone (GnRH) agonists were introduced and changed concepts on ovarian stimulation. This method also requires luteal phase support and is expensive. We adopted it with some reluctance, because clomiphene/HMG was virtually equally successful in establishing pregnancies and much less costly, although more difficult to handle endocrinologically.
The Jones Institute flourished and contributed enormously to the development of IVF in the 1990s. Their team was the first to test intracytoplasmic sperm injection (ICSI), and I believe they failed only because they did not inject the oocyte hard enough. Personnel from the Norfolk team populated many clinics worldwide, especially in the USA. Throughout this decade, they continued to set the IVF scene in the USA, as more and more clinics were opened. It was a pleasure for me to deliver the Jones Lecture in 2000, established in Hopkins. Like me, Georgeanna and Howard were ageing but still indomitable as we all celebrated a birthday. I wish to dedicate the following text to them, wishing them a happy and prosperous future as ever. I have chosen to discuss some broader aspects of IVF, in a salute to the 90-year-young couple.
5. The preimplantation human embryo today
During that brief six weeks in 1965, Georgeanna, Howard and I would walk up the hill behind Hopkins, debating and arguing every inch of the way. I quickly learned to respect the intellectual approaches of my newfound colleagues. Georgeanna asked the most penetrating questions on endocrinology, especially on follicle growth and multiple ovulation. Howard had become a world leader in reproductive surgery and was developing a programme on the sex chromosomes and autosomes in clinical care. He was fascinated at the prospect of scoring chromosomes in preimplantation human embryos. Both had a thirst for knowledge and discussion, aimed at helping their patients. Little did we know then, as we talked about successful embryo transfers in several animal species, that the human embryo would turn out to be completely different to those of most other mammals. First among our thoughts was whether IVF would lead to increased numbers of abnormal births compared with natural conception. Inevitably, this proved to be an ongoing topic over many years.
5.1. Quality of human preimplantation embryos after artificial or natural conception
Preference is thus given in this tribute to the preimplantation human embryo and the safety of IVF. Clear indications now exist as to the low quality of human embryos in vitro, a situation that may also exist in vivo. For example, implantation rates of human embryos during IVF are dismal. For some evolutionary reason, our species has become a reproductive near-failure, with so many factors going really wrong during pre- and early-post implantation development. The scale of these anomalies is enough to jeopardize the great majority of human pregnancies. Suspicions that our species is quite unlike rodents, ruminants and probably other primates arose as IVF developed.
Patrick Steptoe and I initially associated the low pregnancy rates of 12.5% in Oldham in the early days to poor culture methods, or to the stress of handling human embryos in vitro. There is no doubt that extracting human oocytes from their follicles and then placing them in vitro for fertilization can change their metabolic processes. For example, pyruvate consumption is greatly altered, among other things. Culturing embryos in artificial media can have unusual consequences, as in the well-known large calf syndrome. Manipulating oocytes and eggs at critical stages can also influence metabolic and regulatory systems. One recent example that may be due to manipulations performed at a critical moment involved two cases of babies with Angelmann's syndrome, an imprinting syndrome, which emerged from the use of ICSI in one clinic (Cox et al., 2002). Whether these two babies were a consequence of an interruption in the methylation of paternal and then maternal chromosomes remains to be decided. Chromosome methylation occurs just as ICSI is being performed and spermatozoa enter the egg, so it is possibly susceptible to interruption (Surani, 2002). Several multicentre analyses have also indicated higher risks arising with IVF than with natural conception, the frequency of anomalous births being approximately 1.8 times higher with IVF and ICSI (Hansen et al., 2002). This difference persists after adjusting for certain characteristics typical of assisted conception, such as multiple pregnancies and births.
Does this evidence imply that IVF is dangerous? I strongly doubt that concept. There is some extra risk to fetuses because infertile couples might carry higher frequencies of gene disorders or other factors impairing normal embryo growth. An indication that this suggestion could be correct is provided by studies on births to surrogate pregnancies established by embryo transfer, which carry the same risks as for babies born after natural conception. In this sense, surrogacy has quite inadvertently shown how IVF embryos develop normally within the uterus of fertile women. The increased risk reported by Hansen et al. (2002) and others seems to involve very few offspring and might be due to inherent defects in the uterine environment of some infertile patients.
