Ethics of Assisted

Reproductive Technologies
(ART)
Lisa Campo-Engelstein, Ph.D.
Associate Professor
Alden March Bioethics Institute & Department of OBGYN
Albany Medical College, NY
[email protected]
 Learning objectives

• Recognize some of the limitations with the current

definition of infertility and some of the public’s
misperceptions about infertility
• Describe some common objections to ART generally
• Discuss some of the ethical considerations of
specific ARTs, including fertility preservation

Overarching goal: Be more equipped

to discuss the ethics of assisted
reproductive technologies
Brief Bioethics Background
 What is bioethics?

Bio = medicine and science

Ethics = the study of right and
wrong

Bioethics = the study of right

and wrong in medicine and
science
 Normative vs. Descriptive
• Descriptive claim: a claim that examines how
things actually are, what our reality is
– Scientists and clinicians are interested in
descriptive questions
• Normative claim: a claim that examines how
things ought to be, how things should be
– Ethics is concerned with justifying normative
claims
– “Ought implies can” → any normative claims
we make should be descriptively possible
 Spectrum of views
• Viewpoints are not always dichotomous, but exist on
a spectrum
• Universalism: the belief that there is only one right
answer
• In the extreme, doesn’t allow for tolerance of different
views
• Relativism: the belief that there is more than one
right answer
• In the extreme, we can’t make any normative claims
 Ethics ≠ Opinion

• Goal is to construct a “position”

or make a “case”→ move
toward rational justification
– Incorporates objectives
elements: facts, sound analysis,
inferential reasoning, judgment,
etc.
• Social and cultural differences
relevant as context but not
necessarily definitive
• The lack of precision or the
possibility of error does not
make ethics “just opinions”
“Philosophical” Method
1. Question
2. Research
3. Hypothesis/Thesis
4. “Experiment” by using logic
and reasoning to construct
arguments
-- We “test” our thesis by applying
various ethical theories and
principles, conducting thought
experiments, and anticipating and
responding to objections
5. Analysis
6. Conclusion
 A good ethical argument has
• True premises (supporting claims for an
argument)
• Valid reasoning (conclusion follows from the
premises)

Argument 1 Argument 2
• Premise 1: All eagles can fly. • Premise 1: Some people like
• Premise 2: I am an eagle. to eat fish.
• Conclusion: I can fly. • Premise 2: Some bears like
to eat fish.
False premise, valid • Conclusion: Some people
reasoning are bears.

False reasoning, true

premises
Ethical theories and principles
• Tools to draw on to support arguments

• Intra and inter theory conflict may occur

for any given case
– This can help us to understand the ethical
problem and our values better
 Utilitarianism
• An action is good if it maximizes
the greatest amount of good
(pleasure) for the greatest number
– Focused on consequences

http://tomkow.typepad.com/tomkowcom/2011/04/trolleyproblems.html
 Deontology
(Kantian ethics)
• An action is good if it
adherence to a rule or duty
– Concerned with intention,
not consequences

• “Golden rule”
• Dignity requires treating people
as ends in themselves, not
merely as means to an end
 Four bioethics principles
• Respect for autonomy
– Respect autonomous decisions
– Protect those without capacity
• Nonmaleficence
– Do no harm
• Beneficence
– Relieve, lessen, or prevent harm
– Provide benefits and balance benefits against risks and
costs
• Justice
– Equal and fair distribution of resources
 Negative vs. positive rights
• Negative rights: the right from something;
basically the right to be left alone and not
to be interfered with
– Right to bodily integrity
– e.g. right to refuse treatment
• Positive rights (entitlement rights): the right
to something
– Entail duties from others
– Often contentious
– e.g. right to healthcare
DEFINING INFERTILITY
 What is infertility?
• In the U.S. the standard definition is not
achieving pregnancy after one year of
regular unprotected heterosexual
intercourse for women under 35. For
women over 35, the timeframe reduces
to 6 months.
 Definitions of infertility by organization
Organization Definition of Infertility

A disease of the reproductive system defined by the failure to

World Health
achieve a clinical pregnancy after 12 months or more of regular
Organization (WHO)
unprotected sexual intercourse.

Infertility means not being able to become pregnant after a year

National Institute of
of trying. If a woman keeps having miscarriages, it is also called
Health (NIH)
infertility.
RESOLVE: The (US) Infertility is defined as the inability to conceive after one year of
National Infertility unprotected intercourse (six months if the woman is over age 35)
Association or the inability to carry a pregnancy to live birth.
Infertility is the result of a disease (an interruption, cessation, or
disorder of body functions, systems, or organs) of the male or
female reproductive tract which prevents the conception of a child
American Society of
or the ability to carry a pregnancy to delivery. The duration of
Reproductive Medicine
unprotected intercourse with failure to conceive should be about
(ASRM)
12 months before an infertility evaluation is undertaken, unless
medical history, age, or physical findings dictate earlier evaluation
and treatment.
 Who is minimized or excluded
from standard definitions of
infertility?

