The
Global North consumption is higher than its production (shown by the
red color), while the Global South produces more than consumes (green
color). The resource proportion between consumption and production
relates to the amount of environmental degradation.
Ecological debt refers to the accumulated debt seen by some campaigners as owed by the Global North to Global South countries, due to the net sum of historical environmental injustice, especially through resource exploitation, habitat degradation, and pollution by waste discharge.
The concept was coined by Global Southerner non-governmental
organizations in the 1990s and its definition has varied over the years,
in several attempts of greater specification.
Within the ecological debt broad definition, there are two main aspects: the ecological damage caused over time by a country in one or other countries or to ecosystems
beyond national jurisdiction through its production and consumption
patterns; and the exploitation or use of ecosystems over time by a
country at the expense of the equitable rights to these ecosystems by other countries.
History
The
term 'ecological debt' first appeared on paper in 1985, in a yellow
booklet with the title "Women in movement" made by the German
ecofeminist Eva Quistorp and edited by the Green Party
in Germany in 1985. The work was intended to be used for a workshop she
gave on 'women, peace and ecology' in Nairobi during the United Nation Women's Conference (the first workshop of this kind).
In 1992, the term appeared again in two reports published in different places around the world: “Deuda ecológica” by Robleto and Marcelo in Chile and “Miljöskulden” by Jernelöv in Sweden. Robleto and Marcelo's report, published by the critical NGO Instituto de Ecologia Politica (IEP),
was a political and activist response to the global environmental
negotiations happening during the Rio Summit. It shed light on the
debate occurring in Latin America since the 1980s about the crucial
nature's heritage that had been consumed and not returned (i.e.
ecological debt). On the other hand, Jernelöv's report goal was to
calculate the Swedish debt for future generations and was intended to serve nationally for the Swedish Environmental Advisory.
Although the last one had less world-wide influence in the concept's
debate, it is important to note that both reports have opposite approach
in considering the ecological debt: Robleto and Marcelo's report
expresses it in symbolic terms, focusing on the moral and political
aspects, whereas Jernelöv's report tries to quantify and monetize it in
economic terms.
Wahu Kaara (Global justice
activist / Kenya Debt Relief Network) spoke at the closing ceremony of
Klimaforum09 – People's Climate Summit in Copenhagen December 2009.
In 1994, the Colombian lawyer Borrero, wrote a book on ecological debt.
It referred to the environmental liabilities of Northern countries for
the excessive per capita production of greenhouse gases, historically
and at present. The concept has then been reused by some environmental organizations from the Global south. Campaigns on the ecological debt were launched since 1997 by Accion Ecologica of Ecuador and Friends of the Earth.
Overall, the ecological debt 'movement' was born of the
convergence of three main factors during the 80s–90s: 1) the
consequences of the debt crisis in the 70s due to the Volcker shocks or the drastic increase of interest rates (followed by structural adjustments made by the US to solve the stagflation
in 1981, and thus putting heavily indebted third world countries in an
impossible situation in regards to debt repayment); 2) the rising of
environmental awareness as seen previously (activists and NGOs attending
the Rio Summit in 1992); 3) an increase in recognition of the violence caused by colonialism over the years (the demand of recognition is over 500 years, since Columbus arrived in North America).
In 2009, ecofeminist scholar Ariel Salleh explained how the capitalist processes at work in the global North exploit nature and people simultaneously, ultimately sustaining a large ecological debt in her article, "Ecological Debt: Embodied Debt". At the 1992 Rio Earth Summit, politicians and corporate leaders from the global North introduced the supposed solution for the foreign debt crisis in the global South. They proposed 'debt for nature swaps', which essentially means that those countries that possess abundant biodiversity and environmental resources would give them up to the global North in return for the World Bank reducing their debt.
Feminist environmentalists, Indigenous activists, and peasants
from the Global South, exposed how the Global North is much more
indebted to the Global South.
Salleh justified this by explaining how the 500-year-long colonization
process involving the extraction of resources has caused immense damage
and destruction to the ecosystem of the Global South. In fact, scientists at the US National Academy for Sciences state that in the time period of 1961–2000, by analyzing the cost of greenhouse gas emissions
created by the rich (the Global North) alone, it has become apparent
that the rich have imposed climate changes on the poor that greatly
outweigh the poor's foreign debt. All of this environmental degradation amounts to ecological debt, seizing the people's livelihood resources in the Global South.
In 2009 as well, Andrew Simms
used the ecological debt in a more bio-physical way and defined it as
the consumption of resources from within an ecosystem that exceeds the
system's regenerative capacity. This is seen in particular in non-renewable resources
wherein consumption outstrips production. In a general sense in his
work, it refers to the depletion of global resources beyond the Earth's
ability to regenerate them. The concept in this sense is based on the
bio-physical carrying capacity of an ecosystem; through measuring ecological footprints
human society can determine the rate at which it is depleting natural
resources. Recent writings have highlighted the ubiquity of ecological
debts, such as to Pacific salmon populations, groundwater and polluted
waterways. Ultimately, the imperative of sustainability
requires human society to live within the means of the ecological
system to support life over the long term. Ecological debt is a feature
of unsustainable economic systems.
Political dimension
Historical context
There
have been several debates around the notion of ecological debt, and
this is mostly because the concept arises from various social movements
in response to the distributional injustice of climate change's
consequences on the environment and people's livelihood.
Salleh, in particular, showed how the ecological debt manifested
in the destruction of the environment and associated climate change the
North has created is made possible through the process of modernization and capitalism.
The rise of the nature-culture divide that emerged due to rapid
industrialisation is a perfect illustration of a human-nature dualism in
which human being
has the central role above everything else. The notion of humans being
embedded in the ecosystem that they live in is crucial to the discipline
of political ecology.
In political ecology, which reconnects nature and the economy,
ecological debt is crucial because it recognizes that colonization has
not only resulted in a loss of culture, way of life, and language for Indigenous peoples, but it has shaped the world economy into one that monetizes and commodifies the environment. For example, when the Colonization of south america occurred over 500 years ago, European settlers brought with them their Eurocentric values, seeing themselves as better than and therefore entitled to the Indigenous people's knowledge and the land they lived on. In a perceived postcolonial world, large corporations and Western governments tend to present solutions to global warming by commodifying nature and hoping to make a profit out of it. This better-than-thou attitude has created the conditions for global warming to occur, making the North's ecological footprint soar, while also constructing an ecological debt so large as to completely rid the entire Global South of their financial debt.
During the Rio Earth Summit in 1992, attending NGOs
created the Debt Treaty, a document gathering all information to better
define the ecological debt concept. They demanded compensation for
damages over 500 years (1992 is exactly 500 years after the arrival of Columbus in North America). The countries in question were given options from the World Bank and the International Money Fund a choice to defaulting on these debts or make structural adjustments to continue to receive further funding.
It was the first push back, reversing the stream, but it stayed as a
draft paper not recognized by international institutions or lead
countries at that time.
Copenhagen Climate Summit in 2009 – Action Aid demonstration
Today
In
the 2000s two networks were created and still exist today: the Southern
Peoples Ecological Debt Creditors Alliance (SPEDCA) which is a network
of creditors
that launched a campaign for the recognition of ecological debt, and
the European Network for the Recognition of Ecological Debt (ENRED)
which is a network of debtors.
During the COP in Copenhagen in December 2009, some governments from developing countries or countries most vulnerable to climate change
consequences (such as Bolivia, Mauritania, Chad, or island countries as
Maldives or Haiti) have argued that the principle of shared
responsibility demands that rich nations or developed economies (such as the United States, some European countries, China) go beyond donations or adaptation credits
and make reparations that recognize an ecological debt for excessive
pollution over several decades. The top United States ambassador, Todd Stern, flatly rejected arguments by diplomats from these countries that the United States owed such a debt.
The COP 21
in Paris brought minor progress with an increase in financial aid for
developing countries. Although the goal was to prepare future action to
be undertaken for adapting to climate change and consider loss and
damages (especially displaced people) of some countries, no real action was adopted. There were no recognition of responsibilities but recommendations only.
Calculations
Climate debt
When discussing ecological debt, climate debt appears to be the only example of a scientific attempt to quantify the debt. It incorporates two different elements: the adaptation debt which is the cost to communities of adapting to climate damages
they are not responsible for, and the consumption debt or emission's
debt which is compensation due for emitting carbon in the present time.
Emission debts should hypothetically be paid for by those countries that
have over-emitted their fair-share of emissions. To determine this
debt, an emissions or carbon budget can and is calculated, and distributed among countries.
Calculations
Academic work on calculations of the ecological debt came later. An article published in 2008 looked at the distribution of ecological impacts for various human activities. Studies were also produced at regional level within countries, for instance for Orissa in India.
As seen previously, calculation of the ecological debt implies various aspects related to political ecology.
While calculating the amount of emissions, some scholars have disregard
inequalities of emissions from the past whereas others have considered
historical accountability. In addition, there is a connection between
ecological issues and the economy due to the value natural resources
have and the important role they play in benefiting our economy.
In 2000 Neumayer calculated what he named the 'historical
emissions debt', consisting on the difference in emissions of actual
historical emissions (from a specific date in the past) and equal
per-capita emissions (current emissions).
Theoretically it may be possible to put a money value on
ecological debt by calculating the value of the environmental and social
externalities
associated with historic resource extraction and adding an estimated
value for the share of global pollution problems borne by poor countries
as the result of higher consumption levels in rich ones. This includes efforts to value the external costs associated with climate change.
In 2015 Matthews proposed a method to calculate the ecological
debt, by looking at the accumulated `carbon debts' for each country. The model uses historical estimates of national fossil fuel CO2 emissions
and population and this since 1960. Furthermore, it runs a comparison
between temperature changes each year by each country's emissions
compared to a proportional temperature change of each country's share of
the world population (this same year). This gives the accumulated
credits and debts related to a larger range of emissions and the
'climate debts' obtained would be the difference between the actual
temperature change (caused by each country) and their per-capita share of global temperature change.
Other scholars have proposed a different approach, a `modified
equal shares' approach, that would consider each country's basic needs
and would weight each ones' share of emissions.
However, this approach brings potential ethical and political
difficulties to quantitatively defining what would thus be the equal
shares.
