Infertility and Assisted Reproductive Technology: Current Issues and Recommendations

When the French legislators voted to accept artificial reproductive techniques (ART) in 1994, it was intended as a response for couples faced with infertility.

Although this response only circumvents infertility without ‘healing’, it has gradually led to unprecedented situations and raised major ethical questions, such as freezing extra embryos, allowing them to be used for research, or anonymous gamete donations. This has sometimes resulted in painful experiences for children who discover that they were conceived by anonymous gamete donors.

Just prior to the 2011 bioethics’ law revision, claims were made by a small minority to extend access to ART to include women without a male partner, and to allow oocyte self-preservation as a “precautionary” measure for young women without any fertility problems.

This document is a review of the current infertility issues, and points out the dangers of resorting to ART as a remedy for every situation, and presents our major recommendations. Legislatures are urgently requested that priority be given to implementing a genuine health policy to treat infertility.

 

I – Infertility: a major health issue

According to the World Health Organization (WHO), infertility is defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.

The French National Institute of Health and Medical Research (INSERM) has noted that oftentimes couples request referrals for specialized consultations quite early on. Birth control methods have made people more anxious and impatient whenever it takes a while to become pregnant.

Infertility has become a major health issue. According to a 2008 study by INSERM epidemiologists and demographers Henri Léridon and Rémy Slama, 1 out of 6 couples requested infertility consultations, with 1 out of 10 receiving treatments.

  • Male infertility has increased in the past 50 years. During that time span, in the Western world, spermatozoa density has decreased by half. Scientists attribute this trend to the degradation of the environment (pesticides and pollution) – and to causes induced by lifestyle (smoking, being sedentary, etc…).
  • The average age of pregnancy keeps advancing, thereby increasing the number of age-related infertility consultations.

 

II –ART and technical limits

When faced with medically-diagnosed cases of infertility, the current principle recommendation given is to resort to ART: reproductive treatments or techniques to achieve reproduction with ‘artificial’ or ‘assisted’ means. ART does not actually restore fertility but attempts to bypass infertility for couples who have medically-diagnosed infertility problems (whether or not the cause can be elucidated).

  • There are 2 principle techniques: artificial insemination which involves collecting the spouse’s sperm which the doctor inserts into the uterine cervix, and represents 25% of the infants born via ART in France. Insemination by sperm donors has been permitted in this country since the 1994 bioethics law.
  • In Vitro Fertilization (or IVF) which represents 75% of the French children born by ART. This technique includes ovarian stimulation, puncturing the follicles to extract the oocytes (under anesthesia), followed by in vitro selection of the oocyte(s) and the sperm previously collected. The oocytes and spermatozoa can either be retrieved from the spouses or from donors. Intracytoplasmic Sperm Injection or ICSI is an IVF procedure in which a single sperm cell is injected directly into the cytoplasm of an oocyte (inside the egg).

These techniques are burdensome, both physically and psychologically for the woman as well as the couple.

Half of these couples who turn to ART will have no child in the outcome.

 

III – Current principle ethical and societal issues

Disjunctions in the reproductive process: multiple ethical issues

Performing ART introduces disjunctions: they interrupt the reproductive continuum by disassociating it. The National Consultative Committee on Ethics (“CCNE”) analyzed the various and multiple ethical issues raised at each disjunction in the reproductive process.

IVF leads to overproducing and freezing embryos, known as “supernumerary” embryos. Today there are 223,836 supernumerary embryos; a third of which are no longer intended for a “parental project” for procreation. This situation raises ethical questions regarding the respect for the human embryo. Parents may be confronted with difficult and often unanticipated choices, on the future fate of their embryos. These embryos may either be donated to scientific research or to another couple, or discarded after 5 years. Storing frozen embryos changes the variable of time in the reproductive process, and thus could impact the order of generations. Embryos created at the same time could be born decades apart.Excessive embryo production: never enough

The number of frozen embryos is continually growing (a 20% rise since 2011), although the bioethics law provided for limitations in the number of preserved embryos.

Impact on gamete donation: reflections on lifting donor anonymity

In addition, ART raises the issue of gamete donation, which intentionally deprives a child of half of his biological origins, since gametes carry heredity (via the DNA sequence). About 1,300 children are born annually from gamete donations (oocytes or sperm).