• men
• anticipated infertility
• social infertility
Minimizes men’s infertility
• Men and women equally likely to be
infertile
• Historical and cultural belief that
women are more likely to be infertile
• More inclusive definition: “Infertility is the
result of a disease … of the male or female
reproductive tract which prevents the
conception of a child or the ability to carry
a pregnancy to delivery.” ASRM
 Anticipated infertility
• Not currently trying to conceive, but
have foreseeable infertility
– individuals with cancer or other medical
conditions
– individuals who are transgender or have
differences of sex development
– women who experience age-related
infertility
• Usually not covered by insurance
 Social infertility
• People can be infertile because of
who their partner is or because they
don’t have a partner
• The WHO recently changed their
definition of infertility to include
lesbian and gay couples and single
individuals
• Lesbian couples suing NJ because
of the requirement to have
heterosexual intercourse in order to
“prove” infertility
Lo, W., and L. Campo-Engelstein. “Expanding the Clinical Definition of Infertility to Include Socially Infertile Individuals and Couples” in
Reproductive Ethics: New Ideas and Innovations (2018). https://www.nj.com/essex/index.ssf/2016/08/lesbian_couples_sue_nj_say_fertility_laws_discrimi.html
 Misperceptions about
who is infertile
• Perception: people who are infertile are
generally white, middle-class, educated
people who have chosen to delay
childbearing
– These individuals are the most likely to
use ART.
• Reality: people who are infertile are
typically people of color, poor, less
educated, and within their prime
childbearing years
Barut, M. U., et al. (2016). "There is a Positive Correlation Between Socioeconomic Status and Ovarian Reserve in Women of Reproductive
Age." Medical Science Monitor : International Medical Journal of Experimental and Clinical Research 22: 4386-4392.
Bell, A. V. (2014). Misconception: Social Class and Infertility in America, Rutgers University Press.
 Is infertility a disease?
• Public says no • Medicine says yes
– 72.2% in one study • Infertility is an
• Infertility treatment aberration of
does not treat an “normal” functioning
underlying disease • Infertility can lead to
but rather produces psychological
a desired outcome problems
(i.e. a child).

Ho, J. R., et al. (2017). "Public attitudes in the U.S. toward insurance coverage for IVF and the provision of infertility services to lower income
patients." Fertility and Sterility 108(3): e9.
GENERAL ETHICAL
ISSUES WITH ART
 What types of regulation
should be required for ART?
 Regulation comparison
USA UK
• Limited governmental
oversight
– FDA regulates human
reproductive tissue
– Federal Clinic Success – Governmental agency
Rate and Certification regulating fertility
Act of 1992 treatment and research
– Legality of surrogacy
varies by state
• ASRM provides
guidance
Who should pay for ART?
 Classification of infertility
Individuals should pay Insurance should pay
• ARTs are not medically • Much of medicine today
necessary is focused on improving
• There are other ways to quality of life
build a family (e.g. • Justice demands treating
adoption) infertility like other
medical conditions
• Genetic parenthood as a
right
 Financial
Individuals should pay Insurance should pay
• ARTs are expensive • Expense of ARTs unfairly
• There are more important burdens individuals
health needs that could • ARTs account for only
help more people 0.06% of the total health
care expenditure in the
US

Chambers GM, Sullivan EA, Ishihara O, Chapman MG, Adamson GD. The economic impact of assisted reproductive technology: a review of selected
developed countries. Fertility and Sterility. 2009;91(6):2281–2294
How should we ethically
understand and legally
classify embryos?
 Embryos

• Entities with moral status are entitled to

certain rights
• What is the moral status of embryos?
– Can they be destroyed?
– Can they be used in research?
– Do embryos have a right to be implanted?
 Embryos
• Legally embryos are considered a form
of property
– cannot be adopted
• “Snowflake babies”
– cannot be bought and sold
 Sofia Vergara vs. Nick Loeb
• Vergara and ex-fiancé, Nick Loeb, created
embryos using IVF
• Contract said they’d only implant embryos if
both agreed; they’ve since broken up
• Loeb is suing for custody of the embryos
• 1986 Louisiana law declares embryos to be
“juridical persons”
• Lawsuit in Louisiana filed on behalf of the
embryos claiming that Vergara has
abandoned them and that they are being
deprived of their inheritance from a trust by
not being born
Should biological parenthood
be prioritized and does ART
reinforce “normative
parenthood”?
 ART prioritizes biology

