Fertility technology giveth, and fertility technology taketh away. In a custody case for the new millennium, a U.K. woman named Natallie Evans recently lost a much-publicized legal battle for the right to try to get pregnant using embryos fertilized by her former partner. The pair had created the embryos via in vitro fertilization before Evans underwent treatment for ovarian cancer, which left her infertile. Following their breakup, her ex withdrew his consent for their implantation, which would be required by U.K. law; the European Court ruled that her desire to be a mother did not override his desire not to be a father, and ordered Evans to destroy the embryos, which represented her last chance for biological children of her own.
The controversial case engendered much public soul-searching about what it means, today, to be a mother, a father, a partner, an embryo -- along with discussion of what options technology might have offered, or could still offer, Evans and her putative offspring. If only she'd frozen eggs, not embryos! If she used a donor egg and donor sperm, perhaps she could still experience pregnancy! If she offered the embryos for "adoption," they wouldn't be destroyed!
Here in the U.S., fertility is estimated to be a $3 billion industry. Nearly 50,000 U.S. children were born via IVF in 2003, a 128 percent increase since 1996; 30,000 had donor sperm for dads. Donor eggs or embryos, gestational carriers (surrogates), screening of embryos for serious disease: Taken all together, the techniques of advanced reproductive technology (ART) add up to more than private discussions between doctors and would-be parents, more than individual stories of heartbreak and bliss. And according to journalist and author Liza Mundy, ART is not just changing "how we think" about parenting and procreation. In her exhaustively reported and tenaciously argued new book, "Everything Conceivable: How Assisted Reproduction Is Changing Men, Women and the World," Mundy observes that virtually every trend documented in the most recent National Vital Statistics Report is related to fertility technology. ART is changing us all: our very society, our very cells.
But maybe you're done having children, or are pretty good at it, fertility-wise, or not interested in the first place. How does ART have anything to do with you? For one thing, private decisions have public health implications. Your children could be exposed to chemicals today that will affect their fertility tomorrow. (According to Mundy, some researchers suggest that sinking teen pregnancy and birth rates may be due in part to environmentally induced reduced sperm count in teen boys.) Or, thanks to the prevalence of fertility treatments, the "epidemic" of multiple births -- now, one out of every 33 U.S. children born is a twin -- could, given the common medical challenges of multiples, contribute to steadily increasing healthcare costs. ART has sent such tremors through the political terrain that even (some) feminists are speechless and some super-conservatives -- like the director of "embryo adoption" agency Snowflakes, interviewed by Mundy -- are saying things like, "Family is not just that little nuclear genetic family it was in the 1950s." Writes Mundy: "Assisted reproduction is having a social impact as profound as the widespread availability of the birth control pill in the 1960s, and the passage of Roe vs. Wade ... in 1973. Now, the same sort of impact is being created by newer technologies that permit people to create children rather than avoid them."
Salon recently interviewed Mundy about the results of what she calls a vast, "radical" -- and ongoing -- "social experiment."
Your idea for this book came, in part, from an article you wrote for the Washington Post about poor people and infertility -- in response to which you received some very scathing letters. Why do you think assisted reproduction arouses such judgment and hostility?
I think all issues having to do with children and how we raise them attract hostility and judgment. Anybody who writes about work and family issues -- you know you're going to experience a torrent of opinions about the choices that you've made. People are just very opinionated about how other people form families. The technology and the science probably exacerbate that. I also think there is a fear that with these technologies people are going to be able to "design" their babies and choose what sort of child they want to have. That obviously raises the level of alarm, and in some cases it should. But I hope with my book to broaden the picture by providing a lot of real reporting about the choices people are making.
One thing you say in your book, though, is that we're actually a long way from "designing" our own babies.
It's true that the science of genetics and genetic diagnosis is moving forward, but people have the sense that science is rocketing forward, and I think when discussion happens around these technologies the assumption is that "designer babies" are either happening now or are about to happen. But people are completely unaware that the problems now have to do with aspects of technology that have not rocketed ahead -- for example, doctors and scientists not being able to diagnose in advance which embryos will "take" [in an IVF cycle] and the resulting problem of multiple births. While the general public often thinks of IVF patients as picky parents poring over donor profiles, in truth, so many IVF parents I interviewed are all too happy to do whatever they need to to care for twins and triplets born under challenging circumstances: hovering in the NICU unit over premature babies, driving three sick kids to three different pediatric appointments, taking care of, say, a triplet set in which two children are fine and the other is born with a touch of scoliosis, or vision issues, or hearing problems. In the here and now, IVF science is driving up rates of infant mortality and prematurity, and all the complications that ensue.
In fact, it's important to keep in mind that in some ways, IVF science is driving evolution backward rather than forward. While assisted reproduction may someday lead to a master race of genetically designed humans -- the future always looks like Uma Thurman, doesn't it? -- in the here and now what it's doing, often, is creating babies who are at a disadvantage, rather than unfairly enhanced. This is true of techniques that allow men with very low sperm counts to procreate, creating, in some cases, infertile sons. Through the procedure called ICSI [intracytoplasmic sperm injection, for men with low sperm counts], widely done now, where you can inject a sperm directly into an egg, infertile men could have sons likely to inherit the same genetic issue and to need the same treatment. Scientists and doctors recognize that there may be other genetic issues with some infertile men that are now being introduced into the gene line of their sons and possibly exacerbated. Doctors even joke about creating the next generation of infertility patients. There's even one doctor who's done a mathematical calculus showing that thanks to ICSI someday every man will be infertile.
You hear a lot about women who "wait" to have children driving up the rates of birth defects, but not so much about men. As we learn more about male infertility -- and the implications of treatment -- do you see that focus changing?
