Assisted Reproductive Technologies

The term assisted reproductive technologies (ARTs) refers to a variety of procedures that enable people to reproduce without engaging in genital intercourse. Most people who use ARTs do so because they are infertile and other methods of treating their infertility have proven unsuccessful. Some people without fertility problems also use ARTs to minimize the risk of transmitting certain genetic disorders or to reproduce without a partner of the opposite sex.

Basic ART Procedures

The most commonly used type of ART is assisted insemination (also known as artificial insemination). With assisted insemination, sperm is obtained from the male through masturbation and then placed in the woman's vagina, cervix, or uterus with a syringe or similar device. Assisted insemination is used to overcome medical conditions that interfere with the ability of sperm to reach and fertilize an egg.

In-vitro fertilization (IVF), a more complex and expensive procedure than assisted insemination, is used for a variety of diagnoses, including unexplained infertility. With IVF, physicians surgically retrieve eggs from the woman's body (in most cases, following a series of hormonal treatments that stimulate the production of multiple eggs), fertilize the eggs in a petri dish, culture the resulting embryos in the laboratory for several days, and then transfer some or all of the embryos back into the woman's uterus for implantation.

Two procedures related to IVF are gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT). With GIFT, as with IVF, physicians remove eggs from the woman's body, but instead of fertilizing the eggs in a petri dish they transfer the unfertilized eggs, along with sperm, back into the woman's fallopian tubes. With ZIFT, the eggs are fertilized in a petri dish before they are transferred, but instead of transferring the embryos directly into the uterus (as they are in IVF), the embryos are inserted into the fallopian tubes. GIFT and ZIFT were developed as potentially more effective alternatives to IVF, but since success rates with IVF have improved, the popularity of GIFT and ZIFT has declined.

The likelihood that IVF, GIFT, or ZIFT will succeed varies considerably, depending on factors such as the woman's age, the nature of her infertility, and the skills and experience of the practitioners performing the procedures. In 1999, approximately 25 percent of these procedures led to a live birth (Center for Disease Control and Prevention 2002).

IVF is sometimes performed in conjunction with intracytoplasmic sperm injection (ICSI), a procedure in which fertilization is achieved by injecting a single sperm directly into each egg. Because only a few normal sperm are required to perform the procedure, ICSI can be used for men who have poor-quality sperm or extremely low sperm counts. The first successful pregnancy resulting from ICSI was reported in 1992, marking a milestone in the treatment of male infertility.

Variations on the Procedures

Although ARTs are usually performed with the gametes (i.e., sperm and eggs) of the intended parents, in some cases gametes of one of the intended parents are combined with donor gametes. Gamete donors may be friends or relatives of the intended parents, or they may be individuals who have been recruited by the ART program and paid for their services. In the latter situation, the identity of the donor is usually not disclosed to the recipients, although nonidentifying medical and personal information may be made available.

Sperm donation is used for a variety of purposes. First, it may be used when the male partner is unable to produce a sufficient amount of viable sperm. It is a far less expensive treatment for this purpose than ICSI and, because it can be used in conjunction with assisted insemination, the woman does not have to undergo the medical risks and burdens of IVF. Second, sperm donation may be used by couples at risk of transmitting certain genetic diseases. For example, if both partners are carriers of a recessive genetic disorder, such as sickle-cell disease, using sperm from a donor who is not a carrier will ensure that the resulting child is not born with the disease. Finally, sperm donation may be used by single women or lesbian couples who seek to reproduce without a male partner. Sperm donation is a simple process that involves no physical risks to the donor.

Although sperm donation has been available since the 1950s, egg donation is a relatively new procedure, available only since the early 1980s. It is used by women who are unable to produce eggs of their own or, as with sperm donation, by couples who want to avoid transmitting certain genetic diseases. Egg donation enables women to have children long after they have passed menopause; in 1997, physicians reported a successful pregnancy in a 63-year-old woman who had used egg donation (New York State Task Force on Life and the Law 1998). Unlike sperm donation, being an egg donor is time consuming and involves medical risks, primarily those associated with ovarian stimulation and egg retrieval. Donors are generally college-age women, and they are typically paid several thousand dollars for each cycle of donation.