• Reinforces the belief that biological

children are better than nonbiological
children
• Minimizes the importance of
parenthood as a social relationship
• Undervalues adoption and
“alternative” ways of family formation
 ART upholds racial boundaries
Donor matching reinforces shame in infertility
and racial boundaries

NY Post Headline: Black Baby Born To Lawsuit states: "On August 21, 2012, Jennifer
White Pair gave birth to Payton, a beautiful, obviously
mixed-race baby girl. Jennifer bonded with
“A Park Avenue fertility clinic’s blunder Payton easily and she and Amanda love her
has left a family devastated – after a very much. Even so, Jennifer lives each day
black baby was born to a Hispanic with fears, anxieties and uncertainty about her
woman and her white husband, the future and Payton's future."
couple charges in a lawsuit.”

“Blood Is Thicker than Water: Policing

Donor Insemination and the
Reproduction of Whiteness.” Seline
Szkupinski Quiroga
Should there be limits to ART
based on age?
 Aging and ART
• There is a “normal” and “natural” time for
childbearing, especially for women, and it is
best for women and children if people have
children during that timeframe.
 Paternal age
• Objections about age
usually directed at women
– More public knowledge
about how age affects
women’s fertility than
men’s
– Assumes women will be
primary caregiver
• Older paternal age linked
to schizophrenia, Down
syndrome, and autism
 Age and preconception harm
in US newspapers
• Almost three times more likely to be
surprised about men’s age and harm
than women
• Over twice as likely to blame women
than men
• Over three times more likely to reassure
men than women

Campo-Engelstein, L., L.B. Santacrose, Z. Master, and W.M. Parker. “Bad Moms, Blameless Dads: The Portrayal of Maternal and
Paternal Age and Preconception Harm in U.S. Newspapers.” American Journal of Bioethics Empirical Bioethics 7.1 (2016).
 Too young for ART?
• Is there any age that is too young to
offer ART?
 Minors and fertility
preservation
• Assent/consent
• Best interest standard
• Parental and provider pressure
• Cost and insurance coverage
• Experimental treatment

Campo-Engelstein, L. and D. Chen. “Ethical Issues in Pediatric and Adolescent Fertility Preservation” in Pediatric and Adolescent
Oncofertility, eds. T.K. Woodruff and Y.C. Gosiengfiao (2017).
McDougall RJ, Gillam L, Delany C, et al. Ethics of fertility preservation for prepubertal children: should clinicians offer procedures
where efficacy is largely unproven? Journal of Medical Ethics 2018;44:27-31.
What social and ethical issues
are raised by multifetal
pregnancies?

Should multifetal pregnancies

via ART be permitted?
 Multifetal pregnancies
• Fertility drugs and IVF can increase the
likelihood of multiples
• There is a strong risk of severe
prematurity for all the fetuses, which
could lead to significant health
problems for them
• There are also risks the pregnant
woman, including higher incidence of
preeclampsia, premature labor,
gestational diabetes, and premature
rupture of membranes
• The US does not have any regulations
on the number of embryos that can be
implanted
Comparison of Outcomes Average Costs in the First
For Twins, Singletons, and Year of Life, Preterm and Full
Reduced Cases Term Infants, 2008 to 2009

Evans, M.I., et al., Fetal reduction from twins to a singleton: a reasonable consideration? Obstet Gynecol, 2004. 104(1): p. 102-9.
Dramatic increase in multiples
Live Birth Rate by Number of IVF
Embryos Transferred

2007 Assisted Reproductive Technology Success Rates, Centers for Disease Control and
Prevention and American Society for Reproductive Medicine, Figure 33, December 2009.
 Public fascination
with multiples
• Heroic nature of medicine
• Fascination with medical “freaks”
• White, heterosexual, Christian couples
receive positive media attention
– Upholds dominant cultural beliefs: pro-
natalist, traditional gender norms, Christian
faith, pro-life
 McCaughey
Septuplets
• Bobbi McCaughey used
fertility drugs and gave birth
to septuplets in 1997
• The parents received a
donated 16-room house, a
15-passenger van, baby
food from Gerber, a lifetime
supply of Pampers from
Procter & Gamble, and a
call from President Clinton
• Religious Christian, pro-life
white heterosexual couple
who already had a 2 year
old biological daughter
 Chukwu Octuplets/Septuplets
• After using fertility drugs,
Nkem Chukwu gave birth to
octuplets in 1998. One of the
babies died shortly after birth
• The family lives in a donated,
six-bedroom suburban home,
and the stay-at-home mom
had a small army of volunteers
help feed and care for the
seven surviving babies for the
first few years
• Religious heterosexual black
couple born in Nigeria and
now living in Texas who didn’t
have any other children
 Gosselin Twins and Sextuplets
• Using fertility drugs, the Gosselins had twins (2000)
and sextuplets (2004)
• Before fame they had help from their community,
especially their church; gained fame through their TV
show and then received many gifts and
endorsements
• Religious Christian, pro-life heterosexual couple
 Quints by Surprise Raising Sextuplets