The unproven risks claimed for IVF should also be set against the reduced risk of some birth defects. These include the reduction of trisomic births and abortions, following preimplantation genetic diagnosis (PGD) for chromosomal analyses on embryos (Munné, 2002). Today, translocations and other intrachromosomal variants can be detected and avoided by comparative genomic hybridization (Wells and Delhanty, 2000). PGD is also helping to avoid the birth of children –and even the implantation of embryos –carrying single gene defects such as cystic fibrosis. These methods could have a considerable impact on the frequency of many genes for inherited diseases, and would be of much greater significance if higher implantation rates could be achieved after IVF. Currently, several embryos must be typed to obtain one implanted embryo, so adding to the cost and burden of PGD. This technique would thus become far less expensive and tedious.
Subtle problems with IVF increasing the rate of fetal anomalies could be difficult to detect. They might involve redesigning media and avoiding growth factors and other compounds. Methods of ovarian stimulation might need revision, using approaches that reduce the numbers of growing follicles, by avoiding the stimulation of small follicles. Selecting embryos for transfer might have to be stricter, choosing only those with the finest characteristics of polarities, speed of cleavage, fragments and normal division, because regulatory factors such as timers clearly control many aspects of embryo quality (Johnson, 2002). Endocrine treatments stimulate follicles in varying stages of growth, and these variations might be reflected in embryo quality. It seems unlikely that IVF will get worse and lead to more anomalous forms of growth, and the immense effort now addressed to Cochrane analyses, multicentre trials and improved methods of detecting anomalies should result in steady overall improvements.
5.2. Embryo selection and the improvement of implantation rates
IVF can only get better in another sense: in identifying the few embryos of high quality, so that single chosen embryos will provide high implantation potential and so avoid multiple births, except for identical twins. Progress in this field has been astonishing in the last 2–3 years. Initial approaches came from Bourn Hall in 1984 (Edwards et al., 1984), following detailed analyses of cleavage times in 1-cell and 2-cell embryos growing in vitro. Embryos were examined every few hours as their time of cleavage approached, enabling the first-cleaving embryos to be selected with precision. Results were astounding, with the fastest-growing embryos to 2- or 4-cell stages having rates of implantation approaching 50%, compared with 10% or thereabouts for slower embryos. Unfortunately, a higher number of clinical abortions in the fastest-growing groups cast some doubt on this procedure, and it was applied only by counting blastomeres on the day of transfer. Increased abortion rates have not been reported in more recent studies on selecting the quickest-growing embryos, which provides further data confirming the value of timing regulators and their essential roles in determining embryo quality. Measures of scoring polarities and their timing are highly effective, as witnessed by estimating nucleolar number in pronuclei, their size, shape and polarization. Fragmentation patterns are also highly effective in selecting the best embryos, suggesting that cell cycle factors are equally pertinent in establishing quality (Alikani et al., 1999). No doubt other factors will apply as further studies are aimed at selecting those embryos with the highest implantation potential.
Growing embryos to blastocysts is another means of selecting those capable of high implantation rates (Gardner and Schoolcraft, 1998). This approach presumably depends on the metabolic properties of the best quality embryos. Available details of cell metabolism seem to be less important than producing media that sustain embryonic growth to blastocysts, when high rates of implantation can be attained. Blastocyst transfers can involve five or six days in culture, a disadvantage when compared with day 2 or 3 transfers. Indeed, many embryos capable of implanting if transferred up to day 3 might lose this property with continued culture. Shorter culture periods might also reduce the risks of stress to embryos in culture, avoid accidents and reduce embryologists' workloads. Some investigators argue that transfer of cleaving embryos into the human uterus provides sub-optimal conditions for embryos to grow, as judged by animal experiments. In point of fact, human embryos will grow from 1-cell stages to full term in utero. It is even possible to transfer oocytes 3 h after insemination with spermatozoa attached to their zona pellucidae and obtain respectable pregnancy rates. Such evidence shows how fertilization and cleavage are sustained within the human uterine cavity, and the only question is whether implantation rates are higher if 1-cell, 8-cell or blastocyst stages are transferred to the uterus. Transfers on day 1 after nucleolar scoring or after fast cleavage to the 2-cell stage could be the optimal manner to conduct an IVF centre.
