ART in America
In the Old Testament, Abraham's wife, Sarah, foremother of a people, was initially unable to conceive a child. Despite harmonious marital relations, she bled every month and her belly failed to swell. Longing for a son, she did what any resourceful wife of her day would have done: she dispatched her husband to her maidservant, Hagar. The plan worked, but Hagar, having succeeded where Sarah had failed, lost respect for her barren mistress. Sarah, in turn, began to treat her harshly, making her fetch extra water and denying her seconds of stew. It was an unpleasant situation for everyone--with the possible exception of Abraham.
Hagar bore a son, Ishmael, on Sarah's behalf. Fourteen years later, though, God stepped in. He blessed Sarah--by then wizened and post-postmenopausal--with a child by blood, Isaac. "Who would have said to Abraham that Sarah would suckle children!" marveled the triumphal nonagenarian. "Yet I have borne a son in his old age." Eventually she instructed Abraham to cast Hagar and Ishmael out into the desert.
Had Sarah lived in the twenty-first century, she would have had a menu of options to consider before resorting to concubine recruitment. She could have tried fertility drugs, a few rounds of in vitro fertilization (IVF) or a trick called intracytoplasmic sperm injection to escort Abraham's seed to its destination. If all that failed, she could have had eggs extracted from Hagar or taken her pick among strangers with higher SAT scores. There likely would have been no need to wait until her 90s to bear a child--although if she were to give birth at that age, she would have had no shortage of company in the never-ending tabloid contest for World's Oldest Mother.
Couples throughout history have sought to control reproduction, with varying degrees of success. To avert pregnancy, there were always crude contraceptive techniques--withdrawal, proto-condoms--or cold baths. But if your problem was a fertility deficit, there wasn't much you could do besides adopt, enlist a third party or pray. For the most part family planning was the domain of God or nature until, in the twentieth century, technology and feminism joined forces to make childbearing preventable for many women. While lagging in effectiveness, remedies for infertility evolved too. By the late 1930s, hormonal treatments and tubal surgeries had become available, and the 1970s brought the spectacular breakthrough of IVF.
Today, infertility groups consider this array of treatments an extension of "reproductive choice," while flummoxed prochoice groups fear that their terminology has been hijacked. Despite the discord--and the very real differences--the two camps are intimately linked. Both are trying to sort through our increased reliance on technology to shape our lives and solve our problems--problems often created by other technologies. Indeed, in a significant minority of cases the demand for assisted reproductive technology (ART) results more or less directly from old-school reproductive rights: happily, women can take advantage of birth control and abortion to postpone motherhood--but some find that when they're finally ready and willing to get pregnant, they're no longer able to.
Some feminists are suspicious of ART because it allows women to fulfill a traditional role rather than emancipating them from one. Others, feminist or not, squirm at the commercialism: ordering a child, for a considerable price, and in some cases shopping for gametes or leasing a uterus. The availability of these items as consumer products elicits a jumble of reactions: why must we turn to the market to meet all our needs? Isn't there something character-building about accepting limitations and life circumstances? That said, why should only the poor have to accept such limits? Oh and, um, incidentally, what's the going rate for the sperm of a Harvard alum with low blood pressure and silky hair?
Likewise, we may instinctively recoil from the unnaturalness of ART. But this response warrants further scrutiny. "Unnatural" is a smear that can be leveraged against anything from birth control to vaccines. Manipulations of nature can be liberating or oppressive: medical science can be used to prevent pregnancy, to induce it and to provide a cosmetic "mommy job" to erase the residual signs of it. And while we all have opinions about these various technological applications, our judgments are bound to be colored by self-interest. A college sophomore who swears she'll never have kids is going to look at ART very differently from a 40-year-old in her third year of pregnancy attempts. The former could someday become the latter, struck by baby lust she had never anticipated, and distaste for ART could turn to gratitude. In this area, moral disapprobation is a slippery luxury.
Since Louise Brown, the first "test-tube baby," was born in 1978, more than 3 million children have been conceived by IVF worldwide. But the technology has advanced faster than the ethical and political consensus. This gap is especially conspicuous in the United States. Due to our peculiar abortion politics and free-market fetishism, the fertility industry--widely known among doctors and bioethicists as the Wild West of medicine--operates with virtually no government oversight.