Sextuplets Take New York Table for 12

 Suleman
Octuplets
• Nadya Suleman had 6
embryos implanted and
gave birth to 8 babies in
2009
• Although she has received
some gifts, many
companies don’t want to be
affiliated with her
• Single woman, not overtly
religious, sexual orientation
not “confirmed,” Middle-
Eastern descent who
already had 6 children
SPECIFIC ARTS
FERTILITY PRESERVATION
 What factors should play into
whether oncofertility is offered?

• Social factors (SES, marital status,

sexual orientation, etc.) should not play
a role
• What role should prognosis play?

Campo-Engelstein, L. “Common Ethical Issues in Oncofertility” in Oncofertility Research and Practice: A Multidisciplinary Approach,
ed T.K. Woodruff (2019).
 Should insurance companies cover
oncofertility?
• Arguments for covering ARTs
• Cancer patients often only have one shot at
preserving their fertility
• Infertility is iatrogenic
Justice and iatrogenic conditions
• Treatments to prevent potential iatrogenic
conditions are usually covered by insurance
– Storing one’s own blood in case of an
emergency transfusion
– Breast reconstruction after lumpectomy or
mastectomy
• Infertility and breast loss or asymmetry are both
iatrogenic conditions that are often not considered
medically necessary when naturally occurring

Campo-Engelstein, L. “Consistency in Insurance Coverage for Iatrogenic Conditions Resulting from Cancer Treatment Including Fertility
Preservation.” Journal of Clinical Oncology 28.8 (March 10, 2010).
 Fertility Preservation Coverage Legislation 2017-2018
Stat Bill Status Structure Proposed Coverage
e
CT HB7124 Signed into law 6/20/17 Medically necessary Changed statutory definition of “infertility” to include “medical necessary” treatment; amended
existing IVF mandate
RI S 0821A & H Signed into law 7/05/17 FP for iatrogenic Standard FP services if necessary medical treatment may cause iatrogenic infertility; amended
6170A infertility existing IVF mandate
MD SB271 & Signed into law 5/18/18 FP for iatrogenic Standard FP services if necessary medical treatment may cause iatrogenic infertility; large groups
HB908 infertility only
DE SB139 Signed into law 6/30/18 IVF+FP New infertility mandate, includes IVF and FP. Coverage for specifically delineates infertility
treatments, including IVF and FP. Doesn’t include state employees or state Medicaid recipients
IL HB2617 Signed into law 8/27/18 FP for iatrogenic Standard FP services if necessary medical treatment may cause iatrogenic infertility; broad coverage
infertility including state employees and state Medicaid recipients
NJ A3150 & Pending FP for iatrogenic IVF mandated was updated in 2017; FP to be added in 2018
S2133 infertility
AZ SB1149 Intro in Senate; Inactive IVF+FP (iatrogenic) IVF mandate; specific procedures listed; includes FP

CA SB172 Heard in Sen. Health Cmte; FP for iatrogenic Standard FP services if necessary medical treatment may cause iatrogenic infertility
Inactive infertility
HI HB2669 Heard in House HHS Cmte; FP-cancer only Oocyte, and sperm cryo for adult patients dx w/cancer; have not started treatment. Limit: one cycle
Deferred; Inactive
KY SB95 Passed Senate; Inactive FP for iatrogenic Coverage includes procedures for ooctye & sperm banking; one year of storage; lifetime limit of one cycle
infertility
LA HB698 Hearings in House; sent to FP-cancer only Coverage for embryo, oocyte, and sperm cryopreservation; limited to 18-40 yrs old; dx of cancer only; has
Cmte on Approps for not started cancer treatment. Limit: one cycle
reconsideration; Inactive
MS HB1198 Died in Cmte; Failed IVF+FP (iatrogenic) IVF mandate; specific procedures listed; includes FP

MO HB2388 Referred to House Judiciary FP-cancer only Coverage for embryo, oocyte, and sperm cryopreservation; limited to 18-40 yrs old; dx of cancer only; has
Cmte; Inactive not started cancer treatment. Limit: one cycle
NY A02646A & A02646A passed Assembly IVF+FP (iatrogenic) Update existing infertility mandate to include IVF and fertility preservation for iatrogenic infertility
S3148 2017 & 2018; S8441b passed
S8441b Senate, 6/20/18; Inactive

