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Assisted Reproduction at 30

August 25th 2008

Science - Designer Embryo

Thirty years ago the assisted reproduction industry was born. From tiny but noisy beginnings, it grew through an occasionally troubled adolescence to maturity. Now it's time for it to become a responsible member of society. 

The modern industry's symbolic birth was on July 25th, 1978, when the first "test-tube baby" was born. It was one of the great media launches of all time. Louise Brown, who celebrates her 30th birthday on Friday, is English, but her birth was on the cover of Time magazine before it even happened. As Newsweek said, her first yell was "a cry heard round the brave new world." By late 1978, polls revealed that a remarkable 93% of Americans were aware of her -- and 85% of American women thought infertile couples should have the chance to try in-vitro fertilization (IVF). 

"IVF was a gigantic step," according to Alan Trounson, who now runs the California Institute for Regenerative Medicine. "We didn't realize it at the time; people didn't think it would work that well. We never envisaged that it would expand so dramatically around the world."

An estimated 4 million babies have been born using IVF. In the U.S. alone, over 52,000 were born in 2005, the latest year for which data is available, slightly more than 1% of all births in the country. That's more than two-and-a-half times the 1996 number, and the rate keeps increasing. 

Exact numbers for the U.S. industry's turnover are hard to come by, but most estimates put it somewhere north of $3 billion a year. It's also thought to be extremely profitable. One British practitioner is known to have paid himself $4 million a year, and it would be no surprise if some American counterparts approached that. It's worth noting, however, that assisted reproduction is used less in the U.S. than in any other country in the 2007 survey by the International Federation of Fertility Societies. It's five times as common in Denmark, for example, with Finland and Australia not far behind. 

Treatment is expensive, and is rarely covered by insurance. One well-regarded estimate put the median cost per live birth at $56,419 in 2001. The full cost to parents can be much higher than that. For multiple births -- twins, triplets and more -- medical costs escalate dramatically, and fully one quarter of IVF births in the U.S. are multiples. 

The unfortunate dynamic is that a multiple birth is, in general, a greater success for the clinic than for the patient. This problem was much worse in the rambunctious adolescence of the industry, when one doctor actually pronounced, "God doesn't make babies -- I do." Another told an anxious mother of triplets, "What do you mean you're not happy? This is everything you wanted and then some." 

Nowadays, the American Society for Reproductive Medicine issues guidelines, and the Centers for Disease Control collect data, but there are essentially no sanctions for violations. If a particular clinic transfers, on average, 4 or 5 embryos for a patient under 35 (as some do, far exceeding the guideline of 1 or 2), consumers may choose not to go there, but otherwise, caveat emptor. 

That's why so many moderate, sympathetic analysts complain that the industry is "not enveloped by a coherent whole regulatory framework" (Kathy Hudson, Johns Hopkins). "A bit of mandatory reining in might not be a bad thing," suggests Peggy Orenstein, who has written about her own experience with assisted reproduction. As Debora Spar, President of Barnard College, says, "Governments need to play a more active role in regulating the baby trade." 

The demand for regulation will only grow as the industry tries to broaden its markets. Some new techniques are useful, such as those allowing previously infertile men to father children (though there remain some medical questions about the results). Others are more problematic. Egg freezing is being pushed as a techno-solution to the "problem" of working women wanting to delay pregnancy. And on the horizon, getting closer all the time, is the idea of choosing your baby's height or body type or perhaps even intelligence. 

That may not be possible -- these are multi-factorial traits -- but you might be able to tweak the odds. And that raises very serious ethical questions. Should an individual have the right to do that? And what about actually changing genes, that is, inserting novel genes into an embryo to create a "post-human?" That's below the horizon, but there are advocates for just that. Does society have the right, indeed the duty, to step in and regulate these issues? Most people, according to opinion polls, say that some applications should actually be banned. Should we not be having these discussions? 

These issues are not new. Back in 1978, Dr. C. Everett Koop, later President Reagan's surgeon general, while supporting IVF worried about "the next step, when Mrs. Jones decides she wants a child from that tall, blond gene pool down the block." A prominent liberal British MP feared that "we are moving to a time when an embryo purchaser could select in advance the color of the baby's eyes and its probable IQ." 

The British, to their credit, set up an agency to oversee these and related issues so long ago that it is now in the process of reform. The U.S., observers say, should also take the next step to properly oversee an industry that needs to take its rightful place in society -- supported, available to all, and legally regulated. 

Pete Shanks is the author of Human Genetic Engineering and a contributor to the Biopolitical Times blog (www.biopoliticaltimes.org).


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