Key debates
Although some recent emerging countries have participated in the increase of carbon emissions, the situation tend to stay uneven in-between developing and developed countries regarding who is affected the most versus who pollutes the most.
Recent studies on ecological debt focus more on sub-topics as the notion of historical responsibility
(whether or not a country is considered ethically responsible or
accountable for carbon emissions prior 1990, i.e. when global warming
was universally recognized), the components of climate debt (see above sections), the difficulties in deciding when to start counting past emissions
and if this debate is slowing the implementation of programs or the
legal and political consecration of the debt through treaties.
Present key debates focus on how is the debt going to be paid back. First, some academia have pushed for financial debt cancellation
rather than being paid for ecological damages and then paying back the
country's national financial debt. However, financial debts were not
even agree by people (in developing countries especially) in the first
place, calling it the unfair "Volcker debt". Accepting this option could hold the risk of giving legitimize credits to these financial debts. A second solution proposed is the Basic income guarantee
(BIG) or the universal basic income. It consists on regular cash
payments to everyone in a community (or country) and has proven a
certain efficacy in some places around the world (like Namibia).
Another debate addresses the fact that the ecological debt risks
"commodifying nature" is exhausting ecosystem services. Researchers have
tackled this risk by showing how it will expand the inclination of
objectifying, monetizing and ultimately commodifying nature.
Moreover, the language of debt, repayments, credits and so forth is
understood in Northern countries mostly, and is mostly focused on
recognition of wrongdoing but not payment for loss of services for
instance.
In vitro fertilisation (IVF) is a process of fertilisation in which an egg is combined with spermin vitro ("in glass"). The process involves monitoring and stimulating the ovulatory process, then removing an ovum or ova (egg or eggs) from the ovaries and enabling sperm to fertilise them in a culture medium in a laboratory. After a fertilised egg (zygote) undergoes embryo culture for 2–6 days, it is transferred by catheter into the uterus, with the intention of establishing a successful pregnancy.
IVF is a type of assisted reproductive technology used to treat infertility, enable gestational surrogacy, and, in combination with pre-implantation genetic testing, avoid the transmission of abnormal genetic conditions. When a fertilised egg from egg and sperm donors implants
in the uterus of a genetically unrelated surrogate, the resulting child
is also genetically unrelated to the surrogate. Some countries have
banned or otherwise regulated the availability of IVF treatment, giving
rise to fertility tourism. Financial cost and age may also restrict the availability of IVF as a means of carrying a healthy pregnancy to term.
In July 1978, Louise Brown was the first child successfully born after her mother received IVF treatment.
Brown was born as a result of natural-cycle IVF, where no stimulation
was made. The procedure took place at Dr Kershaw's Cottage Hospital in Royton, Oldham, England. Robert Edwards, surviving member of the development team, was awarded the Nobel Prize in Physiology or Medicine in 2010.
When assisted by egg donation and IVF, many women who have reached menopause,
have infertile partners, or have idiopathic female-fertility issues,
can still become pregnant. After the IVF treatment, some couples get
pregnant without any fertility treatments.
In 2023, it was estimated that twelve million children had been born
worldwide using IVF and other assisted reproduction techniques.
A 2019 study that evaluated the use of 10 adjuncts with IVF (screening
hysteroscopy, DHEA, testosterone, GH, aspirin, heparin, antioxidants,
seminal plasma and PRP) suggested that (with the exception of
hysteroscopy) these adjuncts should be avoided until there is more
evidence to show that they are safe and effective.
Terminology
The Latin term in vitro,
meaning "in glass", is used because early biological experiments
involving cultivation of tissues outside the living organism were
carried out in glass containers, such as beakers, test tubes, or Petri
dishes. The modern scientific term "in vitro" refers to any biological
procedure that is performed outside the organism in which it would
normally have occurred, to distinguish it from an in vivo procedure (such as in vivo fertilisation), where the tissue remains inside the living organism in which it is normally found.
A colloquial term for babies conceived as the result of IVF,
"test tube babies", refers to the tube-shaped containers of glass or
plastic resin, called test tubes, that are commonly used in chemistry and biology labs. However, IVF is usually performed in Petri dishes, which are both wider and shallower and often used to cultivate cultures.
The first successful birth of a child after IVF treatment, Louise Brown,
occurred in 1978. Louise Brown was born as a result of natural cycle
IVF where no stimulation was made. The procedure took place at Dr
Kershaw's Cottage Hospital (now Dr Kershaw's Hospice) in Royton, Oldham, England. Robert G. Edwards, the physiologist who co-developed the treatment, was awarded the Nobel Prize in Physiology or Medicine in 2010. His co-workers, Patrick Steptoe and Jean Purdy, were not eligible for consideration as the Nobel Prize is not awarded posthumously.
The second successful birth of a 'test tube baby' occurred in
India on October 3, 1978, just 67 days after Louise Brown was born. The
girl, named Durga, was conceived in vitro using a method developed
independently by Subhash Mukhopadhyay, a physician and researcher from Hazaribag. Mukhopadhyay had been performing experiments on his own with primitive instruments and a household refrigerator. However, state authorities prevented him from presenting his work at scientific conferences, and it was many years before Mukhopadhyay's contribution was acknowledged in works dealing with the subject.
Adriana Iliescu
held the record as the oldest woman to give birth using IVF and a donor
egg, when she gave birth in 2004 at the age of 66, a record passed in
2006. After the IVF treatment some couples are able to get pregnant
without any fertility treatments.
In 2018 it was estimated that eight million children had been born
worldwide using IVF and other assisted reproduction techniques.
IVF may be used to overcome female infertility when it is due to problems with the fallopian tubes, making in vivo fertilisation difficult. It can also assist in male infertility, in those cases where there is a defect in sperm quality; in such situations intracytoplasmic sperm injection
(ICSI) may be used, where a sperm cell is injected directly into the
egg cell. This is used when sperm has difficulty penetrating the egg.
ICSI is also used when sperm numbers are very low. When indicated, the
use of ICSI has been found to increase the success rates of IVF.
According to UK's National Institute for Health and Care Excellence
(NICE) guidelines, IVF treatment is appropriate in cases of unexplained
infertility for people who have not conceived after 2 years of regular
unprotected sexual intercourse.
In people with anovulation, it may be an alternative after 7–12 attempted cycles of ovulation induction, since the latter is expensive and more easy to control.
Success rates
IVF
success rates are the percentage of all IVF procedures that result in
favourable outcomes. Depending on the type of calculation used, this
outcome may represent the number of confirmed pregnancies, called the pregnancy rate, or the number of live births, called the live birth rate.
Due to advances in reproductive technology, live birth rates by cycle
five of IVF have increased from 76% in 2005 to 80% in 2010, despite a
reduction in the number of embryos being transferred (which decreased
the multiple birth rate from 25% to 8%).
The success rate depends on variable factors such as age of the
woman, cause of infertility, embryo status, reproductive history, and
lifestyle factors. Younger candidates of IVF are more likely to get
pregnant. People older than 41 are more likely to get pregnant with a
donor egg.
People who have been previously pregnant are in many cases more
successful with IVF treatments than those who have never been pregnant.
Live birth rate
The live birth rate is the percentage of all IVF cycles that lead to a live birth. This rate does not include miscarriage or stillbirth; multiple-order births, such as twins and triplets, are counted as one pregnancy.
A 2021 summary compiled by the Society for Assisted Reproductive
Technology (SART) which reports the average IVF success rates in the
United States per age group using non-donor eggs compiled the following
data:
< 35
35–37
38–40
41–42
> 42
Live birth rate (%)
54
40.5
26
13.3
4
In 2006, Canadian clinics reported a live birth rate of 27%.
Birth rates in younger patients were slightly higher, with a success
rate of 35.3% for those 21 and younger, the youngest group evaluated.
Success rates for older patients were also lower and decrease with age,
with 37-year-olds at 27.4% and no live births for those older than 48,
the oldest group evaluated.
Some clinics exceeded these rates, but it is impossible to determine if
that is due to superior technique or patient selection, since it is
possible to artificially increase success rates by refusing to accept
the most difficult patients or by steering them into oocyte
donation cycles (which are compiled separately). Further, pregnancy
rates can be increased by the placement of several embryos at the risk
of increasing the chance for multiples.
Because not each IVF cycle that is started will lead to oocyte
retrieval or embryo transfer, reports of live birth rates need to
specify the denominator, namely IVF cycles started, IVF retrievals, or
embryo transfers. The SART summarised 2008–9 success rates for US
clinics for fresh embryo cycles that did not involve donor eggs and gave
live birth rates by the age of the prospective mother, with a peak at
41.3% per cycle started and 47.3% per embryo transfer for patients under
35 years of age.
IVF attempts in multiple cycles result in increased cumulative
live birth rates. Depending on the demographic group, one study reported
45% to 53% for three attempts, and 51% to 71% to 80% for six attempts.
According to the 2021 National Summary Report compiled by the
Society for Assisted Reproductive Technology (SART), the mean number of
embryos transfers for patients achieving live birth go as follows:
< 35
35–37
38–40
41–42
> 42
Mean # of transfers
1.33
1.28
1.19
1.11
1.10
Effective from 15 February 2021 the majority of Australian IVF
clinics publish their individual success rate online via
YourIVFSuccess.com.au. This site also contains a predictor tool.
Pregnancy rate
Pregnancy rate may be defined in various ways. In the United States, SART and the Centers for Disease Control
(and appearing in the table in the Success Rates section above) include
statistics on positive pregnancy test and clinical pregnancy rate.
The 2019 summary compiled by the SART the following data for non-donor eggs (first embryo transfer) in the United States:
<35
35-37
38-40
41–42
>42
Positive pregnancy test rate (%)
55.1
44.8
32.9
19.1
8.5
Clinical pregnancy rate (%)
47.5
38.3
27.5
15.5
6.3
In 2006, Canadian clinics reported an average pregnancy rate of 35%.
A French study estimated that 66% of patients starting IVF treatment
finally succeed in having a child (40% during the IVF treatment at the
centre and 26% after IVF discontinuation). Achievement of having a child
after IVF discontinuation was mainly due to adoption (46%) or spontaneous pregnancy (42%).