5.3. Improved knowledge on the growth of human embryos
Faced with these problems of embryo quality, the best recourse is to discover as much as possible about regulatory factors in the embryo, although embryologists still face a lack of understanding about the early regulation of the mammalian embryo, especially the human embryo. I remember Howard describing how, during his career, he had witnessed endless reports of this or that medium containing a hormone or growth factor, and this indication had been proved by later work. The same applies to embryology. I have always been fascinated by fate maps, first studied in amphibians many years ago, which describe the destination of single or groups of cells in the developing embryo. Many authors knew or suspected many of these characteristics also applied to mammalian eggs. A glance at the review by Lewis and Wright (1935) reveals discussions on polar axis, the uneven size of the two 2-cell blastomeres, and the more rapid division of the larger blastomere to produce two slightly larger daughters in 4-cell stages. They also hint at differing cleavage planes in the two 2-cell blastomeres –still a hot topic today.
Based on such research until the end of the 20th century, fate maps for the mouse and human embryo were devised five years ago (Edwards and Beard, 1997, 1999). Misleading photographs in a paper published by other investigators on the distribution of oct-4 in some or all blastomeres in 8-cell mouse embryos weakened certain conclusions drawn from this model. This error was corrected in a newer form of the model, which incorporated more knowledge, including data on very early genetic activity in the sperm head and the male pronucleus concerned with transcription factors and imprinting (Pitoggi et al., 2000; Surani, 2002). The model predicted slight differences between 2-cell blastomeres, confirmed by Antczak and Van Blerkom (1997) who studied the distribution in fertilized eggs and cleaving embryos of maternal leptin and STAT3 (signal transducer and activator of transcription3) located at the animal pole of the oocyte. Applying the cleavage model of Gulyas (1975) led to proposals that one blastomere in 2-cell embryos produces soma, whereas the other is probably already allocated to trophectoderm/germline (Edwards and Beard, 1997). By the 4-cell stage, two blastomeres are the founders of soma, a third controls the formation of trophectoderm, and the fourth blastomere might be the founder of the germ line.
If this model is correct, the blastomere that founds trophectoderm might produce HCG mRNA. A very recent discovery has shown that among a group of human embryos, three-quarters of them contained a single blastomere which was synthesizing HCGβor LHβ(Hansis et al., 2002). This could be exciting news if the same blastomere also carries large amounts of the trophectoderm markers leptin and STAT3. Why should one blastomere produce LH and not HCG? This finding is unexpected; perhaps the shortenedβ chain is synthesized in one blastomere of some embryos due to a failure of normal transcription or because LH has unknown functions in the embryo.
Models of early mammalian embryos must explain why removing one blastomere (e.g. for PGD) can be overcome and the embryos develop normally. This plasticity is typical of most models of differentiation. Cells enter an initial phase, called allocation, when they are tending to develop into a particular type of tissue. They are still able to switch courses and be allocated again to a different tissue. They are committed only when they produce transcripts or compounds specific to one tissue. The background genetics of this system is perhaps explained by the concept of stem cell loops, in which many transcripts are produced at very low levels in allocated but not committed cells, until an inductive stimulus activates one loop to great activity and simultaneously switches off the others (Fuchs and Segre, 2000). A similar activity in cleavage and blastocyst stages could equally explain their developmental plasticity in early growth stages.
