Chapter 1 – Conceptions
There were two. Each came into being under different circumstances during the same year, one in a dish and the other in the normal way, one among many and the other by itself. One of the embryos was created both deliberately and accidentally, the other in a moment of passion and without responsibility. One had two biological parents, the other four. At a stage unknown to anyone and despite the confident assertions of scientists and legal experts, each was endowed with a soul, and these two souls were linked by an existential thread that extended across the width of Missouri.
To better understand this cryptic beginning, one must start with the activities of a certain fertility clinic in Kansas City. This establishment offered hope to childless couples unable to procreate without medical assistance. It operated, in general, like many other fertility clinics elsewhere. Multiple eggs would be harvested from a hopeful mother following completion of the necessary hormonal treatments. A hopeful father donated sperm in the privacy of a room stocked with reading materials suitable to the occasion. In a process known as in vitro fertilization, these sperm and eggs would be mixed together in a laboratory dish and allowed to do what sperm and eggs normally do. Several fertilized eggs, thus obtained, were incubated and allowed to grow for five days or so until each reached an embryonic stage called the blastocyst. In a mother of young enough age, only one embryo was implanted into the uterine wall, and the best embryo was selected for this purpose. Hopefully, a normal and successful pregnancy would then ensue. Together, all of these methods were referred to as assisted reproductive technology.
All drugs and devices used in conjunction with this technology were subject to regulation by the Food and Drug Administration. The Center for Disease Control in Atlanta, Georgia, enforced the 1992 Fertility Clinic Success Rate and Certification Act by receiving and evaluating reports from fertility clinics throughout the United States. The Clinical Laboratory and Improvement Act of 1988 also applied to clinics engaged in assisted reproductive technology practices. In addition to these regulations, the clinic of this story also claimed to follow the recommendations of the American Society of Reproductive Medicine, so a raft of agencies and laws were involved in the oversight of its activities.
After the selected embryos had been implanted, the remainder were typically frozen and stored in liquid nitrogen at minus eighty degrees Celsius. The spares were kept for future implantations should initial efforts fail. In keeping with widespread practice, couples paying for the services of this clinic signed legally binding documents which contained specific instructions as to what should be done with their excess embryos once they had no use for them. Some were designated for research or for donation to couples who could not produce eggs or sperm of their own. Other embryos were to be thawed and discarded. This, of course, generated ethical questions owing to the uncertain status of these products of artificial conception. Were they merely small masses of biological tissue, or were they human beings? Were they something in between? The signed documents absolved the clinic of legal responsibility.
In spite of this precaution, some couples could not be contacted for one reason or another, and the personnel operating the clinic were reluctant to proceed without notifying these couples. The problem was not unique. In fact, it was common. As many as four-hundred-thousand human embryos existed in a type of frozen limbo in the United States.
Two couples, one white, one black, and both of sufficient means to afford the process underwent it at the same time and at the aforementioned clinic. Each mother was given a series of injections. These began with daily doses of drugs to suppress her menstrual cycle. Once this was accomplished, follicle stimulating hormone was injected over a period of ten to twelve days to stimulate her ovaries to produce more eggs. Progress was monitored by vaginal ultrasound scans and blood tests. Thirty-four to thirty-eight hours before her scheduled egg collection, each woman was given another hormone injection to facilitate the maturation of her eggs. The series of hormonal treatments just described produced predictable yet difficult mood swings in the recipients.
Each mother was sedated for the collection procedure. Guided visually by an ultrasound display, a physician inserted a needle through the vagina and into first one ovary and then the other to withdraw eggs. After separately undergoing this process, the two mothers were then given progesterone to prepare the endometrial linings of their wombs for the eventual implantations of their embryos. Each father made his contribution in the aforementioned manner on the same day as the eggs were collected. Next, in vitro fertilizations were performed for each couple.
During just under a week of incubation, the fertilized eggs of both couples divided several times and formed embryos. At intervals, these embryos were inspected under a microscope until they reached the blastocyst stage. Since each mother was over the age of thirty-seven, it was agreed that two blastocysts, those deemed the healthiest, would be chosen from her batch of embryos for implantation into her womb. That should have been all that the procedures entailed, but it was not.