Depending on applicable state law, some ART programs offer the option of surrogate parenting (also known as surrogacy). Surrogacy does not refer to a specific type of ART, but rather to a social arrangement in which a woman agrees to become pregnant and relinquish the child to the intended parents after birth. Surrogacy is used by couples in which the female partner is unable to gestate a pregnancy, or by single men or gay male couples who want to reproduce without a female partner. With genetic-gestational surrogacy (sometimes referred to as traditional surrogacy), the surrogate becomes pregnant by undergoing assisted insemination with the intended father's sperm. With gestational surrogacy, the intended parents create an embryo through IVF (using their own gametes, donor gametes, or a combination), and the embryo is then transferred into the surrogate to establish a pregnancy.

The ability to cryopreserve, or freeze, gametes and embryos is an important part of many ART procedures. Both sperm and embryos can be cryopreserved. Some success has been achieved with freezing unfertilized eggs, although the cryop-reservation of eggs is still considered experimental. One of the benefits of cryopreservation is that it can preserve the reproductive capacity of individuals about to undergo chemotherapy or other medical treatments that might impair their fertility. In addition, for couples undergoing IVF, the ability to cryopreserve extra embryos makes it possible to engage in additional attempts at pregnancy without having to undergo ovarian stimulation and egg retrieval each time. If couples have excess frozen embryos after they are finished with their treatment, they can keep them in storage indefinitely, destroy them, donate them to other patients, or make them available to researchers (Coleman 1999).

Some people use ARTs in order to take advantage of pre-implantation genetic diagnosis (PIGD). With PIGD, physicians create embryos through IVF, remove one or more cells from each embryo (a process that does not harm the embryos), and then perform genetic testing on the removed cells. PIGD enables individuals at risk of transmitting serious genetic disorders to select for implantation only those embryos found not to be affected. It also permits prospective parents to determine the sex of their children by transferring embryos of only one sex. In addition to PIGD, individuals who want to increase the likelihood of having a child of a particular sex can do so before conception through the use of sperm-sorting technologies, although, unlike PIGD, these techniques cannot guarantee the birth of a child of a particular sex.

In the future, it may be possible to go beyond the process of genetic screening to affirmative genetic manipulation of embryos. Such techniques could give individuals significant control over their children's genetic makeup by enabling physicians to eliminate traits considered undesirable, or to add traits considered desirable.

Medical Risks of ARTs

Like any medical procedure, ARTs involve both benefits and risks. Fertility drugs, whether used alone or in conjunction with IVF, can lead to a condition known as ovarian hyperstimulation syndrome, which, in rare cases, can be life threatening. This risk extends not only to women taking the fertility drugs for their own benefit, but also to egg donors who take fertility drugs to increase the number of eggs they will be able to donate.

One of the most serious risks associated with ARTs is the significantly increased likelihood of multiple gestation. About one-third of all IVF-generated pregnancies result in multiple births; approximately one-fifth of these multiple pregnancies are triplets or higher-order multiples. The use of fertility drugs without IVF also is associated with an increased risk of multiple pregnancies.

Multiple pregnancies involve significant risks. A woman pregnant with multiples is more likely to develop diseases like anemia, high blood pressure (hypertension), and pre-eclampsia. In addition, approximately 10 percent of children in multiple births die before their first birthday, and the surviving children are at significantly increased risk of lifelong disability. To reduce these risks, some women who have high-order multiple pregnancies undergo multifetal reduction, a procedure in which one or more of the fetuses are aborted. Although this procedure increases the likelihood that the remaining fetuses will be born healthy, it does not eliminate the risks associated with multiple gestation. Moreover, it is emotionally difficult and ethically problematic for many patients.