Among the roughly 15 percent of Americans who have struggled with infertility is first-time author Beth Kohl. As a married woman in her late 20s, she was diagnosed with Polycystic Ovarian Disorder, which prevented her from conceiving the low-tech way. Embryo Culture is a memoir of her quest for pregnancy via IVF. (She lives in Illinois, where, unusually for the United States, a state mandate requires insurers to cover four rounds of that treatment.)
Unfortunately, Kohl's book is often marred by clunky prose--modifiers such as "spoony-looking" and "nonquiet"--as well as a scattered narrative. But it offers a serviceable introduction to the infertility scene. She covers an IVF cycle in detail: countless hours in the waiting room of the fertility clinic; daily self-administered injections of hormones; bloated discomfort and teary mood swings. Her husband, Gary, "worried about me, about us. He wanted to be of help, but I was becoming too much for him to handle. I was becoming too much for Freud or FEMA to handle." The ordeal is punctuated by moments of encouragement. When an ultrasonographer monitors the drug-induced follicles in her uterus, she thinks, with a touching desire for normality, "I was getting ultrasounds, just like any old pregnant woman."
Kohl's aim is not only autobiography; she wants to explore the ethical territory of ART. While she gamely acknowledges the standard concerns, however, her probing is perfunctory. When Gary suggests considering adoption, she replies, "Trust me.... I just know that this is the right thing for me. For us." This assertion of intuition is always the gist of her answer. In her foray into religious questions, she wonders "if I should put my faith in an all-knowing yet benevolent God who shall, at an unspecified miraculous point in the future, deliver a son or daughter unto me, patient member of His flock." She then confides her uneasiness at the prospect of spending more money to create a child than most parents spend to raise one. Her response to these worries: "But a force, an inner drive, is pushing me toward IVF." Ultimately, she fails to do the work of grappling with her reservations and spelling out why they are insufficient to override her decision.
Perhaps Kohl embodies a common attitude--the deep irrational drive to reproduce, in the face of which qualms are defenseless. But she is more a symptom of this tendency than a diagnostician. Two other recent books on the subject do a better job of analyzing the intense hunger for parenthood, as well as the fertility industry's manipulations of it. In Waiting for Daisy, Peggy Orenstein describes the incremental steps she took down a path of treatments she'd sworn she'd never try, such as egg donation, because, "What if this worked? What if it was the only way I could have a baby?" As Debora Spar argues in The Baby Business, this logic could lead to cloning: not out of an egomaniacal desire for self-replication but as a last recourse for patients who have tried everything else. It's not that infertility patients lack a moral compass, Spar suggests, but that they are vulnerable--which is an argument for policies setting certain legal limits.
Kohl was relatively lucky: although her first IVF cycle failed, she subsequently had two successful rounds. In the end, her story is quite conventional. The sole obstacle to a traditional family was her medical condition. She always expected to have kids, and when a problem arose, the remedy was available. Thanks to insurance coverage, she was spared the commercial excesses that are common in the United States. Hand-wringing notwithstanding, Kohl's essential feeling toward infertility treatment is gratitude. Her true worries center not on the ethics of assisted reproduction as a method but on its effects: whether IVF poses risks for the babies it brings to life. According to her research, it might. One study found an appreciably higher incidence of birth defects, especially heart problems and urinary- and genital-tract problems, in IVF children.
The apparent health of Kohl's three daughters, two of whom are twins, appears to reassure her on this point. Her agonizing then shifts to another question: what to do with the seven excess frozen embryos? Knowing and loving what the embryos could become, she is reluctant to discard them like so many leftovers. As the book ends, the embryos are still in the limbo of the freezer.
Even prochoice patients tend to think of their frozen embryos as, in Liza Mundy's words, "souls on ice." In Everything Conceivable, Mundy reports that some 400,000 frozen embryos are in storage in the United States. They belong mostly to American parents but also to foreigners who come here for the "reproductive tourism" they enjoy under the United States' relaxed laws. These parents haven't yet made the "disposition decision": whether to discard the embryos, give them to a different couple, try for another pregnancy themselves or donate them to science (a daunting prospect, thanks to religious-right activism against embryo research). In Louisiana, such embryos have been designated "juridical persons" entitled to some legal rights--a source of alarm for Roe v. Wade supporters. And like other outgrowths of the fertility industry, this one has spawned its own lucrative niche: companies devoted to managing the ever-growing embryo inventories of clinics. The staffs of such companies sometimes find themselves offering impromptu counseling to patients, who typically receive little guidance from any other source.