The floors of fertility clinic laboratories were very busy places, and many different personnel were responsible for their activities. In an extreme minority of cases, mistakes had been made in various locations around the country. In one instance covered by the media, a labeling mistake had resulted in the embryo of one couple being implanted into the wrong mother. Having caught this mistake, the clinic responsible had notified both sets of parents. Out of a sense of religious conviction, the unintended surrogate had carried the baby to term and surrendered it to its biological parents shortly after birth. A legal settlement between both couples and the clinic responsible had been reached out of court. In another published case, a white mother had given birth to black twins due to a similar error in embryo identification.
To prevent this type of tragedy from happening again, various safeguards were put into place. Egg samples, sperm samples, and embryo culture dishes were carefully labeled and inspected. Some clinics utilized a so-called “double key” system in which one individual performed an assigned procedural step while another observed and verified. Both then signed a form which doubled as a laboratory record and legal document. Some clinics went so far as to verify embryo identities videographically with patient names and identification numbers visually “stamped” onto the video. As with all rules designed to protect patients and their rights, the success of these measures depended on how effectively they were followed, and this was impacted by the physical organization of the clinic floors and by how well assigned work schedules reduced the likelihood of fatigue and error.
In the clinic relevant to this story, there was a high volume of business and a correspondingly high level of activity by multiple personnel. Nurses either administered injections to female patients or, depending on their willingness and capabilities, instructed them in how to inject themselves at home. They also counseled these clients in order to educate them and to alleviate any misgivings they might have. Technicians ushered male clients into the sperm donation rooms, waited outside, and received and labeled the samples. They also labeled embryo culture dishes and served ancillary functions in other procedures. Physicians performed the egg collections. Embryologists performed the in vitro fertilizations, monitored embryo development, and selected the healthiest embryos for implantation. They worked closely with the technicians who assisted them. Physicians implanted the chosen embryos.
The clinic in question had multiple work stations. Eggs withdrawn along with follicular fluid were mixed with sperm in an embryo culture dish under a laminar flow hood and then placed in an incubator at body temperature. The air in the incubator was controlled for optimal percentages of oxygen, nitrogen, carbon dioxide, and relative humidity. This formula, arrived at empirically, was believed most favorable for the development of the embryos.
Periodically, the covered dishes were briefly removed from the incubator and placed on the heated stage of an inverted stereomicroscope in the laminar flow hood. The temperature of the microscope stage was the same as that of the incubator to allow the embryos to remain as undisturbed as possible. Their progress was observed in this way until the desired stage of development had been reached. Throughout this process, the embryos in each dish were evaluated. Due to the additional cost of time, equipment, and personnel needed for videographic verification, that method was not utilized in this particular clinic.
As has already been mentioned, each of the two prospective mothers was over thirty-seven years of age, so the decision had been made to implant two blastocysts in each to improve the odds of successful pregnancy. Everything that had taken place in the two culture dishes so far had been according to approved protocol. The events that transpired next constituted a type of perfect storm allowing for the mishap that followed. The recipe for disaster included profit motive, hubris, and fear of malpractice suits on the part of those managing the clinic, and this was mixed with just the right sprinkling of unexpected illness, fatigue, stress, and carelessness among their subordinates. The last ingredient was the malfunction of a small but crucial instrument.
The wives of both of the couples this account has been following were scheduled for implantation on the same day and at the same time. This was to involve placing the culture dish for each couple in a separate isolette, an enclosed glove box equipped with a stereomicroscope. One of the embryologists on duty was to use a catheter device – which was essentially a flexible tube held within a rigid casing and attached to a plunger – while working on a particular sample. While observing with the stereomicroscope, he or she would select the best two embryos and gently suction them into the catheter by pulling back on the plunger. Another embryologist would do the same with the other sample. The catheters, properly labeled, would be handed to the respective attending physicians for the different implantation procedures. Each doctor would deliver the two embryos into the uterus of his patient by inserting the catheter up the vagina and through the cervix before depressing the plunger. If all went as planned, normal pregnancies would follow, and responsibility for prenatal care would then shift to each woman’s preferred obstetrician.