S7163 & Sent to Cmte in both chambers; FP for iatrogenic Coverage for standard fertility treatment when a necessary cancer treatment may directly or indirectly
A10660 Inactive infertility due to cancer cause iatrogenic infertility
treatment
VT H629 Referred to Cmte on FP-cancer only Coverage for embryo, oocyte, and sperm cryopreservation; limited to 18-40 yrs old; dx of cancer only; has
Healthcare; Inactive not started cancer treatment. Limit: one cycle

Credit: Joyce Reinecke, Alliance for Fertility Preservation

 Medically Necessary Fertility
Preservation Act
• Section 1. Short Title.
– This Act shall be known as the, “Medically Necessary Fertility Preservation Act.”
• Section 2. Summary.
– This Act shall provide coverage for medically necessary expenses for standard fertility preservation
services when a medically necessary treatment may directly or indirectly cause iatrogenic infertility.
• Section 3. Definitions.
– “Iatrogenic Infertility” means an impairment of fertility caused directly or indirectly by surgery,
chemotherapy, radiation, or other medical treatment.
– “Standard Fertility Preservation Services” means procedures to preserve fertility that are consistent
with established medical practices or professional guidelines published by the American Society of
Clinical Oncology or the American Society for Reproductive Medicine.
– “Medical Treatment That May Directly or Indirectly Cause Iatrogenic Infertility” means medical
treatment with a potential side effect of impaired fertility as established by the American Society of
Clinical Oncology or the American Society of Reproductive Medicine.
• Section 4. Plans Covered.
– Every health care service plan sold in the State that provides hospital, medical, or surgical coverage
shall include coverage for medically necessary expenses for standard fertility preservation services
when a necessary medical treatment may directly or indirectly cause iatrogenic infertility to a covered
person.
– This Act shall apply to all policies, contracts, and health benefit plans issued, delivered, amended, or
renewed in the State on or after January 1, 2020.
• Section 5. Effective Date.
– This Act shall take effect January 1, 2020. Credit: Joyce Reinecke, Alliance for Fertility Preservation
What ethical issues are there
with fertility preservation for
minors who are transgender?
 Transgender minors
• Assent/consent
• Affect on transition
• Masturbation
• Discordance between gender identity
and gametes
• Sexual orientation
• Cost and insurance coverage

“Fertility Preservation for a Transgender Teen.” Pediatrics 142.3 (August 2018).

What ethical issues are there
with fertility preservation for
minors who have differences
or disorders of sex
development?
 DSD minors
• Assent/consent
• Gonadectomy
• Discordance between gender identity
and gametes
• Gender dysphoria
• Risk to future children
• Experimental treatment and false hope
• Cost and insurance coverage
Campo-Engelstein, L., D. Chen, A. Baratz, E. Johnson, and C. Finlayson. “The Ethics of Fertility Preservation for Pediatric Patients with
Differences (Disorders) of Sex Development.” Journal of the Endocrine Society 1.6 (2017).
What are ethical issues are
raised by planned oocyte
cryopreservation (OC)?
 Planned oocyte
cryopreservation
Addresses age-related infertility
• Huge growth in planned OC market
• ESHRE and ASRM lifted the experimental label
on egg freezing in 2012
0.7

0.6

0.5

0.4

0.3

0.2

0.1

Elective/Any Cancer-Related Medical/Non-Cancer

Indication
Indications for Oocyte Cryopreservation

Rudick, B., et al. (2010). "The status of oocyte cryopreservation in the United States." Fertil Steril 94(7): 2642-2646.
 Change in ASRM guidelines
• “The Ethics Committee previously supported OC for
women facing immediate, medically induced loss of
fertility. But there are many less-immediate
developments that could also threaten women's
ability to have children in the future. These
developments include diseases, primary ovarian
insufficiency, traumatic injury, planned female-to-
male gender transition, and the fertility loss that
occurs as a woman ages. Planned OC may also
benefit women seeking children in response to
unanticipated future events such as remarriage or the
death of an existing child.”
(2018). "Planned oocyte cryopreservation for women seeking to preserve future reproductive potential: an
Ethics Committee opinion." Fertil Steril 110(6): 1022-1028.
 ASRM supports planned OC
• “For all stakeholders who provide and use planned
OC, caution is warranted. There is a risk of misplaced
confidence in the effectiveness of this procedure, as
well as scientific unknowns concerning long-term or
transgenerational offspring health. Mindful of these
cautions, however, this Committee finds the use of
OC for women attempting to safeguard their
reproductive potential for the future to be ethically
permissible.”