Absolute anonymity for gamete donations is guaranteed in France, although it is an anomaly which contradicts the principle of inalienability of the human body and ignores a child’s rights to know his origins. Given these ethical and human issues, the law requires parents, who have recourse to gamete donation, to furnish a notarized consent form to guarantee that the child born from the technique will have a father and a mother.

The debate on abolishing the anonymity for artificial reproduction has changed due to the development of mega-medical databases. A 34-year-old French man, born by artificial insemination by donor, found his biological father by using a genetic test performed in the US, thus abolishing the anonymity retroactively.

Nevertheless, abolishing anonymity does not eliminate the injustice of a confusing and fragmented filiation for the child.

Oocyte autopreservation: new pressure on women

Autopreservation of a woman’s oocytes is currently legal in two situations:

  • cases of pathologies or treatments affecting fertility (as a result of cancer, for example),
  • gratuitous donations.

Ovarian punctures are still burdensome and are not devoid of risks:  a regrettable 8 to 14% of women report having mild adverse effects, while severe complications occur in 0.7% of cases.

Oocyte autopreservation for young childless women, even in the absence of infertility pathologies, is being requested, mainly by reproductive scientists, as a promise of having children later.

This practice is only a good idea at first sight: it cannot ensure maturity and would put additional pressure on women.

Growing pressure for medicalization of women’s bodies

The CCNE had previously rendered an unfavorable opinion in 2017 by underlining that “since oocytes are first retrieved from a still youthful body and reintegrated at a later date (after their fertilization), the body will not have been spared the passage of time and would carry a child to term with less ease.” There is no guarantee of becoming pregnant, especially since after age 40, success rates with ART are extremely low.

The CCNE’s policy reversal (September 2018 Opinion Letter N°129) is unethical; attested by the divergent positions by members within the committee. Contrary to their statements, this measure would deprive women of their procreative autonomy, leading them to become more and more dependent on medical technology.

This measure is an excuse to generate stocks of oocytes, to provide illusions of “insurance policies” for advanced-age pregnancies. Furthermore, oocyte donation has inherent risks for both the donor and the recipient. Pre-eclampsia is a major obstetric risk for the mother and the child, and is multiplied when pregnancy is postponed to a later age. There is a greater risk for oocyte donations, which is exacerbated and more prevalent for double donations. Oocyte donation pregnancies are not standard pregnancies due to the immunological problems they cause, and comprise significant risks for the woman.

Economic Coercion

The Google and Apple companies were strongly criticized in France when they announced reimbursing the cost of cryopreservation to their American employees, as a lure to persuade them into postponing pregnancies, and take advantage of having a younger workforce.

This event sets up a major stumbling block to maternity via socio-economic coercion.

The French Health Minister claims to be alarmed by such a proposal that would put pressure on all women, the majority of whom would be able to have children naturally in due course when the time comes.

As Alliance VITA had already advocated during the Bioethics Law revision in 2011, awareness campaigns are needed for boys and girls to understand the importance of their biological clocks for having children during their relatively young fertile years. Preventing infertility depends on genuinely understanding its’ causes, coupled with a political commitment to promote conditions for young women to reconcile educational time periods of varying lengths, with their entry into the professional workplace and their maternity.

 

IV – Considerations to broadening access to ART beyond medical infertility cases

The precautionary principle is warranted for current appeals to legalize insemination or allow IVF with donors, for reasons besides medical infertility: such as making it available for female couples or a woman on her own. Indeed, this legal modification comprises worrying and multiple consequences.

Deleting the current criterion of infertility

If the law modifies the medically-diagnosed infertility clause, one of the immediate consequences has not yet been sufficiently evaluated. If the criteria for infertility and for male/female couples are both deleted, henceforth any adult whomsoever could claim access to ART, without any restrictive requirements. Inevitably on the grounds of non-discriminatory provisions, it is difficult to see how conditions might remain more restrictive for individuals requesting ART for “personal convenience” purposes.

Obliterating paternal references

Legalizing ART with donors, but in the absence of a male partner, would purposefully deprive any resulting child from his father and any paternal reference.

In June 2018, the IFOP opinion poll on the French and paternity reported that the overwhelming majority (93%) believe that the father plays an essential role in a child’s upbringing. According to 61% of those queried: “we must focus on the need of each child to have a father by reserving ART to male/female couples with infertility problems.”

