The field of assisted reproduction has evolved at a rapid pace over the past 40 years and fertility patients are now faced with a plethora of treatment options. Patients have to decide which fertility clinic to use, which treatment to opt for, whether to pay for fertility treatment add-ons, whether to screen their embryos for genetic abnormalities, whether to freeze all of their embryos, whether to transfer one embryo or two, whether to change their treatment strategy and, ultimately, whether to stop treatment all together.
Professor Robert Klitzman, professor of psychiatry at Columbia University Medical Centre, became fascinated with the decisions fertility patients have to make after a close friend asked him to consider becoming a sperm donor. Professor Klitzman ultimately declined the proposition but decided to focus his academic studies on the ethical, economic and social challenges that arise in relation to assisted reproductive technologies (ARTs). His new book, 'Designing Babies: How technology is changing the ways we create children', explores the findings of his research.
While the book title might conjure up images of scientists creating bespoke, made-to-order babies in a laboratory, the actual content of the book is a far cry from the dystopian, Brave New World narrative that we have come to expect from critical observations of modern-day reproduction. Instead, the book offers a fascinating insight into the American fertility field today.
The book explores how fertility patients and treatment providers navigate the ethical, financial and social dilemmas that can arise when ARTs are used to build a family. Each chapter examines a different dilemma in depth, such as, when it is time to use an egg donor or surrogate, and who is responsible for making these decisions. The inclusion of real-life experiences from both patients and medical providers makes the book both accessible and relatable.
As someone who has previously worked in a UK fertility clinic, I found it fascinating to compare the ways in which the American and UK fertility sectors differ. Fertility treatment in America is largely unregulated. Service providers have almost complete autonomy in terms of deciding which treatments to offer and which patients to treat. In addition, most patients have to pay privately for fertility treatment as health insurance coverage is often lacking. These two factors seem to have moulded the American fertility industry into the highly competitive, consumer-driven marketplace that it is today.
One theme which runs throughout the book is the tension that can arise when medicine is combined with business. Professor Klitzman describes countless situations where medical professionals are reluctant to refuse a patient's treatment request because they believe that the patient will simply move to another clinic and that they'll consequently lose business.
I found it particularly worrying to read that the majority of American egg agencies, which buy and sell donor eggs, are not operated by medical professionals. To make matters worse, these private businesses are not expected to adhere to professional fertility guidelines because they are not classified as medical organisations, thereby placing potential egg donors in a vulnerable position.
One contentious issue for American fertility providers is whether to perform sex selection for social reasons. This practice is not permitted within the UK but can be performed freely in the USA. American treatment providers differ widely in their ethical and moral viewpoint of social sex selection. Professor Klitzman recounts how one clinician refuses to offer sex selection because 'sex is not a disease'. However, other clinicians feel that the practice is harmless as 'parents request boys and girls equally'.
In the absence of formal treatment legislation, American fertility clinics have had to find creative ways to balance patient demand for sex selection with the ethical stance of their organisation. Some clinics are happy to provide sex selection for 'family balancing' reasons but would be reluctant to offer sex selection for a first or second child. Some clinics try to increase the chance of a patient having a baby of the desired sex by offering sperm selection, where the heavier 'female sperm' are separated from the lighter 'male sperm' prior to treatment. In a similar vein, some clinics offer to transfer one female embryo and one male embryo each cycle and leave the outcome up to nature. The latter two options represent a compromise between patients that want a child of a specific sex and clinics that are ethically opposed to selecting/discarding embryos based on sex alone.
Sex selection is just one of the many fertility 'grey areas' that can create tension between the medical practitioners, the patients and the profit margin of the clinic. The number of embryos that are transferred each IVF cycle is another challenging issue within the American fertility field.
Professor Klitzman describes how many fertility patients want to have twins 'to save time and money'. This demand has created the precedent for transferring two to five embryos per IVF cycle, despite the well documented health risks associated with a multiple pregnancy. Shockingly, many clinics attempt to manage these risks by asking patients to consent to a 'fetal reduction' if they get pregnant with three or more babies, rather than asking patients to transfer fewer embryos at the outset.
Unfortunately, there seems to be little financial incentive for the fertility clinic to intervene earlier and recommend a single embryo transfer. Transferring more embryos per cycle can boost the clinic's success rate, which can attract more 'customers'. In addition, fetal reduction is often not covered by health insurance, thereby creating another business opportunity. Without the security of fixed, legal boundaries, medical practitioners struggle to identify where their professional responsibilities lie, and ultimately, patient safety is compromised for monetary gains.
Throughout the book, Professor Klitzman calls for enhanced regulation and guidance within the American Fertility Sector. At a minimum, he believes that all fertility clinics should be required to report the outcome of every treatment cycle. He also highlights the benefits that could be gained from applying penalties or sanctions on clinics that fail to adhere to professional guidelines.
On a personal level, I agreed with Professor Klitzman's pleas for regulatory improvement and the book as a whole made me thankful for the fertility regulations that we have in place in the UK. In contrast, most American fertility providers felt that additional regulation was unnecessary and could impede clinical practice. Practitioners were particularly wary of any government involvement in the fertility sector and expressed concerns that politicians could implement treatment policies that reflect their own ethical agenda (eg, a pro-life stance) rather than patient need.
Overall, Professor Klitzman has created an incredibly detailed, thought-provoking book which shines a light on the dilemmas that fertility patients and medical practitioners face on a daily basis. This book will likely appeal to a wide range of individuals, including professionals that work in the fertility sector, fertility patients, policy makers and academics with an interest in bioethics.