Mundy, a staff writer for The Washington Post Magazine, thoroughly explores this and other aspects of ART in America, bringing to bear impressive reporting skills and a sharp analytical mind. With empathy and wit, she illuminates the ironies and absurdities, the tragedies and dilemmas, but also the joys, of assisted reproduction. As she observes, "Parenting has been divided up; it has been compartmentalized; it has been outsourced. At the same time it has been made deliciously possible."
Mundy writes accessibly about science, but the human dimension is at least as prominent in her work. Her accounts vividly dramatize the resolve of aspiring parents and the improvisatory pluck ART calls for. She also looks at the new types of relationships formed--between egg donors and intended mothers, sperm donors and their genetic children, gay parents and surrogates. Among her sources these relationships tend to be warm, as opposed to, say, the conflict between Sarah and Hagar or the infamous case of Baby M, whose biological mother, hired as a surrogate, fought a legal battle to keep her. Like Kohl, Mundy has a rosy view of the fundamental premise of ART; she scarcely addresses philosophical objections. But she is by no means blind to its practical problems. Her book identifies serious flaws in its implementation and makes persuasive policy recommendations for ameliorating them.
Mundy ventures beyond the confines of Kohl's first-person narrative, finding several patterns that diverge from that conventional scenario. We encounter women who deferred parenthood--due to career pressures, nonexistent or reluctant partners, or their own ambivalence. When they have at last prepared to start a family, some find that their fertility has diminished with age. (An increasing number of this group purchase eggs from younger donors for anywhere from about $5,000 to $50,000 a batch.) We also meet would-be moms who refuse to wait for Mr. Right--or, rather, seek him on the website of their local sperm bank instead of on Match.com. There are lesbians who employ the same method, while gay dad wannabes go to even greater lengths. Consider the case of Eric Ethington and Doug Okun. In an increasingly typical instance of "collaborative reproduction," this San Francisco couple hired a surrogate to carry twins, using the eggs of a second woman. The twins, while gestating in the same womb, were half-siblings; each egg had been deliberately fertilized by one of the men.
The beautiful twins and their devoted dads make a happy ending (except, of course, for those offended by the notion of plural fathers in a single family). But the surrogate who carried them, Ann Nelson, hemorrhaged dangerously from the delivery, necessitating a hysterectomy. Nelson, an environmental activist and counselor of pregnant teens, considers surrogacy part of "a grassroots thing. I thought, 'I could help these poor people.'" Married to a firefighter paramedic, she had given birth, via C-section, to four of her own children and one for a different gay couple. This time, although her doctor had cleared her to bear twins or triplets, she suffered from placenta accrete, a condition more likely after a previous C-section, in which the placenta is not fully expelled upon delivery. Nelson's generosity strains belief--she calls surrogacy her "passion" and claims she accepted payment only for her family's benefit--but others object to what they call the exploitation of women like her, who are paid about $20,000. As Mundy notes, such arrangements manage to elicit disapproval from both the left and the right. She quotes feminist bioethicist Barbara Katz Rothman: "Any man with a checkbook can buy a baby.... The pieces are all for sale."
The commercialization of ART is not just unseemly; it carries real risks. Clinics competing for clients want to boast high rates of successful pregnancies, leading them to transfer greater numbers of embryos to increase the chance that at least one will bloom into a baby. This tendency has contributed to an "epidemic" of multiple births in the United States. (There are other factors at play, too: fertility drugs alone tend to produce the quintuplets and sextuplets that make the evening news.) The twinning rate, Mundy reports, has risen by 300 percent in three decades, while the rate of births involving higher-order multiples has increased by about 1,000 percent. "If Nature thought it was appropriate for homo sapiens to have litters, Nature would not have selected against it," one doctor tells her. Multiple births have a much greater incidence of prematurity, low birth weight and other risks. Mundy describes the calamitous pregnancy of Tammy LaMantia, who, having told her IVF doctor she wanted no more than twins, conceived triplets, all of whom died at or before birth.