Miscarriage rate
According to a study done by the Mayo Clinic, miscarriage rates for IVF are somewhere between 15 and 25% for those under the age of 35. In naturally conceived pregnancies, the rate of miscarriage is between 10 and 20% for those under the age of 35. Risk of miscarriage, regardless of the method of conception, does increase with age.
Predictors of success
The main potential factors that influence pregnancy (and live birth) rates in IVF have been suggested to be maternal age, duration of infertility or subfertility, bFSH and number of oocytes, all reflecting ovarian function. Optimal age is 23–39 years at time of treatment.
Anti-Müllerian hormone levels, with higher levels indicating higher chances of pregnancy, as well as of live birth after IVF, even after adjusting for age.
People with ovary-specific FMR1 genotypes including het-norm/low have significantly decreased pregnancy chances in IVF.
Progesterone elevation on the day of induction of final maturation is associated with lower pregnancy rates in IVF cycles in women undergoing ovarian stimulation using GnRH analogues and gonadotrophins. At this time, compared to a progesterone level below 0.8 ng/ml, a level between 0.8 and 1.1 ng/ml confers an odds ratio
of pregnancy of approximately 0.8, and a level between 1.2 and
3.0 ng/ml confers an odds ratio of pregnancy of between 0.6 and 0.7.
On the other hand, progesterone elevation does not seem to confer a
decreased chance of pregnancy in frozen–thawed cycles and cycles with
egg donation.
Characteristics of cells from the cumulus oophorus and the membrana granulosa, which are easily aspirated during oocyte retrieval.
These cells are closely associated with the oocyte and share the same
microenvironment, and the rate of expression of certain genes in such
cells are associated with higher or lower pregnancy rate.
An endometrial thickness (EMT) of less than 7 mm decreases the
pregnancy rate by an odds ratio of approximately 0.4 compared to an EMT
of over 7 mm. However, such low thickness rarely occurs, and any routine
use of this parameter is regarded as not justified.
As maternal age increases, the likelihood of conception decreases and the chance of miscarriage increases.
With increasing paternal age, especially 50 years and older, the rate of blastocyst formation decreases.
Tobacco smoking reduces the chances of IVF producing a live birth by 34% and increases the risk of an IVF pregnancy miscarrying by 30%.
A body mass index
(BMI) over 27 causes a 33% decrease in likelihood to have a live birth
after the first cycle of IVF, compared to those with a BMI between 20
and 27. Also, pregnant people who are obese have higher rates of miscarriage, gestational diabetes, hypertension, thromboembolism and problems during delivery, as well as leading to an increased risk of fetal congenital abnormality. Ideal body mass index is 19–30, and many clinics restrict this BMI range as a criterion for initiation of the IVF process.
Some studies also suggest that autoimmune disease may also play a role in decreasing IVF success rates by interfering with the proper implantation of the embryo after transfer.
Aspirin is sometimes prescribed to people for the purpose of increasing the chances of conception by IVF, but as of 2016 there was no evidence to show that it is safe and effective.
A 2013 review and meta analysis of randomised controlled trials of acupuncture as an adjuvant therapy
in IVF found no overall benefit, and concluded that an apparent benefit
detected in a subset of published trials where the control group (those
not using acupuncture) experienced a lower than average rate of
pregnancy requires further study, due to the possibility of publication bias and other factors.
A Cochrane review came to the result that endometrial
injury performed in the month prior to ovarian induction appeared to
increase both the live birth rate and clinical pregnancy rate in IVF
compared with no endometrial injury. There was no evidence of a
difference between the groups in miscarriage, multiple pregnancy or
bleeding rates. Evidence suggested that endometrial injury on the day of
oocyte retrieval was associated with a lower live birth or ongoing
pregnancy rate.
A Cochrane review
in 2015 came to the result that there is no evidence identified
regarding the effect of preconception lifestyle advice on the chance of a
live birth outcome.
Method
A graphic explaining the details of IVF
Theoretically, IVF could be performed by collecting the contents from
the fallopian tubes or uterus after natural ovulation, mixing it with sperm,
and reinserting the fertilised ova into the uterus. However, without
additional techniques, the chances of pregnancy would be extremely
small. The additional techniques that are routinely used in IVF include ovarian hyperstimulation to generate multiple eggs, ultrasound-guided transvaginal oocyte retrieval directly from the ovaries, co-incubation of eggs and sperm, as well as culture and selection of resultant embryos before embryo transfer into a uterus.
Ovarian hyperstimulation is the stimulation to induce development of
multiple follicles of the ovaries. It should start with response
prediction based on factors such as age, antral follicle count and level of anti-Müllerian hormone.
The resulting prediction (e.g. poor or hyper-response to ovarian
hyperstimulation) determines the protocol and dosage for ovarian
hyperstimulation.
Ovarian hyperstimulation also includes suppression of spontaneous
ovulation, for which two main methods are available: Using a (usually
longer) GnRH agonist protocol or a (usually shorter) GnRH antagonist protocol.
In a standard long GnRH agonist protocol the day when hyperstimulation
treatment is started and the expected day of later oocyte retrieval can
be chosen to conform to personal choice, while in a GnRH antagonist
protocol it must be adapted to the spontaneous onset of the previous
menstruation. On the other hand, the GnRH antagonist protocol has a
lower risk of ovarian hyperstimulation syndrome (OHSS), which is a life-threatening complication.
For the ovarian hyperstimulation in itself, injectable gonadotropins (usually FSH analogues) are generally used under close monitoring. Such monitoring frequently checks the estradiol level and, by means of gynecologic ultrasonography, follicular growth. Typically approximately 10 days of injections will be necessary.
When stimulating ovulation after suppressing endogenous
secretion, it is necessary to supply exogenous gonadotropines. The most
common one is the human menopausal gonadotropin (hMG), which is obtained by donation of menopausal women. Other pharmacological preparations are FSH+LH or coripholitropine alpha.
IVF using no drugs for ovarian hyperstimulation was the method for the conception of Louise Brown.
This method can be successfully used when people want to avoid taking
ovarian stimulating drugs with its associated side-effects. HFEA has estimated the live birth rate to be approximately 1.3% per IVF cycle using no hyperstimulation drugs for women aged between 40 and 42.
Mild IVF
is a method where a small dose of ovarian stimulating drugs are used
for a short duration during a natural menstrual cycle aimed at producing
2–7 eggs and creating healthy embryos. This method appears to be an
advance in the field to reduce complications and side-effects for women,
and it is aimed at quality, and not quantity of eggs and embryos. One
study comparing a mild treatment (mild ovarian stimulation with GnRH
antagonist co-treatment combined with single embryo transfer) to a standard treatment (stimulation with a GnRH agonist
long-protocol and transfer of two embryos) came to the result that the
proportions of cumulative pregnancies that resulted in term live birth after 1 year were 43.4% with mild treatment and 44.7% with standard treatment. Mild IVF can be cheaper than conventional IVF and with a significantly reduced risk of multiple gestation and OHSS.
When the ovarian follicles have reached a certain degree of development, induction of final oocyte maturation is performed, generally by an injection of human chorionic gonadotropin (hCG). Commonly, this is known as the "trigger shot." hCG acts as an analogue of luteinising hormone, and ovulation would occur between 38 and 40 hours after a single HCG injection,
but the egg retrieval is performed at a time usually between 34 and 36
hours after hCG injection, that is, just prior to when the follicles
would rupture. This avails for scheduling the egg retrieval procedure at
a time where the eggs are fully mature. HCG injection confers a risk of
ovarian hyperstimulation syndrome. Using a GnRH agonist
instead of hCG eliminates most of the risk of ovarian hyperstimulation
syndrome, but with a reduced delivery rate if the embryos are
transferred fresh. For this reason, many centers will freeze all oocytes or embryos following agonist trigger.
The eggs are retrieved from the patient using a transvaginal technique called transvaginal
ultrasound aspiration involving an ultrasound-guided needle being
injected through follicles upon collection. Through this needle, the
oocyte and follicular fluid are aspirated and the follicular fluid is
then passed to an embryologist to identify ova. It is common to remove
between ten and thirty eggs. The retrieval process, which lasts
approximately 20 to 40 minutes, is performed under conscious sedation or general anesthesia
to ensure patient comfort. Following optimal follicular development,
the eggs are meticulously retrieved using transvaginal ultrasound
guidance with the aid of a specialised ultrasound probe and a fine
needle aspiration technique. The follicular fluid, containing the
retrieved eggs, is expeditiously transferred to the embryology
laboratory for subsequent processing.
Egg and sperm preparation
In the laboratory, for ICSI treatments, the identified eggs are stripped of surrounding cells (also known as cumulus cells) and prepared for fertilisation. An oocyte selection
may be performed prior to fertilisation to select eggs that can be
fertilised, as it is required they are in metaphase II. There are cases
in which if oocytes are in the metaphase I stage, they can be kept being
cultured so as to undergo a posterior sperm injection. In the meantime,
semen is prepared for fertilisation by removing inactive cells and seminal fluid in a process called sperm washing. If semen is being provided by a sperm donor, it will usually have been prepared for treatment before being frozen and quarantined, and it will be thawed ready for use.
Co-incubation
Demonstration of ICSI
The sperm and the egg are incubated together at a ratio of about 75,000:1 in a culture media in order for the actual fertilisation
to take place. A review in 2013 came to the result that a duration of
this co-incubation of about 1 to 4 hours results in significantly higher
pregnancy rates than 16 to 24 hours. In most cases, the egg will be fertilised during co-incubation and will show two pronuclei. In certain situations, such as low sperm count or motility, a single sperm may be injected directly into the egg using intracytoplasmic sperm injection
(ICSI). The fertilised egg is passed to a special growth medium and
left for about 48 hours until the embryo consists of six to eight cells.
In gamete intrafallopian transfer,
eggs are removed from the woman and placed in one of the fallopian
tubes, along with the man's sperm. This allows fertilisation to take
place inside the woman's body. Therefore, this variation is actually an
in vivo fertilisation, not in vitro.