Thus we can see that the French are very attached to the figure of paternity, not only in engendering children, but also in education. Being deprived of one of his biological parents (by absence, separation or death…) is not innocuous for a child. This is the reason why French solidarity funds are made available whenever one of the child’s parents is no longer present.

In general, one should neither stigmatize nor trivialize situations where children do not have the advantage of the complementary relationship between a father and a mother.

Switching to a procreation business marketplace

Pushing beyond the boundaries of a medical context for ART, will inevitably lead to claiming one’s “right for a child”, as well as either a national or an ultra-liberal procreation marketplace, and increasing business prospects to obtain gametes. In Belgium, where this practice is allowed, the sperm banks are short on donations (which are gratuitous as in France). Purchases are thus made at Danish sperm banks in order to accommodate 80% of the Belgium requests.

This business thrives on industrializing artificial reproduction techniques. It denigrates men and women to the level of suppliers of raw material (oocytes, sperm, and uterus) in order to fill clients’ requests, with the child as a product to be ordered or even “tailor-made”. Expectations regarding the results continue to become more demanding for quality and selection with prenatal and pre-implantation diagnostic screening tests. Furthermore, since this subject is influenced by the “market”, it leaves the topic of disabled persons with no room for hope on how to better accommodate their needs.

The predictable escalation towards surrogacy and surrogate mothers

By chain reaction, broadening ART access to “all women” leads to way for men to claim access to surrogacy and “surrogate mothers”, on the grounds of non-discrimination between men and women. In surrogacy, the child becomes a contractual item between the sponsors and the surrogate mother (who agrees to abandon her child at birth), innate with all the previously underlined negative consequences previously cited by a multitude of organizations and individuals.

These women are being exploited uniquely for their bodies’ reproductive capacities. This fact seriously undermines the fundamental principles of inalienability and non-commodification of the human body.

 

V – Future policies?

Current infertility research without alternative propositions to ART is inadequate. The causes of skyrocketing infertility rates and the complete absence of any health prevention policy need to be examined.  The 2011 bioethics law stipulated for reports to be provided on the causes of infertility. One report was published in 2012, without any proactive follow-up recommendations.

  • To understand infertility, medical research needs to be encouraged to evaluate causes induced by our lifestyles, and our environment, and also to investigate treatments which focus on restoring fertility. By monitoring body rhythms, and hormonal events, different approaches such as the Natural Procreative or so-called “NaPro” technologies could replace ART, and thereby preserve couples’ reproductive autonomy.
  • To facilitate this research, the Biomedicine Agency should provide an annual summary, to enumerate the reasons listed on ART request forms, in order to steer research and to evaluate possible alternatives to ART.
  • To communicate better with young people, informational awareness campaigns need to be organized. As the CCNE recommends, “information on the progressive decline in women’s fertility with advancing age should be communicated very early to all young people”, as well as “the risks of obstetrical complications at an advanced maternal age, for the woman herself and for the unborn child; the decreased success rate of ART in older women; and the uncertain health for children born via ART at an advanced age.
  • To improve living and working conditions which would allow couples to start having children at a younger age, as the CCNE and the Biomedical Agency’s Steering Committee recommended. Appropriate measures should be studied in-depth in coordination with public authorities, local communities, medical organizations and social workers.
  • Maintain the status-quo for the original definition of ART: a medical procedure which responds to cases of medically-diagnosed infertility. As stated in the 2016 report by the French Senate: if the current requirements for medical infertility and sexual complementarity (alterity) were eliminated, “the French concept of ART would be turned upside-down, and pave the way for the ‘right to have a child’ and artificial reproduction of convenience “.
  • Obtain a universal ban on surrogacy, because “ethical” or “non-commercial or altruistic” surrogacy is non-existent. As the emblematic country for defending human rights, France has a major role to play in promoting these initiatives both on a European and on a worldwide level, for non-commodification of women’s bodies and for the respect of a child’s dignity, which cannot be regarded as a commodity to be bought, sold or given away.

France does not have to lower its ethical standards. Claims for the “right to have a child” are incompatible with the French ethical tradition of non-commodification of the human body and the protection of children. As the State Council concluded in 2009, France does not have to lower its’ standards to those which are “less ethical”. Defending children’s rights is imperative for integral and humane ecology and it rises above all differences. A state’s legitimate purpose is to regulate the desires of the strongest in order to protect the weak.

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