A significant chunk of Everything Conceivable is devoted to the phenomenon of multiples. When they survive, they are more likely to suffer from long-term disadvantages. One couple, unable to afford IVF, used fertility drugs and conceived quadruplets. Born at twenty-five weeks, three of the babies survived and stayed in the hospital for months; at age 3, one was preparing to learn Braille and walk with a cane. Even in the absence of such problems, parents are often utterly overwhelmed. "The theme of uncontrollable crying," Mundy notes dryly, "entered into many conversations I had with mothers raising high-order multiples."
Whether or not there is a veritable "epidemic," more responsible medical practice and better regulations would result in fewer multiple pregnancies and lower health risks for mothers and children. Doctors tend to leave the choice of how many embryos to implant to the patients, who are desperate to conceive and typically given little time and information to make the decision. LaMantia's pregnancy probably would have gone smoothly if her doctors had transferred two embryos instead of three. (She later gave birth to twins.) Mundy convincingly argues that the number of embryos transferred should be limited by law to two, as is already the case in much of Europe.
Another culprit here is the lack of federal funding for embryo research, thanks to antiabortion activism. We're more familiar with the impact of the funding ban on stem-cell research, the most promising area of medicine that holds the potential to cure diseases such as Parkinson's and maybe even to regrow limbs. But the same funding ban has seriously hampered reproductive medicine too, with the result that all experimentation happens inside wombs. Meanwhile, infertility groups support embryo research but oppose government regulation of the fertility industry, on the grounds of reproductive freedom. The two campaigns have contributed to more multiple pregnancies, miscarriages, selective reduction and infant mortality. In effect, these disparate ideologies have colluded to undermine the interests of their respective constituencies--"preborn children" and infertility patients.
Mundy emphasizes that while bioethicists and the media fret about "designer babies," the more pressing issue is closer to the opposite. ART is creating children with disadvantages--those from multiple births but also, as Kohl touches on, IVF singletons. This affects not only the children and parents but also society at large, in terms of staggering healthcare costs and special educational needs.
Yet these dangers seem unlikely to captivate the popular imagination the way designer babies have: low birth weight, miscarriages and overwhelmed parents are mundane, compared with choosing Tyler's eye color or trying to engineer Chloe's IQ. The prospect of manufacturing a dream baby plays on desires and fears, harking back to our uncertainty about the ethics of usurping God or nature. Our doubts derive not only from the hazards of the process or the inequities that would ensue; the awesome possibilities are themselves threatening. In the same vein, one wonders if the right-wing resistance to stem-cell science is about more than the embryo. Perhaps, especially to people of conservative temperament, there's something hubristic, even blasphemous, about the radical curative potential. Even those of us who support stem-cell research can probably relate to the uneasiness about revolutionary advances and miracles of human provenance.
Such uneasiness regarding these and other innovations is a reaction to what bioethicists call a "yuck factor." These cringes are worth our attention, especially in the realm of personal decisions. But a big part of the yuck factor is novelty. In 1985 Leon Kass, the conservative bioethicist and future chair of the President's Council on Bioethics (2002-05), thundered that IVF would inevitably lead to "self-degradation and dehumanization." Now he endorses the treatment for married couples. Kass famously relies on the "wisdom of repugnance" in assessing biotechnology, but apparently repugnance has a half-life.
The yuck factor is alive today, but its power is eroding as we become ever more blasé about novelty and as our connections with nature become ever more mediated. That's why, in the end, ART isn't really very shocking. On the contrary, it fits right into our world. Although some ART parents hesitate to tell their children about their origins, the kids in Mundy's book don't seem particularly nonplussed. "I'm a miracle!" exults one little girl. A teenage boy says, charmingly, "I'm very thankful for all the technology and all the money put into, um, me."
After all, to kids who grow up in a culture thoroughly dominated by technology and commercialism, what could seem more natural? Indeed, given the extreme measures some take to produce children, the debt and the hormone injections and the devastating failures, what seems amazing is that other people accomplish the same feat with a method that's free and easy and that they'd presumably be more than happy to do anyway. Now that is a miracle.