The main durations of embryo culture are until cleavage stage (day two to four after co-incubation) or the blastocyst stage (day five or six after co-incubation). Embryo culture until the blastocyst stage confers a significant increase in live birth rate per embryo transfer, but also confers a decreased number of embryos available for transfer and embryo cryopreservation, so the cumulative clinical pregnancy rates are increased with cleavage stage transfer. Transfer day two instead of day three after fertilisation has no differences in live birth rate. There are significantly higher odds of preterm birth (odds ratio 1.3) and congenital anomalies (odds ratio 1.3) among births having from embryos cultured until the blastocyst stage compared with cleavage stage.
Laboratories have developed grading methods to judge ovocyte and embryo quality. In order to optimise pregnancy rates, there is significant evidence that a morphological scoring system is the best strategy for the selection of embryos. Since 2009 where the first time-lapse microscopy system for IVF was approved for clinical use, morphokinetic scoring systems has shown to improve to pregnancy rates further. However, when all different types of time-lapse embryo imaging
devices, with or without morphokinetic scoring systems, are compared
against conventional embryo assessment for IVF, there is insufficient
evidence of a difference in live-birth, pregnancy, stillbirth or
miscarriage to choose between them.
Active efforts to develop a more accurate embryo selection analysis
based on Artificial Intelligence and Deep Learning are underway. Embryo
Ranking Intelligent Classification Assistant (ERICA),
is a clear example. This Deep Learning software substitutes manual
classifications with a ranking system based on an individual embryo's
predicted genetic status in a non-invasive fashion. Studies on this area are still pending and current feasibility studies support its potential.
The number to be transferred depends on the number available, the age
of the patient and other health and diagnostic factors. In countries
such as Canada, the UK, Australia and New Zealand, a maximum of two
embryos are transferred except in unusual circumstances. In the UK and
according to HFEA
regulations, a woman over 40 may have up to three embryos transferred,
whereas in the US, there is no legal limit on the number of embryos
which may be transferred, although medical associations have provided
practice guidelines. Most clinics and country regulatory bodies seek to
minimise the risk of multiple pregnancy, as it is not uncommon for
multiple embryos to implant if multiple embryos are transferred. Embryos
are transferred to the patient's uterus through a thin, plastic catheter, which goes through their vagina and cervix. Several embryos may be passed into the uterus to improve chances of implantation and pregnancy.
Luteal support is the administration of medication, generally progesterone, progestins, hCG, or GnRH agonists, and often accompanied by estradiol, to increase the success rate of implantation and early embryogenesis, thereby complementing and/or supporting the function of the corpus luteum. A Cochrane review found that hCG or progesterone given during the luteal phase may be associated with higher rates of live birth or ongoing pregnancy, but that the evidence is not conclusive. Co-treatment with GnRH agonists appears to improve outcomes, by a live birth rate RD of +16% (95% confidence interval +10 to +22%). On the other hand, growth hormone or aspirin as adjunctive medication in IVF have no evidence of overall benefit.
Expansions
There
are various expansions or additional techniques that can be applied in
IVF, which are usually not necessary for the IVF procedure itself, but
would be virtually impossible or technically difficult to perform
without concomitantly performing methods of IVF.
Preimplantation genetic screening
(PGS) or preimplantation genetic diagnosis (PGD) has been suggested to
be able to be used in IVF to select an embryo that appears to have the
greatest chances for successful pregnancy. However, a systematic review
and meta-analysis of existing randomised controlled trials came to the result that there is no evidence of a beneficial effect of PGS with cleavage-stage biopsy as measured by live birth rate. On the contrary, for those of advanced maternal age, PGS with cleavage-stage biopsy significantly lowers the live birth rate. Technical drawbacks, such as the invasiveness of the biopsy, and non-representative samples because of mosaicism are the major underlying factors for inefficacy of PGS.
Still, as an expansion of IVF, patients who can benefit from PGS/PGD include:
Those who have a family history of inherited disease
Those who already have a child with an incurable disease and need
compatible cells from a second healthy child to cure the first,
resulting in a "saviour sibling" that matches the sick child in HLA type.
PGS screens for numeral chromosomal abnormalities while PGD diagnosis
the specific molecular defect of the inherited disease. In both PGS and
PGD, individual cells from a pre-embryo, or preferably trophectoderm cells biopsied from a blastocyst,
are analysed during the IVF process. Before the transfer of a
pre-embryo back to a person's uterus, one or two cells are removed from
the pre-embryos (8-cell stage), or preferably from a blastocyst.
These cells are then evaluated for normality. Typically within one to
two days, following completion of the evaluation, only the normal
pre-embryos are transferred back to the uterus. Alternatively, a
blastocyst can be cryopreserved via vitrification and transferred at a
later date to the uterus. In addition, PGS can significantly reduce the
risk of multiple pregnancies because fewer embryos, ideally just one,
are needed for implantation.
The Rand Consulting Group has estimated there to be 400,000 frozen embryos in the United States in 2006.
The advantage is that patients who fail to conceive may become pregnant
using such embryos without having to go through a full IVF cycle. Or,
if pregnancy occurred, they could return later for another pregnancy.
Spare oocytes or embryos resulting from fertility treatments may be used
for oocyte donation or embryo donation
to another aspiring parent, and embryos may be created, frozen and
stored specifically for transfer and donation by using donor eggs and
sperm. Also, oocyte cryopreservation can be used for those who are
likely to lose their ovarian reserve due to undergoing chemotherapy.
By 2017, many centres have adopted embryo cryopreservation as
their primary IVF therapy, and perform few or no fresh embryo transfers.
The two main reasons for this have been better endometrial receptivity
when embryos are transferred in cycles without exposure to ovarian
stimulation and also the ability to store the embryos while awaiting the
results of preimplantation genetic testing.
The outcome from using cryopreserved embryos has uniformly been
positive with no increase in birth defects or development abnormalities.
Other expansions
Intracytoplasmic sperm injection (ICSI) is where a single sperm is injected directly into an egg.
Its main usage as an expansion of IVF is to overcome male infertility
problems, although it may also be used where eggs cannot easily be
penetrated by sperm, and occasionally in conjunction with sperm donation. It can be used in teratozoospermia, since once the egg is fertilised abnormal sperm morphology does not appear to influence blastocyst development or blastocyst morphology.
Additional methods of embryo profiling. For example, methods are emerging in making comprehensive analyses of up to entire genomes, transcriptomes, proteomes and metabolomes
which may be used to score embryos by comparing the patterns with ones
that have previously been found among embryos in successful versus
unsuccessful pregnancies.
Assisted zona hatching
(AZH) can be performed shortly before the embryo is transferred to the
uterus. A small opening is made in the outer layer surrounding the egg
in order to help the embryo hatch out and aid in the implantation
process of the growing embryo.
In egg donation and embryo donation,
the resultant embryo after fertilisation is inserted in another person
than the one providing the eggs. These are resources for those with no
eggs due to surgery, chemotherapy, or genetic causes; or with poor egg
quality, previously unsuccessful IVF cycles or advanced maternal age.
In the egg donor process, eggs are retrieved from a donor's ovaries,
fertilised in the laboratory with sperm, and the resulting healthy
embryos are returned to the recipient's uterus.
Embryo splitting can be used for twinning to increase the number of available embryos.
Cytoplasmic transfer is where the cytoplasm from a donor egg is injected into an egg with compromised mitochondria. The resulting egg is then fertilised with sperm and introduced into a uterus, usually that of the person who provided the recipient egg and nuclear DNA. Cytoplasmic transfer was created to aid those who experience infertility due to deficient or damaged mitochondria, contained within an egg's cytoplasm.
Complications and health effects
Multiple births
The major complication of IVF is the risk of multiple births.
This is directly related to the practice of transferring multiple
embryos at embryo transfer. Multiple births are related to increased
risk of pregnancy loss, obstetrical complications, prematurity,
and neonatal morbidity with the potential for long term damage. Strict
limits on the number of embryos that may be transferred have been
enacted in some countries (e.g. Britain, Belgium) to reduce the risk of
high-order multiples (triplets or more), but are not universally
followed or accepted. Spontaneous splitting of embryos in the uterus
after transfer can occur, but this is rare and would lead to identical
twins. A double blind, randomised study followed IVF pregnancies that
resulted in 73 infants, and reported that 8.7% of singleton infants and
54.2% of twins had a birth weight of less than 2,500 grams (5.5 lb).
There is some evidence that making a double embryo transfer during one
cycle achieves a higher live birth rate than a single embryo transfer;
but making two single embryo transfers in two cycles has the same live
birth rate and would avoid multiple pregnancies.
Sex ratio distortions
Certain kinds of IVF have been shown to lead to distortions in the sex ratio at birth. Intracytoplasmic sperm injection (ICSI), which was first applied in 1991, leads to slightly more female births (51.3% female). Blastocyst transfer,
which was first applied in 1984, leads to significantly more male
births (56.1% male). Standard IVF done at the second or third day leads
to a normal sex ratio.
Epigenetic modifications
caused by extended culture leading to the death of more female embryos
has been theorised as the reason why blastocyst transfer leads to a
higher male sex ratio; however, adding retinoic acid to the culture can
bring this ratio back to normal.
A second theory is that the male-biased sex ratio may due to a higher
rate of selection of male embryos. Male embryos develop faster in vitro,
and thus may appear more viable for transfer.
Spread of infectious disease
By sperm washing,
the risk that a chronic disease in the individual providing the sperm
would infect the birthing parent or offspring can be brought to
negligible levels.
If the sperm donor has hepatitis B,
The Practice Committee of the American Society for Reproductive
Medicine advises that sperm washing is not necessary in IVF to prevent
transmission, unless the birthing partner has not been effectively
vaccinated. In women with hepatitis B, the risk of vertical transmission during IVF is no different from the risk in spontaneous conception. However, there is not enough evidence to say that ICSI procedures are safe in women with hepatitis B in regard to vertical transmission to the offspring.
Regarding potential spread of HIV/AIDS,
Japan's government prohibited the use of IVF procedures in which both
partners are infected with HIV. Despite the fact that the ethics
committees previously allowed the Ogikubo, Tokyo Hospital, located in Tokyo, to use IVF for couples with HIV, the Ministry of Health, Labour and Welfare
of Japan decided to block the practice. Hideji Hanabusa, the vice
president of the Ogikubo Hospital, states that together with his
colleagues, he managed to develop a method through which scientists are
able to remove HIV from sperm.