No! Although men are now half or more of infertility patients, there's been so little conversation about this -- and yet so much conversation around the use of technology by women -- older mothers, egg donors. Women continue to be blamed for their infertility, and this drives me crazy. The relatively small subset of infertility patients who are older women, 38 and above, are always assumed to have actively and deliberately "waited too long." There's never any discussion of the reasons why women and men are both conceiving at later ages. The factors that go into later conception have to do with unwilling partners, partners who don't exist yet, bosses who actively discourage women from childbearing -- and yet there's this assumption that these women have just "decided" to wait and brought this upon themselves. I keep waiting for that cover story about men who are "waiting" to conceive.
Or the cover story about how environmental factors could be a major cause of infertility.
There's a group of scientists who are hard at work on that question -- about whether toxic chemicals and artificial estrogens are impacting the reproductive systems of men and women. And there's a major government study now called LifeStudy where NIH is going to be tracking this.
Do you think getting some of those answers might shift the perception that infertility is primarily an affliction of the affluent?
Maybe. But that's an important point: There's this cliché that the rich get richer and the poor have children. But in fact, the lower your income level the more likely you are to suffer from infertility. That's true in this country and in developing countries.
Why have certain fertility advances been so confusing for feminists?
It's hard to know what to think when more affluent women are able to pay other women to be surrogates or egg donors and whether or not that constitutes an exploitative relationship. When gay men are able to contract with both an egg donor and a surrogate and essentially pay women to provide them with the equipment to have biological children -- are these women being exploited, or is it an example of reproductive equity for all? Some feminists have spoken out against egg donation for stem cell research, believing that it endangers women's health and that poorer women will be attracted by the compensation. Others think that it's fine, that it's an expression of reproductive choice, and that as long as it's regulated and monitored and the health of the women is researched, that it's OK. There are issues of socioeconomics and equities that are confusing, and there are choices that were not available 25 years ago when the term "choice" was coined.
Do you think women should be paid for donating eggs for stem cell research or reproductive purposes? [In stem cell research, eggs are used to research a cutting-edge type of therapeutic cloning in which stem cells could be tailor-made for a patient's immunology.]
Yes. Debora Spar had a piece in the New England Journal of Medicine recently in which she said there's no clear reason why women donating for stem cell research should not be paid. I think she's absolutely right. And women donating for reproductive purposes should be paid. We worry a lot about the idea of $25,000 and $50,000 egg donors, but the norm has probably risen incrementally to $5,000 or $6,000.
You know, one of the great ironies of gamete [sperm and egg] donation is that it's one of the few realms in which men are paid less than women. And women of color can be paid more than Caucasian women because of the relative scarcity of donors of color. And so the socioeconomics are sort of upended.
One other thing about that: I was talking to an infertility patient who is a scientist and a science journalist and I asked her if she would donate her eggs for stem cell research. She said no, because there's so much money involved in these stem cell patents that rather than feeling like she was helping science she would feel like she was helping make a ton of money for some private bioresearch company. I thought that was an interesting point -- and another reason why egg donors should be paid. Why should these companies, and not the donors, be able to make all this money off their patents?
Let's go back to multiple births. Why should we be concerned, other than the fact that double strollers are a hazard in the supermarket?
The chance that a baby who is part of a set will be born premature is much higher than for singletons, and -- though medicine can now do incredible things -- the risks associated with prematurity are enormous and in many cases lifelong. Just the costs of delivering multiples are exponentially higher than the costs of delivering singletons. But fertility doctors always say, "Patients want twins, patients want triplets. And we just can't argue them out of it." I find that absurd. That trained medical doctors think they're helpless in the face of patient desire. The industry has not worked hard enough to provide patients with true informed consent, and doctors -- saying it should be the patient's choice -- are still willing to transfer too many embryos [as part of the IVF process] to keep their pregnancy rates up. This is one area in which reproductive "choice" has been co-opted by the fertility industry.
What's to be done?
Well, there has been some effort on the part of fertility doctors to limit the number of embryos transferred -- to stop putting in, say, five. But for a long time in this country they're still going to put in two. One thing that would help cut down on the really high-order multiples would be if insurance companies were required to cover IVF. Because in states where they don't cover IVF, patients' first treatment of choice will often be fertility drugs, which are a much more uncontrolled situation because a woman can ovulate 10, 15 eggs, and she can conceive octuplets. Truly high-order multiples are almost always caused by drugs. And often the patients who rely on the more powerful injectables are working-class or lower-income women who can't afford IVF. Also, insurance companies should exercise leverage over how many embryos are transferred. A lot of IVF has to do with economics: They paid $10,000 for this and if they can get twins, they're basically buying in bulk.
Embryos that don't get transferred often wind up in storage -- and at the center of debates about whether they're "pre-children" or "clumps of cells." Is technology shifting how we think about what constitutes life itself?
Clearly, technology that enables us to visualize life in its earliest stages is complicating our thinking about when life begins and what can ethically be done with it. This is true of sonograms, and it's true of IVF embryos, of which patients are invariably given photographs. And I must say, fertility clinics have not served their patients well in this regard. When patients are starting IVF treatment, they think, "If we have lots of embryos that's great because that raises our chances of having more available if we need them for later treatment." But there's no long conversation about the eventual fate of any excess embryos. And then when patients get to the end of treatment, regardless of whether it succeeded or failed, some assistant will call and say, "So you've got these frozen embryos -- do you want to keep paying for storage?"
The industry likes to define them as "clumps of tissue" because if you define them as "early human life" then politics and regulation are going to come into play. But what's so interesting is that parents often become attached to their embryos and wind up paralyzed by the question of what to do with them [if not use them for another round of IVF], regardless of their politics. Meanwhile, public opinion is swinging in favor of funding embryo research and agreeing to destroy embryos in the process. So I think we're going to be confused about this for a long time.