(2018). "Planned oocyte cryopreservation for women seeking to preserve future reproductive potential: an
Ethics Committee opinion." Fertil Steril 110(6): 1022-1028.
 ESHRE ASRM

• Condones SEF • Discourages SEF

• Ethical principles: • Ethical principles:
reproductive autonomy nonmaleficence
and justice • Cultural values: free
• Cultural values: statist market
pronatalism

Bhatia, R., and L. Campo-Engelstein. “The Biomedicalization of Social Egg Freezing: A Comparative Analysis of European and
American Professional Ethics Opinions and U.S. News and Popular Media.” Science, Technology, & Human Values 43.5 (2018).
 ESHRE’s statement
• ESHRE states that SEF should be made
available to women who, facing “the threat of
time” desire to cryopreserve their own eggs in
order to “give them more breathing space.”
• ESHRE advises against “a paternalistic
attitude” that would decide for a potential patient
how “the importance of keeping open the
prospect of having children later in their
lives…weighs up to the burdens and risks of
repeated stimulation and oocyte-pick up.”

ESHRE Task Force on Ethics and Law. 2012. Oocyte cryopreservation for age-related fertility loss. Human Reproduction 27 (5): 1231-37.
 ESHRE and autonomy
• ESHRE supports SEF for women due to conditions
“beyond their own control.”
– “Fertility preservation for women at risk of disease related or
iatrogenic premature menopause clearly falls within the
scope of reproductive medicine. The same can arguably be
said of fertility preservation for women who want to have
children and are still without a partner at the age of 35.
Their request is understandable, given that there is a
reasonable chance beyond their own control that they
will remain childless.”
– “But what about requests from women who deliberately
choose to postpone childbearing while giving temporary
priority to other life goals such as build-up of a career? …
The postponing ‘career woman’ is not so deviant a
character as many seem to think.”
 ESHRE and justice
• “For men, the combination of fatherhood with
other life plans is not as difficult. Not only do
they tend to leave most of the burdens of
daily care to their partners, but they also have
the opportunity to reproduce until much later
in their lives. Moreover, men already can have
their sperm cryopreserved.”
• “From a feminist perspective, therefore, the
availability of options for female fertility
preservation can be regarded as an important
step towards greater reproductive justice.”
 Statist pronatalist

• “societal benefits [of SEF] include the birth of additional

children at a time of declining birth rates in developed
countries.”
• “in many western societies, there are demographic
reasons for welcoming the birth of any extra child
born to women who are socially, economically, and
physically able to give it a good start in life.”
– SEF secures for the state the selective reproduction of
privileged racialized and classed groups.
• Among eleven final recommendations, ESHRE urges
“policy-makers in countries where IVF is (partly) covered
within the healthcare system” to “consider how women
whose stored oocytes are eventually used for
reproduction can be compensated.”
 ASRM’s statement
• ASRM condones egg freezing for a
number of “medical indications,” most
prominently the case of cancer patients.
• However, ASRM cautions, “there are
not yet sufficient data to recommend
[egg freezing] for the sole purpose of
circumventing reproductive aging in
healthy women.”
The Practice Committees of the American Society for Reproductive Medicine and the Society for Assisted Reproductive Technology.
2013. Mature oocyte cryopreservation: A guideline. Fertility and Sterility 99(1): 37-43.
 ASRM and nonmaleficence
• “Marketing this technology for the
purpose of deferring childbearing may
give women false hope and
encourage women to delay
childbearing. In particular, there is
concern regarding the success rates
in women in the late reproductive years
who may be the most interested in this
application.”
 Free market
• In the US, the field of assisted reproductive
medicine is characterized by a mostly private,
competitive, for-profit market which operates not
only with minimal state interference but also
minimal state support.
• The distilled version of ASRM’s message, “egg
freezing is no longer experimental,” overtook any
cautionary recommendations discouraging non-
medical applications of egg freezing in
mainstream news and popular media.
– Although the ASRM statement did not endorse
SEF, it actually had the effect of unleashing
unrestrained commercialization of SEF.
 Women’s knowledge of
planned OC
• “Those advising women about planned
OC need to be clear about the novelty
of the technology and the unknowns,
attentive to the fact that some may have
obtained information about the
treatment from the media or in other
commercialized settings.”