In the United States, people seeking to be an embryo recipient undergo infectious disease screening required by the Food and Drug Administration
(FDA), and reproductive tests to determine the best placement location
and cycle timing before the actual embryo transfer occurs. The amount of
screening the embryo has already undergone is largely dependent on the
genetic parents' own IVF clinic and process. The embryo recipient may
elect to have their own embryologist conduct further testing.
Other risks to the egg provider/retriever
A risk of ovarian stimulation is the development of ovarian hyperstimulation syndrome, particularly if hCG is used for inducing final oocyte maturation.
This results in swollen, painful ovaries. It occurs in 30% of patients.
Mild cases can be treated with over the counter medications and cases
can be resolved in the absence of pregnancy. In moderate cases, ovaries
swell and fluid accumulated in the abdominal cavities and may have
symptoms of heartburn, gas, nausea or loss of appetite. In severe cases,
patients have sudden excess abdominal pain, nausea, vomiting and will
result in hospitalisation.
During egg retrieval, there exists a small chance of bleeding,
infection, and damage to surrounding structures such as bowel and
bladder (transvaginal ultrasound aspiration) as well as difficulty in
breathing, chest infection, allergic reactions to medication, or nerve
damage (laparoscopy).
Ectopic pregnancy
may also occur if a fertilised egg develops outside the uterus, usually
in the fallopian tubes and requires immediate destruction of the
foetus.
Regardless of pregnancy result, IVF treatment is usually stressful for patients. Neuroticism and the use of escapist coping strategies are associated with a higher degree of distress, while the presence of social support has a relieving effect. A negative pregnancy test after IVF is associated with an increased risk for depression, but not with any increased risk of developing anxiety disorders.
Pregnancy test results do not seem to be a risk factor for depression
or anxiety among men in the case of relationships between two cisgender,
heterosexual people. Hormonal agents such as gonadotropin-releasing hormone agonist (GnRH agonist) are associated with depression.
Studies show that there is an increased risk of venous thrombosis or pulmonary embolism during the first trimester of IVF.
When looking at long-term studies comparing patients who received or
did not receive IVF, there seems to be no correlation with increased
risk of cardiac events. There are more ongoing studies to solidify this.
Spontaneous pregnancy has occurred after successful and unsuccessful IVF treatments. Within 2 years of delivering an infant conceived through IVF, subfertile patients had a conception rate of 18%.
Birth defects
A review in 2013 came to the result that infants resulting from IVF (with or without ICSI) have a relative risk of birth defects of 1.32 (95% confidence interval 1.24–1.42) compared to naturally conceived infants.
In 2008, an analysis of the data of the National Birth Defects Study in
the US found that certain birth defects were significantly more common
in infants conceived through IVF, notably septal heart defects, cleft lip with or without cleft palate, esophageal atresia, and anorectal atresia; the mechanism of causality is unclear.
However, in a population-wide cohort study of 308,974 births (with
6,163 using assisted reproductive technology and following children from
birth to age five) researchers found: "The increased risk of birth
defects associated with IVF was no longer significant after adjustment
for parental factors."
Parental factors included known independent risks for birth defects
such as maternal age, smoking status, etc. Multivariate correction did
not remove the significance of the association of birth defects and ICSI
(corrected odds ratio 1.57), although the authors speculate that
underlying male infertility factors (which would be associated with the
use of ICSI) may contribute to this observation and were not able to
correct for these confounders. The authors also found that a history of
infertility elevated risk itself in the absence of any treatment (odds
ratio 1.29), consistent with a Danish national registry study and "implicates patient factors in this increased risk."
The authors of the Danish national registry study speculate: "our
results suggest that the reported increased prevalence of congenital
malformations seen in singletons born after assisted reproductive
technology is partly due to the underlying infertility or its
determinants."
Risk in singleton pregnancies resulting from IVF (with or without ICSI)
If the underlying infertility is related to abnormalities in spermatogenesis,
male offspring will have a higher risk for sperm abnormalities. In some
cases genetic testing may be recommended to help assess the risk of
transmission of defects to progeny and to consider whether treatment is
desirable.
IVF does not seem to confer any risks regarding cognitive development, school performance, social functioning, and behaviour.
Also, IVF infants are known to be as securely attached to their parents
as those who were naturally conceived, and IVF adolescents are as
well-adjusted as those who have been naturally conceived.
Limited long-term follow-up data suggest that IVF may be associated with an increased incidence of hypertension, impaired fasting glucose, increase in total body fat composition, advancement of bone age, subclinical thyroid disorder, early adulthood clinical depression and binge drinking in the offspring.It is not known, however, whether these potential associations are
caused by the IVF procedure in itself, by adverse obstetric outcomes
associated with IVF, by the genetic origin of the children or by yet
unknown IVF-associated causes. Increases in embryo manipulation during IVF result in more deviant
fetal growth curves, but birth weight does not seem to be a reliable
marker of fetal stress.
In
some cases, laboratory mix-ups (misidentified gametes, transfer of
wrong embryos) have occurred, leading to legal action against the IVF
provider and complex paternity suits. An example is the case of a woman
in California who received the embryo of another couple and was notified
of this mistake after the birth of her son. This has led to many authorities and individual clinics implementing procedures to minimise the risk of such mix-ups. The HFEA,
for example, requires clinics to use a double witnessing system, the
identity of specimens is checked by two people at each point at which
specimens are transferred. Alternatively, technological solutions are
gaining favour, to reduce the manpower cost of manual double witnessing,
and to further reduce risks with uniquely numbered RFID
tags which can be identified by readers connected to a computer. The
computer tracks specimens throughout the process and alerts the
embryologist if non-matching specimens are identified. Although the use
of RFID tracking has expanded in the US, it is still not widely adopted.
Preimplantation genetic diagnosis or screening
Pre-implantation genetic diagnosis
(PGD) is criticised for giving select demographic groups
disproportionate access to a means of creating a child possessing
characteristics that they consider "ideal". Many fertile couples
now demand equal access to embryonic screening so that their child can
be just as healthy as one created through IVF. Mass use of PGD,
especially as a means of population control or in the presence of legal measures related to population or demographic control, can lead to intentional or unintentional demographic effects such as the skewed live-birth sex ratios seen in China following implementation of its one-child policy.
While PGD was originally designed to screen for embryos carrying
hereditary genetic diseases, the method has been applied to select
features that are unrelated to diseases, thus raising ethical questions.
Examples of such cases include the selection of embryos based on histocompatibility (HLA) for the donation of tissues to a sick family member, the diagnosis of genetic susceptibility to disease, and sex selection.
These examples raise ethical issues because of the morality of eugenics.
It becomes frowned upon because of the advantage of being able to
eliminate unwanted traits and selecting desired traits. By using PGD,
individuals are given the opportunity to create a human life unethically
and rely on science and not by natural selection.
For example, a deaf British couple, Tom and Paula Lichy, have petitioned to create a deaf baby using IVF. Some medical ethicists have been very critical of this approach. Jacob M. Appel
wrote that "intentionally culling out blind or deaf embryos might
prevent considerable future suffering, while a policy that allowed deaf
or blind parents to select for such traits intentionally would be far more troublesome."
Industry corruption
Robert
Winston, professor of fertility studies at Imperial College London, had
called the industry "corrupt" and "greedy" stating that "one of the
major problems facing us in healthcare is that IVF has become a massive
commercial industry," and that "what has happened, of course, is that
money is corrupting this whole technology", and accused authorities of
failing to protect couples from exploitation: "The regulatory authority
has done a consistently bad job. It's not prevented the exploitation of
people, it's not put out very good information to couples, it's not
limited the number of unscientific treatments people have access to". The IVF industry has been described as a market-driven construction of health, medicine and the human body.
The industry has been accused of making unscientific claims, and
distorting facts relating to infertility, in particular through widely
exaggerated claims about how common infertility is in society, in an
attempt to get as many couples as possible and as soon as possible to
try treatments (rather than trying to conceive naturally for a longer
time).
This risks removing infertility from its social context and reducing
the experience to a simple biological malfunction, which not only can be treated through bio-medical procedures, but should be treated by them.
Older patients
All
pregnancies can be risky, but there are greater risk for mothers who
are older and are over the age of 40. As people get older, they are more
likely to develop conditions such as gestational diabetes and
pre-eclampsia. If the mother does conceive over the age of 40, their
offspring may be of lower birth weight, and more likely to requires
intensive care. Because of this, the increased risk is a sufficient
cause for concern. The high incidence of caesarean in older patients is
commonly regarded as a risk.
Those conceiving at 40 have a greater risk of gestational
hypertension and premature birth. The offspring is at risk when being
born from older mothers, and the risks associated with being conceived
through IVF.
premenopausal vaginal canal vs menopausal vaginal canal
Adriana Iliescu
held the record for a while as the oldest woman to give birth using IVF
and a donor egg, when she gave birth in 2004 at the age of 66.[citation needed] In September 2019, a 74-year-old woman became the oldest-ever to give birth after she delivered twins at a hospital in Guntur, Andhra Pradesh.
Pregnancy after menopause
Although
menopause is a natural barrier to further conception, IVF has allowed
people to be pregnant in their fifties and sixties. People whose
uteruses have been appropriately prepared receive embryos that
originated from an egg donor. Therefore, although they do not have a
genetic link with the child, they have a physical link through pregnancy
and childbirth. Even after menopause, the uterus is fully capable of carrying out a pregnancy.
A 2009 statement from the ASRM
found no persuasive evidence that children are harmed or disadvantaged
solely by being raised by single parents, unmarried parents, or
homosexual parents. It did not support restricting access to assisted
reproductive technologies on the basis of a prospective parent's marital
status or sexual orientation.
A 2018 study found that children's psychological well-being did not
differ when raised by either same-sex parents or heterosexual parents,
even finding that psychological well-being was better amongst children
raised by same-sex parents.
Ethical concerns include reproductive rights, the welfare of
offspring, nondiscrimination against unmarried individuals, homosexual,
and professional autonomy.
