Fertility rates are decreasing — let's ensure assisted reproductive technologies are regulated

Fertility rates are decreasing — let's ensure assisted reproductive technologies are regulated
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Infertility rates have increased and anecdotal evidence has shown that some women can feel compelled to provide their wombs and eggs to the wealthy. This scenario occurs in Margaret Atwood’s “The Handmaid’s Tale” and its newly released sequel, The Testaments, but also happens today.  

Published in 1985, "The Handmaid’s Tale" has rightly been acclaimed for its dystopian portrayal of a totalitarian regime — the Republic of Gilead — in the U.S. 

Recently, certain politicians have threatened freedom of speech and behavior in ways that, if unchecked, could lead toward such a dictatorship. Luckily, we have not yet reached that point.

But Atwood also foresaw problems with new forms of human reproduction that are now spreading as well. Unfortunately, these parts of Atwood’s cautionary tales have received far less attention. How concerned should we be today about potential abuses of surrogacy, in which a woman lets others use her womb or eggs to create a child?

Increasingly in the U.S. and other Western countries, rates of male and female infertility are indeed rising. Since Atwood wrote "The Handmaid’s Tale," two years after the first test tube baby was conceived and born in Canada, where she lives, assisted reproductive technologies have expanded enormously.  

In the U. S., thousands of young women are selling their eggs and serving as gestational surrogates, “renting” their wombs for cash. In India, Nepal, Ukraine and elsewhere, large markets have grown for buying and selling human eggs and renting wombs.

Yet media stories about these technologies generally celebrate the creation of new lives – smiling, innocent babies — rather than probing the dilemmas involved. A few years ago, a major national network’s morning news show filmed me, commentating on India’s surrogacy industry. 

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I described problems, such as husbands taking the money from their wives and using it for their own purposes. Ultimately, the show’s producers included only one sentence from me, stating, “ethical questions arise.” They then showed an American couple ecstatic at receiving their newborn, shouting, “It’s a boy.” Shortly thereafter, the Indian government closed the company, due to ethical problems.

This past June, the New York State Senate voted to legalize paid gestational surrogacy. Gloria Steinem and other feminists fought the bill, arguing that it would exploit poorer women, especially those of color, who would feel compelled to rent their wombs to wealthy prospective parents — a scenario all to redolent of Atwood’s books. The NYS Assembly rejected the bill, but its sponsors will be seeking approval again this year. 

Potential parents who want to buy eggs can pick from ever-growing assortments online. In the US, thousands of young women sell their eggs through agencies, which are unregulated. But these women receive large injections of hormones, and consequently face risks of ovarian hyper-stimulation syndrome, which can be severe, requiring hospitalization, and sometimes are fatal. Unfortunately, many of these young women do not realize or appreciate these dangers.

The American Society of Reproductive Medicine (ASRM) has issued guidance, saying, for instance, that these women should be over 21 years old — to have sufficient emotional maturity to make these decisions. But most IVF clinics aggressively advertise for younger women. Between agency and clinic ads on Craigslist, 81 and 96 percent, respectively fail to comply with ARSM guidelines.

Wealthy adults can now not only overcome infertility (by buying other women’s eggs and hiring gestational surrogates), but even test embryos to screen out genes associated with various diseases. In the future, breast cancer, for instance, which currently affects both wealthy and poor women, will increasingly become a disease of the poor — since wealthy people will be able to screen out the genes associated with it — resulting in fewer resources devoted to research and care for this condition.

To be sure, we do not now live in a totalitarian state, and women are legally able to make choices about assisted reproductive technologies. But Atwood rightfully highlights the potential perils and needs to avoid these. Many women may not be able to make choices as freely as they should. Only a handful of small studies of paid gestational surrogates and egg donors have been conducted. 

These scant data suggest that most women are not becoming surrogates because of financial distress, as Steinem suggests. But shamefully, these data are far too limited. We don’t know what is now in fact fully happening or will occur in the future. No published research has examined how U.S. egg donors or surrogates look back on their experiences.

Atwood’s books should remind us to remain attuned to potential abuses in not only politics but also reproduction. We urgently need ongoing systematic collection of more data by the Centers for Disease Control and others, stronger guidelines and policies, and enhanced education of physicians, potential parents and women who consider selling their eggs or renting their wombs. 

The answer is not to ban assisted reproductive technologies, but to ensure that we use these powerful, rapidly advancing technologies to benefit as many people as possible, and avoid harms both here and abroad.

Robert Klitzman, M.D., is a professor of psychiatry and director of Online and In-person Masters of Bioethics Program at Columbia University. He is the author of Designing Babies:  How Technology is Changing the Ways We Create Children