Many other authors are contributing in their own way to the issue of quality in human embryos in vitro. The scope of these studies is extremely wide but can be mentioned only briefly here. Mitochondria have attracted immense interest in recent years, and there is no doubt that mitochondrial mutations accumulate in older oocytes (Barritt et al., 2000, 2002). Grafts of mitochondria or ooplasm into animal and human oocytes have not yet produced decisive evidence that any deficiency can be remedied in this manner. More work, and controlled trials, are essential to clarify this area of research. Metabolism continues to attract much attention, with increasing knowledge about amino acid metabolism, the dangers of ammonium and reactive oxygen species, and attempts to clarify the exact nature of the needs of the embryo at various stages of its preimplantation development. Nevertheless, experts still disagree on how modern knowledge on human embryos can help to design the optimal media for preimplantation stages of growth (Gardner and Schoolcraft, 1998; Biggers et al., 2002). This dispute embraces the need for two media to sustain early and later phases of preimplantation growth. Considerable knowledge has also accumulated about oocyte growth, maturation and ovulation, and the nature of goandotrophin versus oocyte control of follicular activities. Polarities and axes have also been clarified in detail, especially gene and systems homologies between mammalian species and Drosophila, C. elegans and Xenopus (Edwards, 2001).
6. Ethics of assisted human conception, then and now
Georgeanna, Howard and I often discussed the emerging ethics of our field in Hopkins in 1965. Even before this time, there had been no doubt in the UK of the considerable ethical and Press interest in matters of reproduction and pregnancy. It was inevitable that complex ethical situations would emerge from IVF and attract the interest of ethicists, theologians and others. They had emerged previously in relation to AID (artificial insemination by donor), ever since the days of John Hunter several centuries ago. A conference devoted to this topic in the early years of the 20th century led a British archbishop to strongly question its ethics and virtually ban it. Even today, decisions are being taken on the right of the child to know the name of the donor, as opposed to being given limited information on his characteristics but nothing more. This issue has even divided closely related nations, shown when rules were stricter in Sweden than in Norway, so many Swedish patients attended Norwegian clinics. I believe this situation is resolved there today. Abortion has an even longer history, having raised ethical issues over centuries. Many legislators considering proposed laws on IVF were apprehensive that stimulating public debate on the future of assisted conception would expand to stimulate abortion debates all over again. Early IVF pioneers thus had to expect a backlash from many interested groups, not least the Roman Catholic Church. Furores had already emerged in the UK following our studies on the successful maturation of human oocytes, and the sexing of rabbit blastocysts as a model for human PGD. At this time, ethical committees were being appointed across the USA, to cope with the increasing concern about many issues raised by biomedicine.
Novel ethical issues with IVF included complex matters known since the early 1960s, such as the ethical and clinical significance of IVF, oocyte donation, surrogate mothers, PGD and stem cells, and the rights of embryos and parents. Surprisingly, there seemed to be no ethical backlash in the USA against our work in Hopkins, nor again during the following year when I worked in Chapel Hill over a summer period. It seemed that all the hostility had been saved until Howard and Georgeanna opened a new IVF clinic in Norfolk, Virginia. I know they had to face immense pressures at that time, as their turn came to face the intensity of ethical objections to their work. They stood their ground, and from what I know, established a flourishing IVF centre against all opposition and supported by many members of their University and profession. They have maintained their close interest in ethics ever since.
By today, there is immense variation in the nature of ethical regulation worldwide. I believe that the UK, certain Australian states, Israel, and several European and Muslim countries have passed liberal legislation regulating IVF, each with its own specific restrictions on certain practices. Germany has a very strict law, based on the principles of totipotency, which restricts any study to a non-totipotent cell. In many European countries, pressure is growing to restrict the numbers of transferred embryos to two, and even to a single embryo in Finland. This legislation has clearly not harmed the practice of IVF, because the proportion of IVF births in the national total is rising above 3% in several Scandinavian countries, whereas this proportion is far lower in the UK and very low in the USA. Spain and several Catholic countries in Latin America have passed legislation, which is generally liberal, although one country in Central America recently banned IVF totally. Specific attention has been paid to cloning virtually everywhere, which usually leads to an instant and outright ban on reproductive cloning. Nevertheless, the UK has legislated in favour of therapeutic cloning with the intention of making embryo stem cells compatible with a recipient. In fact, our own work, and recently published data (Hollands, 1988; Fandrich et al., 2002) has shown how embryo stem cells induce tolerance in recipients, even across major histoincompatibility barriers. It has thus been evident since 1988 that therapeutic cloning might never be needed to avoid rejection, because embryo stem cells can be transplanted into virtually any recipient in mice without inducing rejection, cancers, inflammation or other forms of disorders. If this situation is confirmed in humans, there is no need for‘designer babies’or to search for specific lines of immunocompetent donor cells.