A controversy in California focused on the question of whether
physicians opposed to same-sex relationships should be required to
perform IVF for a lesbian couple. Guadalupe T. Benitez, a lesbian
medical assistant from San Diego, sued doctors Christine Brody and
Douglas Fenton of the North Coast Woman's Care Medical Group after Brody
told her that she had "religious-based objections to treating her and
homosexuals in general to help them conceive children by artificial
insemination," and Fenton refused to authorise a refill of her
prescription for the fertility drug Clomid on the same grounds. The California Medical Association had initially sided with Brody and Fenton, but the case, North Coast Women's Care Medical Group v. Superior Court, was decided unanimously by the California State Supreme Court in favour of Benitez on 19 August 2008.
Nadya Suleman
came to international attention after having twelve embryos implanted,
eight of which survived, resulting in eight newborns being added to her
existing six-child family. The Medical Board of California sought to
have fertility doctor Michael Kamrava, who treated Suleman, stripped of
his licence. State officials allege that performing Suleman's procedure
is evidence of unreasonable judgment, substandard care, and a lack of
concern for the eight children she would conceive and the six she was
already struggling to raise. On 1 June 2011 the Medical Board issued a
ruling that Kamrava's medical licence be revoked effective 1 July 2011.
The research on transgender reproduction and family planning is limited. A 2020 comparative study of children born to a transgender father and cisgender mother via donor sperm insemination in France showed no significant differences to IVF and naturally conceived children of cisgender parents.
Transgender men can experience challenges in pregnancy and birthing from the cis-normative structure within the medical system, as well as psychological challenges such as renewed gender dysphoria. The effect of continued testosterone therapy during pregnancy and breastfeeding is undetermined.
Ethical concerns include reproductive rights, reproductive justice,
physician autonomy, and transphobia within the health care setting.
Alana Stewart, who was conceived using donor sperm, began an online
forum for donor children called AnonymousUS in 2010. The forum welcomes
the viewpoints of anyone involved in the IVF process. In May 2012, a court ruled making anonymous sperm and egg donation in British Columbia illegal.
In the UK, Sweden, Norway, Germany, Italy, New Zealand, and some Australian states, donors are not paid and cannot be anonymous.
In 2000, a website called Donor Sibling Registry was created to help biological children with a common donor connect with each other.
There may be leftover embryos or eggs from IVF procedures if the
person for whom they were originally created has successfully carried
one or more pregnancies to term, and no longer wishes to use them. With
the patient's permission, these may be donated to help others conceive
by means of third party reproduction.
In embryo donation, these extra embryos are given to others for transfer,
with the goal of producing a successful pregnancy. Embryo recipients
have genetic issues or poor-quality embryos or eggs of their own. The
resulting child is considered the child of whoever birthed them, and not
the child of the donor, the same as occurs with egg donation or sperm donation. As per The National Infertility Association, typically, genetic parents donate the eggs or embryos to a fertility clinic where they are preserved by oocyte cryopreservation or embryo cryopreservation
until a carrier is found for them. The process of matching the donation
with the prospective parents is conducted by the agency itself, at
which time the clinic transfers ownership of the embryos to the
prospective parent(s).
Alternatives to donating unused embryos are destroying them (or having them transferred at a time when pregnancy is very unlikely), keeping them frozen indefinitely, or donating them for use in research (rendering them non-viable). Individual moral views on disposing of leftover embryos may depend on personal views on the beginning of human personhood and the definition and/or value of potential future persons,
and on the value that is given to fundamental research questions. Some
people believe donation of leftover embryos for research is a good
alternative to discarding the embryos when patients receive proper,
honest and clear information about the research project, the procedures
and the scientific values.
During the embryo selection
and transfer phases, many embryos may be discarded in favour of others.
This selection may be based on criteria such as genetic disorders or
the sex. One of the earliest cases of special gene selection through IVF
was the case of the Collins family in the 1990s, who selected the sex
of their child.
The ethic issues remain unresolved as no worldwide consensus
exists in science, religion, and philosophy on when a human embryo
should be recognised as a person. For those who believe that this is at
the moment of conception, IVF becomes a moral question when multiple
eggs are fertilised, begin development, and only a few are chosen for
uterus transfer.
If IVF were to involve the fertilisation of only a single egg, or at least only the number that will be transferred,
then this would not be an issue. However, this has the chance of
increasing costs dramatically as only a few eggs can be attempted at a
time. As a result, the couple must decide what to do with these extra
embryos. Depending on their view of the embryo's humanity or the chance
the couple will want to try to have another child, the couple has
multiple options for dealing with these extra embryos. Couples can
choose to keep them frozen, donate them to other infertile couples, thaw
them, or donate them to medical research.
Keeping them frozen costs money, donating them does not ensure they
will survive, thawing them renders them immediately unviable, and
medical research results in their termination. In the realm of medical
research, the couple is not necessarily told what the embryos will be
used for, and as a result, some can be used in stem cell research.
The Catholic Church opposes all kinds of assisted reproductive technology and artificial contraception, on the grounds that they separate the procreative goal of marital sex from the goal of uniting married couples.
The Catholic Church permits the use of a small number of reproductive technologies and contraceptive methods such as natural family planning,
which involves charting ovulation times, and allows other forms of
reproductive technologies that allow conception to take place from
normative sexual intercourse, such as a fertility lubricant. Pope
Benedict XVI had publicly re-emphasised the Catholic Church's opposition
to in vitro fertilisation, saying that it replaces love between a
husband and wife. The Catechism of the Catholic Church, in accordance with the Catholic understanding of natural law, teaches that reproduction has an "inseparable connection" to the sexual union of married couples.
In addition, the church opposes IVF because it might result in the
disposal of embryos; in Catholicism, an embryo is viewed as an
individual with a soul that must be treated as a person.
The Catholic Church maintains that it is not objectively evil to be
infertile, and advocates adoption as an option for such couples who
still wish to have children.
The Lutheran Council in the United States of America, organised by the Lutheran Church–Missouri Synod and parent bodies of the Evangelical Lutheran Church in America, produced an authoritative document on the issue of in-vitro fertilisation, which "unanimously concluded that IVF does not in and of itself violate the will of God as reflected in the Bible, when the wife’s egg and husband’s sperm are used" (LCUSA n.d.:31). The Lutheran Churches approve of artificial insemination by a husband (AIH), though representatives from the Lutheran Church-Missouri Synod
hold that such IVF is only unobjectionable if the sperm and egg come
from husband and wife and all of the fertilised eggs are implanted in
the womb of the wife.
With regard to artificial insemination by a donor (AID), the
Evangelical Lutheran Church in America teaches that it is a "cause for
moral concern", while the Lutheran Church–Missouri Synod rejects it.
Islam
Regarding the response to IVF by Islam,
a general consensus from the contemporary Sunni scholars concludes that
IVF methods are immoral and prohibited. However, Gad El-Hak Ali Gad
El-Hak's ART fatwa includes that:
IVF of an egg from the wife with the sperm of her husband and
the transfer of the fertilised egg back to the uterus of the wife is
allowed, provided that the procedure is indicated for a medical reason
and is carried out by an expert physician.
Since marriage is a contract between the wife and husband during the
span of their marriage, no third party should intrude into the marital
functions of sex and procreation. This means that a third party donor is
not acceptable, whether he or she is providing sperm, eggs, embryos, or
a uterus. The use of a third party is tantamount to zina, or adultery.
Judaism
Within the Orthodox Jewish community the concept is debated as there is little precedent in traditional Jewish legal textual sources. Regarding laws of sexuality, religious challenges include masturbation (which may be regarded as "seed wasting"), laws related to sexual activity and menstruation (niddah)
and the specific laws regarding intercourse. An additional major issue
is that of establishing paternity and lineage. For a baby conceived
naturally, the father's identity is determined by a legal presumption (chazakah) of legitimacy: rov bi'ot achar ha'baal – a woman's sexual relations are assumed to be with her husband. Regarding an IVF child, this assumption does not exist and as such Rabbi Eliezer Waldenberg (among others) requires an outside supervisor to positively identify the father. Reform Judaism has generally approved IVF.
Society and culture
Many
women of sub-Saharan Africa choose to foster their children to
infertile women. IVF enables these infertile women to have their own
children, which imposes new ideals to a culture in which fostering
children is seen as both natural and culturally important. Many
infertile women are able to earn more respect in their society by taking
care of the children of other mothers, and this may be lost if they
choose to use IVF instead. As IVF is seen as unnatural, it may even
hinder their societal position as opposed to making them equal with
fertile women. It is also economically advantageous for infertile women
to raise foster children as it gives these children greater ability to
access resources that are important for their development and also aids
the development of their society at large. If IVF becomes more popular
without the birth rate decreasing, there could be more large family
homes with fewer options to send their newborn children. This could
result in an increase of orphaned children and/or a decrease in
resources for the children of large families. This would ultimately
stifle the children's and the community's growth.
In the US, the pineapple
has emerged as a symbol of IVF users, possibly because some people
thought, without scientific evidence, that eating pineapple might
slightly increase the success rate for the procedure.
Emotional involvement with children
Studies
have indicated that IVF mothers show greater emotional involvement with
their child, and they enjoy motherhood more than mothers by natural
conception. Similarly, studies have indicated that IVF fathers express
more warmth and emotional involvement than fathers by adoption and
natural conception and enjoy fatherhood more. Some IVF parents become
overly involved with their children.
Men and IVF
Research has shown that men largely view themselves as "passive contributors" since they have "less physical involvement"
in IVF treatment. Despite this, many men feel distressed after seeing
the toll of hormonal injections and ongoing physical intervention on
their female partner.
Fertility was found to be a significant factor in a man's perception of
his masculinity, driving many to keep the treatment a secret.
In cases where the men did share that he and his partner were
undergoing IVF, they reported to have been teased, mainly by other men,
although some viewed this as an affirmation of support and friendship.
For others, this led to feeling socially isolated. In comparison with females, males showed less deterioration in mental health in the years following a failed treatment.
However, many men did feel guilt, disappointment and inadequacy,
stating that they were simply trying to provide an "emotional rock" for
their partners.
Ability to withdraw consent
In
certain countries, including Austria, Italy, Estonia, Hungary, Spain
and Israel, the male does not have the full ability to withdraw consent
to storage or use of embryos once they are fertilised. In the United
States, the matter has been left to the courts on a more or less ad hoc
basis. If embryos are implanted and a child is born contrary to the
wishes of the male, he still has legal and financial responsibilities of
a father.