(2018). "Planned oocyte cryopreservation for women seeking to preserve future reproductive potential: an
Ethics Committee opinion." Fertil Steril 110(6): 1022-1028.
 Media Marketing

“Ethics Committee is concerned about coercion and the

line between education of young women and
inappropriately aggressive marketing to them”

(2018). "Planned oocyte cryopreservation for women seeking to preserve future reproductive potential: an
Ethics Committee opinion." Fertil Steril 110(6): 1022-1028.
 Planned OC (social egg freezing)
in US newspapers
Code % Articles

Cost concerns (e.g. SEF is expensive; health insurance 65.2%

usually doesn’t cover SEF)

SEF as a workplace benefit 63.8%

Stop or freeze biological clock 54.4%

SEF is not a guarantee, has low success rates 52.2%

Allows women time to pursue their education and career 50.0%

Egg freezing is no longer experimental 43.5%

Gives women time to find a partner 42.0%

Campo-Engelstein, L., R. Aziz, S. Darivelmula, J. Raffaele, R. Bhatia, and W.M. Parker. “Freezing Fertility or Freezing False Hope? A Content
Analysis of the Portrayal of Social Egg Freezing in the US Print Media.” American Journal of Bioethics Empirical Bioethics (2018).
Planned OC as a workplace
benefit

• Planned OC recognizes the importance of family and

reproductive medicine
• Planned OC as a workplace benefit may enable
women to utilize it who may otherwise not be able to
afford it
• “This [ASRM] Committee commends employers that
have provided insurance coverage for fertility
treatments including planned OC.”
Planned OC as a workplace benefit
benefits employers
• Pushes women to prioritize work
– “By telling their female staff to hold off on having
babies, these companies are demanding their
employees put them before everything else, before
their families, before their health. ... This isn’t a benefit
created to make life better for working women, it’s a
threat.” (Harriet Minter, The Guardian, 10/15/14)
• Easy way to appear women friendly without real
cultural changes
– Lack of other family friendly policies
• neither Apple’s new headquarters nor Facebook’s recent
housing community included on-site childcare
 Planned OC as a workplace
benefit as part of a holistic effort

• “The Ethics Committee encourages employers and

lawmakers to enact policies that reduce the burden of
childbearing and child-raising and that promote
equality of women and men in the workplace and the
world. It is important, however, that women not be
subjected to pressure to cryopreserve their oocytes
to show they are committed to their careers.”

(2018). "Planned oocyte cryopreservation for women seeking to preserve future reproductive potential: an
Ethics Committee opinion." Fertil Steril 110(6): 1022-1028.
 Medical concerns with
planned OC
• Invasive
• Side effects
• Not guaranteed
– Avoid language of “insurance”
 Economic concerns with planned OC
Expensive and not covered by insurance Reproductive medicine
is a for profit market in
the US
• Review of 387
websites of fertility
clinics found that the
majority of websites
rated “poor” in their
adherence to ASRM
guidelines on
planned OC, with an
average score of 3.4
out of a 13 point
scale

Avraham, S., et al., 2014. What is the quality of information on social oocyte cryopreservation provided by websites of
Society for Assisted Reproductive Technology member fertility clinics? Fertility and Sterility
 Social concerns with SEF
• Medical solution to social problem
– Doesn’t help women find partners
• Puts burdens and blame on individual
women
– Shift from option to obligation
What ethical issues are raised by
preimplantation genetic diagnosis
(PGD)?
 Preimplantation genetic
diagnosis (PGD)
• Genetic profiling of embryos prior to
implantation generally used to prevent
certain diseases from being passed on
to the child
• Concerns about devaluing disabled
lives
• Concerns about blurring the line
between therapeutic and enhancement
– “Designer” babies
• Concerns about social justice and
GATTACA future
Is sex selection ethically
permissible?
Sex selection
• Using sperm sorting, PGD, or
abortion to determine the sex
of future offspring
• Concern about cultural
preference for boys and sex
ratio
• Some support family
balancing, which is having a
second or third child of a
different sex than previous
child(ren)
ART WITH A THIRD PARTY
 ART with a third party

• ART that involves “donors”

and surrogates can
challenge the traditional
understanding of the parent-
child relationship
– Confusion and contestation
over parental roles
– Parent-child relationships can
be created in contractual terms
and on commercial grounds
 Classifications of parents

1. Intended or social parents: the people who intend to raise

the child
2. Biological parents: the ones who are genetically related to
the child
3. Birth or gestational parent: the person who carries the fetus
and ultimately gives birth to the child

An individual can fulfill one or more of these parental roles

What ethical issues are raised by
gamete “donation”?
 Egg and sperm “donation”

• The US is one of the only Western countries that

allow gametes to be sold
– Is there an ethical difference between selling gametes and
organs?
• US is largest exporter of sperm
• Gendered differences in gamete donation ads
Campo-Engelstein, L. “Gametes or Organs? How Should We Legally Classify Ovaries Used for Transplantation in the U.S.?” Journal of
Medical Ethics 37.3 (March 2011).
 Lack of regulation

