'I would hope I haven't stretched the boundaries of what will come back retrospectively to haunt me. I don't believe I have - but I don't mind stretching them at the time if I believe I'm right, even though someone else has a different ethical view.'
The Golden Egg, part of Tortoise Media's 'Big Egg' series, opens with these words from Dr Simon Fishel, CEO of CARE Fertility, and founder of ProFaM , the controversial new venture that offers ovarian tissue freezing to postpone the menopause (see BioNews 1010). Even in an oncofertility setting, it's a technology that's used only when egg freezing isn't feasible, but is now being marketed as an empowering choice for women in their 20s to 'freeze the biological clock and prepare for the future'.
The podcast asks the question: how did we end up here? It examines the pushing of boundaries between scientific advances and the ethical questions they raise, and the redefining of boundaries of who can procreate and how. Moreover, it observes that amongst all this boundary-pushing, a lot of people made a lot of money: from the birth of Louise Brown, the world's first baby born through IVF, in 1978 to a global industry expected to be worth $40bn by 2027.
The story begins with a whistle-stop tour through the early years of IVF, pausing in the late 1980s when Dr Fishel describes his frustration at his work being blocked by a catch-22 impasse. The UK authorities insisted he had to prove his new sperm micro-injection technique for male infertility was safe before he could use it on patients - which he says he couldn't prove without being allowed to use it on patients. He continued his cutting edge work in 'the wild West of Italy', where the pendulum subsequently swung the other way to become one of the most stringently regulated countries - to the detriment of patients, he argues.
Innovation both requires and generates money, and the host of technological developments in reproductive medicine in the intervening years went hand in hand with a booming baby business - during which time the opportunities for manipulation, exploitation and malpractice have also risen. Dr Lucy van de Wiel, a research associate at Cambridge University's reproductive sociology research group, cites IVF treatment add-ons as being at the heart of this tension between patients and profit. We don't talk of a cancer industry. When I see my neurologist I'm not given a list of epilepsy treatments from which to pick and choose. Yet as a fertility patient I'm offered a dazzling array of multi-buy packages and add-ons, many of which aren't proven to be either effective or safe. As Dr Arthur Caplan, the director of the division of medical ethics at the New York University Grossman School of Medicine, said, 'Medicine isn't a restaurant. You don't go in and order off the menu.'
From medical infertility to social infertility (no or same-sex partner) to no infertility, the target market for assisted reproductive technology is every woman, all the time. Dr van der Wiel points out that fertility MOTs are inherently designed to create new customers because every result is a pathway to treatment (see BioNews 922). Low ovarian reserve? Best to freeze your eggs now before it's too late. High ovarian reserve? Best to freeze your eggs now for the most effective fertility insurance policy. Whereas IVF is (or was) an option of last resort, fertility treatment for young, healthy, fertile women is now promoted as an option of first resort.
ProFaM is presented as being at the forefront of this expansive and expensive industry, and Dr Caplan expresses similar concerns: 'It's like 'Hey, let's do this for your birthday, or here's a fun Christmas present. How about we preserve your tissues?' (During a media interview last year, Dr Fishel mentioned buying his daughter ProFaM for her birthday). The podcast explores fundamental questions surrounding this technology: is delaying the menopause safe? Is it ethical? Is it desirable? Is it even desired by women at all?
The inclusion of a perspective from a Catholic commentator felt like a missed opportunity; whilst the Church was the loudest opponent of IVF at the outset, in 2020 the moral and ethical questions feel more nuanced than 'playing God.' The discussion around falling fertility rates and whether older women should be mothers skims over why this might be the case. The primary reason women cite for freezing their eggs is because they haven't met the right partner (see BioNews 957). Furthermore, socioeconomic factors are a key reason why many women are having children later. Strikingly, a million women have dropped out of the workforce due to menopause symptoms, which is in no small part due to a lack of support systems. Yet rather than addressing these underlying societal issues to accommodate women (hard), the answer being pushed is to fix women's bodies to accommodate society (easy). And lots of people, mainly men, are getting very, very rich off the back of this.
It's a thought-provoking listen that really gets to the sharp end of the cracks in 'Big Egg'; digging into the debate by asking uncomfortable questions to which there are no easy answers. The podcast ends on a note that's perhaps rather telling. We learn that since the grand fanfare of ProFaM's launch over a year ago, not a single patient has signed up for the procedure. A solution in search of a problem?