The two women were scheduled for the implantation of their embryos on a Saturday in the middle of flu season. Two physicians were standing by for this purpose, but not two embryologists on this fateful date. One embryologist had called in sick at the last minute, and a replacement could not be located in time. A couple of technicians were also indisposed, but a substitute was found for only one. Potential loss of profits and the risk of complaints or lawsuits by women rendered more volatile by hormonal treatments prompted those running the clinic that day to proceed with the already ambitious schedule for that morning and double the workload of the remaining embryologist. The technicians were also rushed and overworked. To maximize efficiency and minimize expense, the double key system was not routinely practiced, even under otherwise ideal conditions.
In an impatient and ill-considered attempt to save time and satisfy the demands of the physicians, the embryologist violated policy and placed both embryo culture dishes in the same isolette. Distracted with their own tasks, none of his co-workers noticed him do this. He microscopically examined the first dish, identified a blastocyst of sufficient quality, and withdrew it into the catheter. He found another candidate and attempted to withdraw it also, but the plunger remained stuck at the current setting. It was an unforeseen manufacturer’s defect. With one embryo in the jammed catheter, the embryologist hurriedly called for a conference with the attending physician. At the physician’s request, he depressed the plunger slightly without dislodging the blastocyst and determined that it could still be used for delivery into the uterus of the first patient.
Personalities cannot be overlooked in such a situation. This particular physician had an abrasive manner and curtly instructed the embryologist to use a fresh catheter for the second embryo to be implanted into his client. On complying with the order, the poor man found to his surprise that he had missed a blastocyst preferable to the second one he had attempted to isolate. This one was removed, and the catheter was delivered by a hastily summoned technician to the physician’s theater of operation.
The embryologist moved to the second dish only to notice that he had trouble distinguishing it from the first. Both labels were similar in that both sets of clients had the same last name. Their first names were different but had the same initials. To further confuse matters, the case numbers differed only by the last digit: “2” in one case and “3” in the other. The “2” scrawled by whatever technician had done the labeling was just sloppy enough to be confused with a “3”. The only easily discernible difference between the two labels was in their colors. In his hurried and distressed condition, the embryologist could not remember checking the color coding on the labels or in his own records. Neither could he be certain as to which dish he had just used. He had, in fact, selected one blastocyst from each dish for implantation into the same mother. During the course of these silent deliberations, the implantation procedure was completed.
Who could fathom the thoughts that then swirled, collided, and did combat in the mind of this normally conscientious professional? For all he knew, and despite his worry, it was possible that no irregularity had occurred. Between himself, the technicians, and the physicians, all with coordinated and overlapping responsibilities, it would be difficult, if not impossible, to trace the source of an error which would not be detected for another nine months, if at all. He could play the odds and hide out in the chain of responsibility. Having decided this, he carefully checked his records and withdrew the next two embryos for the next implantation from the correct dish. The assigned catheter functioned properly and as expected on this try, but the embryos were of slightly poorer quality.
As circumstances would have it, the mixed sample was the only one that resulted in pregnancy. The racial identity of the woman into whom the embryos were introduced is not important to this narrative. Both embryos implanted in the endometrial lining of her uterus, and both remained viable. Very soon afterwards, however, another improbable event took place. In retrospect, it could be considered either fortunate or unfortunate, depending on one’s point of view, but no amount of procedural care could have prevented it.
In the scientific literature, there were reports of human beings who possessed cells of two different genetic types: for example, some with male (“XY”) and some with female (“XX”) chromosomal compositions. It was speculated that they had arisen from rare fusions of two embryos, one male and one female, in the womb. Rare occasions when a mother released two eggs during ovulation, both of which became fertilized by separate sperm, were prerequisites for such oddities. This was also a potential problem in the case of dual implantations by assisted reproductive technology. According to the explanation, embryos that would have become fraternal twins had fused in the womb instead of developing separately.