The high rate of multiple gestation associated with IVF is a result of efforts to increase the likelihood of pregnancy by transferring multiple embryos into the uterus in a single cycle. Physicians have been criticized for failing to adequately inform patients of the risk of multiple gestation (New York State Task Force on Life and the Law 1998). In the United States, professional organizations have recommended limits on the number of embryos transferred per cycle, although physicians are not legally required to adhere to these limits. Some European and Asian countries have imposed mandatory limits on the number of embryos physicians may transfer in each cycle.

Ethical and Religious Perspectives on ARTs

Commentators have taken widely differing positions on the appropriateness of having children through ARTs. Some commentators embrace these technologies with few reservations, emphasizing the benefits they offer both infertile couples and women who want to reproduce without a partner of the opposite sex. Supporters of ARTs argue that society should defer to individual decisions about reproductive matters, citing the legal and ethical principle of individual autonomy and the absence of evidence that ARTs result in tangible harm (Robertson 1994).

Other commentators, although generally supportive of at least some forms of ARTs, have expressed concerns about certain aspects of these technologies. Some commentators worry that, as the use of ARTs becomes more routine, children will come to be seen as products to be manufactured according to parents' specifications, rather than as unique individuals to be accepted and loved unconditionally (Murray 1996). As an example of this phenomenon, some gamete donation programs that allow prospective parents to select donors based on personal characteristics like SAT scores, athletic ability, or physical appearance. Similarly, some disability rights activists worry that technologies designed to avoid the birth of children with genetic disorders send a negative message about the value of people with disabilities who are already alive (Asch 1989). Many commentators express particular concern about the prospect of germ-line modification, particularly if it is used for nondisease related reasons, such as controlling a child's hair or eye color or enhancing athletic ability or other personal characteristics (Mehlman 2000).

The danger that ARTs will change the way that children are valued also underlies some commentators' objections to the increasing commercialization of reproductive services. For example, some commentators decry the high fees paid to egg donors and surrogate mothers, based partly on their fear that purchasing an individual's reproductive capacity inappropriately commodifies the process of reproduction—in other words, that it turns reproduction into a commodity for sale in the market, rather than a private activity motivated solely by love. Some commentators find it difficult to distinguish between paid surrogate parenting and baby selling, as both practices involve the payment of money to obtain a child (New York State Task Force on Life and the Law 1998).

For some commentators, the acceptability of ARTs turns in part on the environment in which the resulting child will be raised. Thus, some commentators support the use of ARTs by married couples unable to reproduce through sexual intercourse but object to the provision of IVF to single women or lesbian couples (Lauritzen 1993). Others oppose the use of egg donation in postmenopausal women, given the possibility that older women might die while their children are still young (Cohen 1996). By contrast, many commentators believe that children can thrive in a variety of environments, and that efforts to restrict reproduction to young married couples are motivated primarily by ignorance or bias (Murphy 1999).

The use of third-party participants in ARTs— particularly egg donors and surrogate mothers— has generated significant controversy. These women undergo significant medical and psychological risks, often at young age, and usually for a considerable amount of money. Many commentators have expressed concern about the potential for exploitation as young women in need of money undergo risks to benefit older, wealthier couples who want to reproduce (Rothman 1989). With surrogate parenting, commentators also argue that a birth mother cannot make an informed and voluntary decision to give up her child before she has gone through pregnancy and childbirth (Steinbock 1988).

Feminist commentators disagree about many of the ethical issues surrounding ARTs (Warren 1988). Some feminists believe that ARTs are a positive development for women because they give women greater control over the timing and manner of reproduction. Others, by contrast, maintain that the increasing medicalization of infertility reinforces the view of women as primarily mothers, making it more difficult for women to choose to remain childless.

Feminists are particularly divided over the practice of surrogate parenting. Some believe that surrogacy, especially paid surrogacy, exploits women by treating them as mere "incubators" (New York State Task Force on Life and the Law 1988, p. 85). Others maintain that efforts to restrict surrogate parenting are based on misguided paternalism, and that women have a right to use their bodies as they see fit.