Even though legislation has spread widely, it is not universal. Many national states have no legislation and do not apparently plan to introduce it. This vacuum has enabled investigators from countries with restrictive legislation to build their laboratories in non-regulated countries and continue work that has been banned back home. This form of science migration is a successor to patient migration across frontiers to utilize methods of assisted conception banned in their home country. Today, for example, some doctors wishing to introduce reproductive cloning have reportedly opened laboratories in countries without legislation. In a sense, ethics becomes international in this way by the drive of individuals, whether scientists or patients. Such prospects never crossed our minds in Hopkins, when ethics in the USA was driven by local ethical committees, and such committees were uncommon in the UK. I doubt that anyone could have forecast how the ethical scene has exploded, or how patient counselling has become a full-time profession. It was clear that many things could be done through IVF, but the astonishing acceptance of some of these new concepts in human reproduction has been surprising. It is also becoming clear that a world ethic will never emerge, despite‘reproductive tourism’of patients and investigators. Nor is there ever likely to be a common European ethic, come to that, because differences in ethical outlook among the various European countries are far too great.
The national ethical situation in the USA is apparently different from virtually anywhere else, and I often wonder what Georgeanna and Howard make of it. Different states make their own local rules, often differing from their neighbors. Two ethical systems seem to operate centrally. One embraces State-funded centres, such as the National Institutes of Health (NIH), and is subject to national legislation. The other involves privately funded centres, which seem to be independent of governmental regulations and have their own ethical committees. Some consequences of this dual system are unique and even strange. The Senate and House of Representatives are prepared to legislate against reproductive cloning, yet it can be done in private centres. Legislators will not allow the use of human blastocysts to make human embryo stem cells, yet individuals and the NIH can purchase them from private clinics at home and abroad. How can complex ethical decisions such as these simply be bypassed in this way? Embryo stem cells from wherever they come demand the use of human embryos. Offering to purchase them simply stimulates the production of yet more cell lines by someone else, who must take the decision to construct them from human blastocysts on behalf of the purchaser. Ethics cannot be set aside for particular purposes or for politicians who believe they can simply ignore their own ethical involvement. The same situation is arising in Germany, which will follow the US example and purchase stem cells, because its own law is very strict and precludes making stem cell lines (Ludwig, 2002). Perhaps a detailed discussion on this complex situation offers grounds for a later celebratory conference saluting the early IVF pioneers.
New ethical situations have emerged over the past 5–10 years. This period has seen an immense growth of PGD, and the opening of a new ethical scenario. While generally acceptable, conflicts have emerged between patients' rights and doctors' rights during PGD procedures. These issues are perhaps best illustrated by the decision of two deaf patients to transfer a‘deaf’embryo, so it would resemble the rest of their family. Presumably few doctors would support this proposal in their own clinics. Using PGD for sex determination has also split attitudes in favour of or against this procedure. Disagreements have become familiar among Western commentators, and this issue also splits Indian opinion, as shown in a recent intense debate (Malpani and Malpani, 2002; Kumar, 2002; Mehta, 2002; Pandiyan, 2002). The concept of‘designer babies’raises ethical rumbles, because embryos are chosen free of a family disease and with a human leukocyte antigen (HLA) genotype compatible with an elder sibling. At birth, cord blood from the IVF baby is donated immediately to the sick elder sibling, to cure its inherited disease (Verlinsky et al., 2001). Major ethical questions arise. Will the IVF baby have to donate bone marrow if cord blood fails to work? Is the IVF child being produced as a commodity? What will the family situation be when the sick child realizes its debt, and the donor baby realizes it may not have been conceived for love. The capacity to identify late-onset diseases in preimplantation embryos, and transferring those free of disease, has also raised ethical issues. Identifying such a disease, e.g. Huntingdon's, senile dementia or late-onset cancer (Verlinsky et al., 2002), cannot be done without risk of disclosing the results to the parents, who may prefer not to know their future. The data could also interest market men and insurance agencies as they search for indicators of market preference of insurance cover. A worldwide consensus on such complex issues again seems unlikely, so varying practices are almost certain to characterize different countries.