Availability and utilisation
Cost
Costs
of IVF can be broken down into direct and indirect costs. Direct costs
include the medical treatments themselves, including doctor
consultations, medications, ultrasound scanning, laboratory tests, the
actual IVF procedure, and any associated hospital charges and
administrative costs. Indirect costs includes the cost of addressing any
complications with treatments, compensation for the gestational surrogate, patients' travel costs, and lost hours of productivity.
These costs can be exaggerated by the increasing age of the woman
undergoing IVF treatment (particularly those over the age of 40), and
the increase costs associated with multiple births. For instance, a
pregnancy with twins can cost up to three times that of a singleton
pregnancy. While some insurances cover one cycle of IVF, it takes multiple cycles of IVF to have a successful outcome.
A study completed in Northern California reveals that the IVF procedure
alone that results in a successful outcome costs $61,377, and this can
be more costly with the use of a donor egg.
The cost of IVF rather reflects the costliness of the underlying healthcare system than the regulatory or funding environment,
and ranges, on average for a standard IVF cycle and in 2006 United
States dollars, between $12,500 in the United States to $4,000 in Japan. In Ireland, IVF costs around €4,000, with fertility drugs, if required, costing up to €3,000. The cost per live birth is highest in the United States ($41,000) and United Kingdom ($40,000) and lowest in Scandinavia and Japan (both around $24,500).
The high cost of IVF is also a barrier to access for disabled
individuals, who typically have lower incomes, face higher health care
costs, and seek health care services more often than non-disabled
individuals.
Navigating insurance coverage for transgender expectant parents
presents a unique challenge. Insurance plans are designed to cater
towards a specific population, meaning that some plans can provide
adequate coverage for gender-affirming care but fail to provide
fertility services for transgender patients.[167]
Additionally, insurance coverage is constructed around a person's
legally recognised sex and not their anatomy; thus, transgender people
may not get coverage for the services they need, including transgender
men for fertility services.
Use by LGBT individuals
Same-sex couples
In
larger urban centres, studies have noted that lesbian, gay, bisexual,
transgender and queer (LGBTQ+) populations are among the fastest-growing
users of fertility care.
IVF is increasingly being used to allow lesbian and other LGBT couples
to share in the reproductive process through a technique called reciprocal IVF.
The eggs of one partner are used to create embryos which the other
partner carries through pregnancy. For gay male couples, many elect to
use IVF through gestational surrogacy, where one partner's sperm is used
to fertilise a donor ovum, and the resulting embryo is transplanted
into a surrogate carrier's womb.
There are various IVF options available for same-sex couples including,
but not limited to, IVF with donor sperm, IVF with a partner's oocytes,
reciprocal IVF, IVF with donor eggs, and IVF with gestational
surrogate. IVF with donor sperm can be considered traditional IVF for
lesbian couples, but reciprocal IVF or using a partner's oocytes are
other options for lesbian couples trying to conceive to include both
partners in the biological process. Using a partner's oocytes is an
option for partners who are unsuccessful in conceiving with their own,
and reciprocal IVF involves undergoing reproduction with a donor egg and
sperm that is then transferred to a partner who will gestate. Donor IVF
involves conceiving with a third party's eggs. Typically, for gay male
couples hoping to use IVF, the common techniques are using IVF with
donor eggs and gestational surrogates.
Transgender parents
Many
LGBT communities centre their support around cisgender gay, lesbian and
bisexual people and neglect to include proper support for transgender
people. The same 2020 literature review analyses the social, emotional and physical experiences of pregnant transgender men. A common obstacle faced by pregnant transgender men is the possibility of gender dysphoria.
Literature shows that transgender men report uncomfortable procedures
and interactions during their pregnancies as well as feeling misgendered
due to gendered terminology used by healthcare providers. Outside of
the healthcare system, pregnant transgender men may experience gender
dysphoria due to cultural assumptions that all pregnant people are
cisgender women.
These people use three common approaches to navigating their pregnancy:
passing as a cisgender woman, hiding their pregnancy, or being out and
visibly pregnant as a transgender man.
Some transgender and gender diverse patients describe their experience
in seeking gynaecological and reproductive health care as isolating and
discriminatory, as the strictly binary healthcare system often leads to
denial of healthcare coverage or unnecessary revelation of their
transgender status to their employer.
Many transgender people retain their original sex organs and
choose to have children through biological reproduction. Advances in
assisted reproductive technology and fertility preservation have
broadened the options transgender people have to conceive a child using
their own gametes or a donor's. Transgender men and women may opt for
fertility preservation before any gender affirming surgery, but it is
not required for future biological reproduction. It is also recommended that fertility preservation is conducted before any hormone therapy.
Additionally, while fertility specialists often suggest that
transgender men discontinue their testosterone hormones prior to
pregnancy, research on this topic is still inconclusive.
However, a 2019 study found that transgender male patients seeking
oocyte retrieval via assisted reproductive technology (including IVF)
were able to undergo treatment four months after stopping testosterone
treatment, on average. All patients experienced menses and normal AMH, FSH and E2 levels and antral follicle counts after coming off testosterone, which allowed for successful oocyte retrieval.
Despite assumptions that the long-term androgen treatment negatively
impacts fertility, oocyte retrieval, an integral part of the IVF
process, does not appear to be affected.
Biological reproductive options available to transgender women
include, but are not limited to, IVF and IUI with the trans woman's
sperm and a donor or a partner's eggs and uterus. Fertility treatment
options for transgender men include, but are not limited to, IUI or IVF
using his own eggs with a donor's sperm and/or donor's eggs, his uterus,
or a different uterus, whether that is a partner's or a surrogate's.
Use by disabled individuals
People
with disabilities who wish to have children are equally or more likely
than the non-disabled population to experience infertility,
yet disabled individuals are much less likely to have access to
fertility treatment such as IVF. There are many extraneous factors that
hinder disabled individuals access to IVF, such as assumptions about
decision-making capacity, sexual interests and abilities, heritability
of a disability, and beliefs about parenting ability.
These same misconceptions about people with disabilities that once led
health care providers to sterilise thousands of women with disabilities
now lead them to provide or deny reproductive care on the basis of
stereotypes concerning people with disabilities and their sexuality.
Not only do misconceptions about disabled individuals parenting
ability, sexuality, and health restrict and hinder access to fertility
treatment such as IVF, structural barriers such as providers uneducated
in disability healthcare and inaccessible clinics severely hinder
disabled individuals access to receiving IVF.
By country
Australia
In
Australia, the average age of women undergoing ART treatment is 35.5
years among those using their own eggs (one in four being 40 or older)
and 40.5 years among those using donated eggs. While IVF is available in Australia, Australians using IVF are unable to choose their baby's gender.
Cameroon
Ernestine Gwet Bell supervised the first Cameroonian child born by IVF in 1998.
Canada
In
Canada, one cycle of IVF treatment can cost between $7,750 to $12,250
CAD, and medications alone can cost between $2,500 to over $7,000 CAD.
The funding mechanisms that influence accessibility in Canada vary by
province and territory, with some provinces providing full, partial or
no coverage.
New Brunswick
provides partial funding through their Infertility Special Assistance
Fund – a one time grant of up to $5,000. Patients may only claim up to
50% of treatment costs or $5,000 (whichever is less) occurred after
April 2014. Eligible patients must be a full-time New Brunswick resident
with a valid Medicare card and have an official medical infertility diagnosis by a physician.
In December 2015, the Ontario
provincial government enacted the Ontario Fertility Program for
patients with medical and non-medical infertility, regardless of sexual
orientation, gender or family composition. Eligible patients for IVF
treatment must be Ontario residents under the age of 43 and have a valid
Ontario Health Insurance Plan
card and have not already undergone any IVF cycles. Coverage is
extensive, but not universal. Coverage extends to certain blood and
urine tests, physician/nurse counselling and consultations, certain
ultrasounds, up to two cycle monitorings, embryo thawing, freezing and
culture, fertilisation and embryology services, single transfers of all
embryos, and one surgical sperm retrieval using certain techniques only
if necessary. Drugs and medications are not covered under this Program,
along with psychologist or social worker counselling, storage and
shipping of eggs, sperm or embryos, and the purchase of donor sperm or
eggs.
China
IVF is expensive in China and not generally accessible to unmarried women.
In August 2022, China's National Health Authority announced that it
will take steps to make assisted reproductive technology more
accessible, including by guiding local governments to include such
technology in its national medical system.
Croatia
No egg or sperm donations take place in Croatia, however using donated sperm or egg in ART
and IUI is allowed. With donated eggs, sperm or embryo, a heterosexual
couple and single women have legal access to IVF. Male or female couples
do not have access to ART as a form of reproduction. The minimum age
for males and females to access ART in Croatia is 18 there is no maximum
age. Donor anonymity applies, but the born child can be given access to
the donor's identity at a certain age
India
The penetration of the IVF market in India
is quite low, with only 2,800 cycles per million infertile people in
the reproductive age group (20–44 years), as compared to China, which
has 6,500 cycles. The key challenges are lack of awareness,
affordability and accessibility.
Since 2018, however, India has become a destination for fertility
tourism, because of lower costs than in the Western world. In December
2021, the Lok Sabha
passed the Assisted Reproductive Technology (Regulation) Bill 2020, to
regulate ART services including IVF centres, sperm and egg banks.
Israel
Israel has the highest rate of IVF in the world, with 1,657 procedures performed per million people per year.
Couples without children can receive funding for IVF for up to two
children. The same funding is available for people without children who
will raise up to two children in a single parent home. IVF is available for people aged 18 to 45. The Israeli Health Ministry says it spends roughly $3450 per procedure.
Sweden
One,
two or three IVF treatments are government subsidised for people who
are younger than 40 and have no children. The rules for how many
treatments are subsidised, and the upper age limit for the people, vary
between different county councils. Single people are treated, and embryo adoption is allowed. There are also private clinics that offer the treatment for a fee.
United Kingdom
Availability of IVF in England is determined by Clinical Commissioning Groups (CCGs). The National Institute for Health and Care Excellence
(NICE) recommends up to 3 cycles of treatment for people under 40 years
old with minimal success conceiving after 2 years of unprotected sex.