Religious perspectives on ARTs are as varied as the positions of secular commentators. At one extreme, the Roman Catholic Church has consistently opposed all forms of ARTs, based on its belief that reproduction must remain inextricably linked to sexual intimacy within a marital relationship (Congregation for the Doctrine of the Faith 1987). The Church has expressed particular concern about ARTs that result in the creation of multiple embryos, as some of these embryos will ultimately be destroyed. Because the Church believes that embryos are persons from the moment of conception, it regards the destruction of an embryo as morally equivalent to killing a person who has already been born.

In most other religious traditions, however, the use of at least some forms of ARTs is considered ethically acceptable (New York State Task Force on Life and the Law 1998). Most Protestant denominations, as well as Jewish, Islamic, Hindu, and Buddhist authorities, support the use of ARTs using gametes from a married couple. Indeed, some Jewish and Islamic theologians suggest that infertile married couples have a duty to use ARTs, given the importance of procreation in these religious traditions. Many of these religions, however, are opposed to the use of donor gametes.

Legal Considerations

ARTs raise a variety of complex legal issues. For example, with ARTs it is now possible for a child to have three biologically related parents—the man who provides the sperm, the woman who provides the egg, and the woman who gestates the child and gives birth—as well as one or more additional social parents who intend to raise the child after it is born. If conflicts arise among these individuals, how should the law apportion their respective rights and responsibilities? Some courts have held that parental rights should be based on the intent of the parties at the time of conception; thus, when one woman gives birth to a child conceived with another woman's egg, the woman who intended to act as the child's parent will be considered the mother. Other courts have rejected this intent-based approach in favor of clear rules favoring either genetic or gestational bonds. In many jurisdictions, the law in this area remains unsettled (Garrison 2000).

Disputes also can arise over the disposition of cryopreserved gametes and embryos. When individuals die before their frozen gametes or embryos have been used, should a surviving spouse or partner have the right to use the frozen specimens without the donor's explicit consent? When a couple freezes their embryos for future use and then divorces, may one partner use the embryos to have a child over the other partner's objection? Internationally, courts have taken widely differing approaches to these issues. To avoid disputes over frozen gametes and embryos, many authorities suggest that people should leave written instructions regarding their future disposition wishes. However, some courts have suggested that, even when such instructions exist, individuals retain the right to change their minds at a later date (Coleman 1999).

The law also governs the relationship between ART practitioners and the patients they serve. Physicians have been accused of understating the risks associated with ARTs, particularly the likelihood and consequences of multiple gestation, as well as overstating the likelihood that treatment will result in a live birth. Such practices may form the basis for legal claims of misrepresentation or failure to obtain informed consent. The law also may constrain the exercise of discretion by physicians in their selection of patients. For example, physicians who are unwilling to provide ARTs to unmarried women or HIV-positive patients may find their decisions challenged under antidiscrimination laws (New York State Task Force on Life and the Law 1998).

Conclusion

ARTs have helped numerous individuals overcome physiological or social barriers to reproduction that, in previous generations, would have made it impossible for them to have children. At the same time, they have generated significant ethical, religious, and legal issues about which no societal consensus yet exists. As developments in ARTs continue to proceed, the challenge will be to promote the beneficial use of technology while minimizing the social harms.

See also:Birth Control: Contraceptive Methods; Birth Control: Sociocultural and Historical Aspects; Family Planning; Fertility; Sexuality Education; Sexuality in Adulthood; Surrogacy

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other resources

American Society for Reproductive Medicine. (2002). Ethical Considerations of Assisted Reproductive Technologies: ASRM Ethics Committee Reports and Statements. Available from www.asrm.org/Media/Ethics/ethicsmain.html.

Centers for Disease Control and Prevention. (2002). Assisted Reproductive Technology Reports. Available from www.cdc.gov/nccdphp/drh/art.htm.

Human Fertilisation and Embryology Authority. (2001). HFEA Code of Practice. Available from www.hfea.gov.uk/frame.htm.

carl h. coleman