7. Final thoughts
Ending on a lighter note, working closely as a team inevitably raises shared interests or past-times. This was certainly the case between Georgeanna, Howard and I. Our field, and its immense possibilities, were enough for some well-informed –and perhaps other less-informed –joint comments and conclusions to be drawn, even though their interests were primarily clinical and mine were dominantly scientific. I remember my curiosity about the huge statue of Christ in the entrance hall to the Johns Hopkins Hospital. If nothing else, it inevitably triggered debates on ethics, religion and architecture.
In a roundabout way, the Joneses and I followed similar pathways into architecture (of all subjects!). Science and medicine do not build cathedrals. They dominate the needs of today's societies, yet most of their buildings are utilitarian often to extremes, unattractive yet highly functional. Fume cupboard effluents and other chimneys or external staircases seem especially designed to destroy any semblance of beauty. Nonetheless, there are grounds for optimism. Travelling the world, I often think that four IVF clinics at least are indeed beautiful, and I might have missed others. We purchased Bourn Hall, a beautiful Jacobean mansion built in a Saxon/Norman setting, and this is obviously my favourite. Yet the Jones Buildings in Norfolk are for me the modern equivalent of Bourn Hall, unique in their flowing style. There are also beautiful clinics in Amman (made of marble) and in Peking (just opened). We made Bourn Hall as attractive as restricted funds permitted, to signal patients that our care for them was reflected in the maintenance of our beautiful inheritance! I often wonder if the same thought has ever struck Georgeanna and Howard.
History was another topic of joint interest. I am always impressed by Georgeanna and Howard's dedicated interest in many things transatlantic. Bourn Hall has a claim to American fame, a fact enjoyed by Georgeanna and Howard. One of its owners in 1620 was Lord Cantelupe, Baron de la Warre, from the branch of a French Huguenot family. His main residence was Syon Park, in Southern England. He became famous when appointed at this time to the post of Captain General of all the territories of Virginia, which was the entire British possessions in eastern North America. His power was immense, and he was clearly a very fine leader. Arriving at James River, he was just in time to persuade the inhabitants of Jamestown to stay in their homes instead of leaving after their first terrible winter. He became so successful that upon his departure to the UK many years later, a portion of Virginia was made into a separate state named in his honour, namely Delaware. Georgeanna, Howard and I shared our historical connections many years later by touring the battleground at Saratoga, a place of no small interest to Anglo-Saxons!
It has been a pleasure to write this tribute to Georgeanna and Howard Jones, cherished colleagues since our formal meeting in Johns Hopkins Hospital in 1965 ( Figure ). They have become outstandingly respected worldwide, in relation to their early work on endocrinology and surgery respectively, and then through their work on IVF. The six-week collaboration in Hopkins provided sufficient oocytes to confirm the provisional timing of human oocyte maturation in vitro, and to open attempts at fertilizing the matured oocytes in culture. This experience was valuable to me in 1966–1967, as I began my search for a simple surgical means of collecting mature oocytes from the human ovary at 36 h post-HCG, which led to me to Patrick Steptoe. It was valuable to Georgeanna and Howard when they opened their clinic in Norfolk in the early 1980s, to join fully in the clinical, scientific and ethical development of IVF.
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