• No national guidelines
determining and confirming
donor eligibility
• No national database to
keep track of donors,
offspring, and frozen
gametes and embryos
 Gamete donation
• Sperm donation often kept secret
to preserve the infertile man’s
masculinity
• Egg donation increasing and more
open → gestational connection is
sometimes more important to
women than biological relationship
• “When a woman gets older, they get donor eggs, which
doesn’t make the baby any less beautiful or
perfect. One’s own eggs only last so long.” Marcia
Cross
 Donation and anonymity
• Could lead to incest
• Importance of family history and
connection for identity
• US allows donor identity to remain
anonymous
• Many other countries allow children to find
out donor’s identity, or at least some
information, when they reach 18
 Donor “designer” babies

• Intended parents pick

gamete “donors”
based on particular
qualities
– Is this a “designer”
baby?
• Deaf lesbian couple
seek deaf sperm donor
to have a deaf child
 Mitochondrial donation

• There are 37 genes in the

mitochondria and around 20,000
genes in the nucleus
• Uses donor mitochondria to prevent
women from passing mitochondrial
diseases to their children
• Children have the genetic material
from 3 parents
• Concerns about what makes
someone a parent
What legal and ethical issues are
raised gestational surrogacy?
 Surrogacy

• Traditional surrogacy: gestational

mother is also the biological mother
• Gestational surrogacy: gestational
mother is not the biological mother
Baby M (1986-1988)
• William and Elizabeth Stern
contracted with Marybeth
Whitehead for traditional
surrogacy.
• Baby M was born in 1986 and
Whitehead refused to give her to
the Sterns.
• The New Jersey Supreme Court
ruled that Williams turned with
have full custody and Whitehead
would have visitation rights.
Surrogacy permissibility by state
 Johnson v. Calvert (1990-1993)
• Zygote using married couple Crispina and Mark
Calvert’s genetic material is created and
implanted into Anna Johnson, a surrogate
• Johnson sought parental rights
• California law only recognizes one mother and
motherhood is based on who gave birth to the
child and who is genetically related to the child—
usually this is the same person
– Court sees no clear legislative preference for one
criterion over the over, so they find another way of
determining the “natural” mother → Intention
 Sherri Shepard
vs. Lamar Sally
• Used Sally’s sperm and egg donor
with gestational surrogate with Sally
and Shepard as intended parents
• Shepard and Sally divorced
• Shepard sued to be removed from
birth certificate; Sally got full
custody of the child
• Judge ruled Shepherd is the legal
mother and must pay alimony and
child support
Jaycee Buzzanca (1996 - 1999)
– Erin Davidson was the egg donor. Her egg was
fertilized with Mr. X’s sperm. Mr. and Mrs. X
donated extra eggs (after having twins) to other
couples
– John and Luanne Buzzanca decided to use
Pamela Snell to carry one of the Davidson/X
embryos to term for them to raise as their child
– John filed for divorce right before Jaycee was born
– The court originally ruled Jaycee and orphan even
though Luanne wanted custody of her
 Surrogacy today
• Mostly positive media coverage
– Decreased stigma
– Stories of celebrities using surrogacy are
common
Straight celebrities using surrogacy
Gay celebrities using
surrogacy
Objections to commercial
surrogacy
• Exploits women
• Commodifies children
• Parent/child relationship not
suited to contract law
• Lack of regulation and
protections for children
• Altruistic surrogacy also
problematic
International surrogacy
• Exacerbates exploitation of women
• Legal status of infants
– Baby’s citizenship
– Intended parents abandoning babies
• Thailand and India banned international
surrogacy
What ethical issues are raised by
uterus transplantation?
 Uterus transplantation
• First birth from uterus
transplantation in 2014 in
Sweden
• Clinical trials in UK and
Cleveland Clinic
• Avoids some of the ethical
concerns with surrogacy
 Concerns about uterus
transplantation
• Expensive and not life-saving transplant
– Temporary transplant
• Uterus not regulated by UNOS
• Concerns about risks to donor,
recipient, and fetus
• Is there a right to gestate?
– For ciswomen, for transwomen, for
nonbinary individuals
 Summary

• Recognize some of the limitations with the current

definition of infertility and some of the public’s
misperceptions about infertility
• Describe some common objections to ART generally
• Discuss some of the ethical considerations of specific
ARTs, including fertility preservation

Overarching goal: Be more equipped

to discuss the ethics of assisted
reproductive technologies
Thank you!

Questions?