Cycles will not be continued for people who are older than 40 years. CCGs in Essex, Bedfordshire and Somerset
have reduced funding to one cycle, or none, and it is expected that
reductions will become more widespread. Funding may be available in
"exceptional circumstances" – for example if a male partner has a
transmittable infection or one partner is affected by cancer treatment.
According to the campaign group Fertility Fairness "at the end of 2014
every CCG in England was funding at least one cycle of IVF". Prices paid by the NHS in England varied between under £3,000 to more than £6,000 in 2014/5.
In February 2013, the cost of implementing the NICE guidelines for IVF
along with other treatments for infertility was projected to be £236,000
per year per 100,000 members of the population.
IVF increasingly appears on NHS treatments blacklists. In August 2017 five of the 208 CCGs had stopped funding IVF completely and others were considering doing so. By October 2017 only 25 CCGs were delivering the three recommended NHS IVF cycles to eligible people under 40. Policies could fall foul of discrimination laws if they treat same sex couples differently from heterosexual ones. In July 2019 Jackie Doyle-Price said that women were registering with surgeries further away from their own home in order to get around CCG rationing policies.
The Human Fertilisation and Embryology Authority
said in September 2018 that parents who are limited to one cycle of
IVF, or have to fund it themselves, are more likely choose to implant
multiple embryos in the hope it increases the chances of pregnancy.
This significantly increases the chance of multiple births and the
associated poor outcomes, which would increase NHS costs. The president
of the Royal College of Obstetricians and Gynaecologists
said that funding 3 cycles was "the most important factor in
maintaining low rates of multiple pregnancies and reduce(s) associated
complications".
United States
In
the United States, overall availability of IVF in 2005 was 2.5 IVF
physicians per 100,000 population, and utilisation was 236 IVF cycles
per 100,000.
126 procedures are performed per million people per year. Utilisation
highly increases with availability and IVF insurance coverage, and to a
significant extent also with percentage of single persons and median
income.
In the US, an average cycle, from egg retrieval to embryo
implantation, costs $12,400, and insurance companies that do cover
treatment, even partially, usually cap the number of cycles they pay
for. As of 2015, more than 1 million babies had been born utilising IVF technologies.
In the US, as of September 2023, 21 states and the District of Columbia
had passed laws for fertility insurance coverage. In 15 of those
jurisdictions, some level of IVF coverage is included, and in 17, some
fertility preservation services are included. Eleven states require
coverage for both fertility preservation and IVF: Colorado, Connecticut,
Delaware, Maryland, Maine, New Hampshire, New Jersey, New York, Rhode
Island, Utah, and Washington D.C.
The states that have infertility coverage laws are Arkansas,
California, Colorado, Connecticut, Delaware, Hawaii, Illinois,
Louisiana, Maryland, Massachusetts, Montana, New Hampshire, New Jersey,
New York, Ohio, Rhode Island, Texas, Utah, and West Virginia. As of July 2023, New York was reportedly the only state Medicaid program to cover IVF.
These laws differ by state but many require an egg be fertilised with
sperm from a spouse and that in order to be covered you must show you
cannot become pregnant through penile-vaginal sex. These requirements are not possible for a same-sex couple to meet.
Many fertility clinics in the United States limit the upper age at which people are eligible for IVF to 50 or 55 years. These cut-offs make it difficult for people older than fifty-five to utilise the procedure.
Legal status
Government
agencies in China passed bans on the use of IVF in 2003 by unmarried
people or by couples with certain infectious diseases.
Sunni Muslim nations generally allow IVF between married couples
when conducted with their own respective sperm and eggs, but not with
donor eggs from other couples. But Iran, which is Shi'a Muslim, has a
more complex scheme. Iran bans sperm donation but allows donation of
both fertilised and unfertilised eggs. Fertilised eggs are donated from
married couples to other married couples, while unfertilised eggs are
donated in the context of mut'ah or temporary marriage to the father.
By 2012 Costa Rica
was the only country in the world with a complete ban on IVF
technology, it having been ruled unconstitutional by the nation's
Supreme Court because it "violated life."
Costa Rica had been the only country in the western hemisphere that
forbade IVF. A law project sent reluctantly by the government of
President Laura Chinchilla
was rejected by parliament. President Chinchilla has not publicly
stated her position on the question of IVF. However, given the massive
influence of the Catholic Church in her government any change in the
status quo seems very unlikely.
In spite of Costa Rican government and strong religious opposition, the
IVF ban has been struck down by the Inter-American Court of Human
Rights in a decision of 20 December 2012.
The court said that a long-standing Costa Rican guarantee of protection
for every human embryo violated the reproductive freedom of infertile
couples because it prohibited them from using IVF, which often involves
the disposal of embryos not implanted in a woman's uterus.
On 10 September 2015, President Luis Guillermo Solís signed a decree
legalising in-vitro fertilisation. The decree was added to the country's
official gazette on 11 September. Opponents of the practice have since
filed a lawsuit before the country's Constitutional Court.
All major restrictions on single but infertile people using IVF
were lifted in Australia in 2002 after a final appeal to the Australian
High Court was rejected on procedural grounds in the Leesa Meldrum case.
A Victorian
federal court had ruled in 2000 that the existing ban on all single
women and lesbians using IVF constituted sex discrimination.
Victoria's government announced changes to its IVF law in 2007
eliminating remaining restrictions on fertile single women and lesbians,
leaving South Australia as the only state maintaining them.
United States
Despite strong popular support (7 out of 10 adults consider IVF access a good thing and 67% believe that health insurance plans should cover IVF), IVF can involve complicated legal issues and has become a contentious issue in US politics. Federal regulations include screening requirements and restrictions on donations, but these generally do not affect heterosexually intimate partners.
Doctors may be required to provide treatments to unmarried or LGBTQ
couples under non-discrimination laws, as for example in California. The state of Tennessee proposed a bill in 2009 that would have defined donor IVF as adoption.
During the same session, another bill proposed barring adoption from
any unmarried and cohabitating couple, and activist groups stated that
passing the first bill would effectively stop unmarried women from using
IVF. Neither of these bills passed.
In 2023, the Practice Committee of the American Society for Reproductive Medicine
(ASRM) updated its guidelines for the definition of “infertility” to
include those who need medical interventions “in order to achieve a
successful pregnancy either as an individual or with a partner.” In many states, legal and financial decisions about provision of infertility treatments reference this “official” definition. On September 29, 2024, California Governor Gavin Newsom signed SB 729, legislation which aligns with the ASRM definition of “infertility”.
In the United States, much of the opposition to the use of IVF is associated with the anti-abortion movement, evangelicals, and denominations such as the Southern Baptists.
Current legal opposition to IVF and other fertility treatment access
has stemmed from recent court rulings regarding women's reproductive
healthcare. In the 2022 Dobbs v. Jackson Women's Health Organization decision, the U.S. Supreme Court overturned the 1973 Roe v. Wade
decision which had federally protected the right to abortion. The 2024
Alabama Supreme Court decision regarding IVF has since threatened IVF
access and legality in the U.S. Frozen embryos at an IVF clinic were
accidentally destroyed resulting in a lawsuit during which the
attorneys for the plaintiff sought damages under the Wrongful Death of a
Minor Act. The court ruled in favor of the plaintiffs, setting a
state-level precedent that embryos and fetuses are given the same rights
as minors/children, regardless of whether they are in utero or not.
This has created confusion over the status of unused embryos and
questions surrounding when life begins. After the court's decision,
numerous IVF clinics in Alabama halted IVF treatment services
for fears of civil and criminal liability associated with the new
rights granted to embryos. Since, laws proposing embryonic personhood
have been proposed in 13 other states, creating fear of further state restrictions. This ruling raised concerns from The National Infertility Association and the American Society for Reproductive Medicine that the decision would mean Alabama's bans on abortion prohibit IVF as well, while the University of Alabama at Birmingham health system paused IVF treatments. Eight days later the Alabama legislature voted to protect IVF providers and patients from criminal or civil liability.
The Right to IVF Act,
federal legislation that would have codified a right to fertility
treatments and provided insurance coverage for in vitro fertilisation
treatments, was twice brought to a vote in the Senate in 2024. Both
times it was blocked by Senate Republicans, of whom only Lisa Murkowski and Susan Collins voted to move the bill forward.
Few American courts have addressed the issue of the "property"
status of a frozen embryo. This issue might arise in the context of a
divorce case, in which a court would need to determine which spouse
would be able to decide the disposition of the embryos. It could also
arise in the context of a dispute between a sperm donor and egg donor,
even if they were unmarried. In 2015, an Illinois court held that such
disputes could be decided by reference to any contract between the
parents-to-be. In the absence of a contract, the court would weigh the
relative interests of the parties.
On February 18, 2025, PresidentDonald Trump
signed an executive order which, according to the White House website,
"directs policy recommendations to protect IVF access and aggressively
reduce out-of-pocket and health plan costs for such treatments". Trump has expressed support for IVF programs in the past, aiming to reduce the cost of such procedures.
Artificial insemination, including intracervical insemination and intrauterine insemination of semen. It requires that a woman ovulates,
but is a relatively simple procedure, and can be used in the home for
self-insemination without medical practitioner assistance.
The beneficiaries of artificial insemination are people who desire to
give birth to their own child who may be single, people who are in a lesbian relationship or females who are in a heterosexual relationship but with a male partner who is infertile or who has a physical impairment which prevents full intercourse from taking place.
Ovulation induction
(in the sense of medical treatment aiming for the development of one or
two ovulatory follicles) is an alternative for people with anovulation or oligoovulation, since it is less expensive and more easy to control. It generally involves antiestrogens such as clomifene citrate or letrozole, and is followed by natural or artificial insemination.
Surrogacy,
the process in which a surrogate agrees to bear a child for another
person or persons, who will become the child's parent(s) after birth.
People may seek a surrogacy arrangement when pregnancy is medically
impossible, when pregnancy risks are too dangerous for the intended gestational carrier, or when a single man or a male couple wish to have a child.
Adoption whereby a person assumes the parenting of another, usually a child, from that person's biological or legal parent or parents.
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