Children derived from mixtures of male and female cells showed certain abnormalities. Depending on the proportion of each cell type, the condition took on different manifestations. Relatively equal percentages of male and female cells produced true hermaphrodites while different ratios resulted in individuals looking outwardly male while inwardly possessing reproductive systems with one testis and one ovary each. Of course, there were instances in which two embryos of the same sex had also fused, in which case chimerism was identified on the basis of other identifiable genetic differences such as HLA haplotypes. The hypothesized fusions were believed to have occurred prior to the formation of the primitive neural streak in each embryo. It was known that the formation of maternal twins by the splitting of an embryo into two individuals of identical genetic composition could not take place after this event at the thirteenth or fourteenth day after fertilization. The assumption was therefore that neither could embryo fusion occur after this time period had elapsed.
Before this critical juncture, the two embryos – one genetically programmed to become black, the other to become white – fused in the womb of the unintentional semi-surrogate, half-mother, or whatever moniker might be deemed appropriate. A standard term to describe her status has yet to be coined and agreed upon due to the uniqueness of her situation. Both embryos were composed of cells containing the male “XY” complement of chromosomes. The result would be a racial chimera, a male identifiable by appearance at birth and by genetic testing shortly thereafter. In such complicated manner, the first individual mentioned at the outset of this chapter was formed.
The second arose from a normal conception in Saint Louis. It would arise from within two statistical categories, both indicative of endemic and chronic societal problems. The parents to be were unwed, and they were drug addicts still young enough in age and new enough to chemical dependency that the bloom of youth and physical attraction had not yet faded. In search of gratification, neither had planned for or against the option of parenthood, and they would not remain together. Sadly, neither even knew the other’s name, and both had availed themselves of multiple partners in the recent past. The young woman of this pair would later find herself at a loss as to the identity of the father.
Amid a confusion of nerve impulses, muscle contractions, hormones, and hydraulics, several sperm were deposited in the upper vagina of the recipient. Beating their tails back and forth in rapid undulations, they swam. A substantial minority made it through the cervix and into the uterus. Some of them lost viability along the way, and there was a high rate of attrition as they moved up the moist uterine wall. The odds against any of these sperm cells reaching the correct oviduct (also known as the Fallopian tube in humans) were roughly fourteen million to one. Once in the left oviduct, the surviving sperm were guided by a chemical signal being emitted from an egg in temporary residence there.
The left ovary of the mother had released this egg as part of a cycle in which alternating ovaries ovulated in alternating months. The egg had moved into the Fallopian tube and was further pulled along by a current generated by the action of microscopic, whip-like cilia lining this passage. It was then encountered by the sperm remnant that had successfully completed their journey of the last few days. Several of these were bound by their heads to the outside of their target, but only one was allowed to penetrate into the interior. In this manner were the chromosomes of the mother combined with those of the father, and they had the “XX” arrangement of a female. This fertilized egg continued its migration down the Fallopian tube and toward the uterus.
Two days post-fertilization, the egg had become a four-celled embryo. In roughly one more day, the number of these cells had increased to eight. Within that same day, a clear, colorless, raspberry-shaped ball of from twelve to fifteen cells had formed. Over the next couple of days, the embryonic cells not only divided but also crawled by ameboid movement to arrange themselves in a hollow sphere with an inner cell mass, a fluid-filled cavity, and a surrounding cell layer. Not long thereafter, this blastocyst implanted into the endometrial lining of the mother’s uterine wall.
Coincidentally, all three of the embryos – two formed with aseptic care in a fertility clinic, one in a less than sanitary tenement – became implanted in the same second of the same minute of the same hour on the same day over two-hundred miles apart. The two fused to form one. The other developed normally. Some two weeks after conception, the embryos in both mothers had undergone the formation of their primitive neural streaks. From these streaks would develop the nervous systems, the organic seats of the souls, of two human beings.
The soul, that abandoned child of contemporary society, ever returns to haunt it. Invisible in essence, it is repudiated as nonexistent. It is redefined and reduced to anatomical dimensions. In a hollow universe of social construction, philosophies concerning the profound abstraction of its operation are all too often simplified into waves of electrochemical impulse. Yet, in spite of the physiological limitations thus imposed upon it, the soul persists.