Changing Fertility: Social, Demographic and Ethical Consequences of Assisted Conception Technologies
Nitzan Peri-Rotem, June '16
The Changing Fertility Forum, an event jointly organized by ReproSoc and the Philomathia Programme was held this spring at the University of Cambridge. The forum has set the scene for an exploration of recent changes in fertility patterns in industrialized societies and the way these are related to the widening use of assisted reproductive technologies (ART). This international event has brought together health professionals, members of NGOs and academics from various disciplines, including history, sociology, anthropology, demography, public health, law and philosophy. This has yield a truly unique conversation between different parties that seldom have the opportunity to exchange ideas, a conversation that enabled us to put together some of the pieces of the changing fertility puzzle.
The two presentations in the first session provided some insights about the different aspects of ART use, from the initial causes of infertility to demographic outcomes of assisted reproduction. Lone Schmidt, an Associate Professor at the University of Copenhagen, discussed this issue from a public health perspective, addressing questions such as how infertility is defined? How widespread is it among men, women and couples? And what are the causes and risk factors of infertility? Although infertility is considered a disease by the World Health Organization (WHO), there are no national preventative strategies to deal with infertility, she said. Moreover, if regarded as a disease, infertility is by far the most prevalent chronic disease among people in the age group of 25-44 in Denmark, as well as in other developed countries. Additionally, while there is an almost exclusive focus on women when addressing issues of reproduction, nearly 40 percent of cases of infertility are male-dependent, as a result of poor semen quality. This is similar to the share of female-dependent infertility, while other cases are either couple-dependent or due to unknown causes. Schmidt noted that not only there is no strategic policy of prevention of infertility, there is substantial variation in access to ART due to financial barriers, even in a country with a relatively generous provision of assisted fertility like Denmark. Finally, even the best assisted reproduction technologies are not sufficient to overcome reduced fertility as a result of advanced female age. Therefore, access to assisted fertility should go hand in hand with prevention.
In order to develop strategies of prevention of infertility, it is important to understand why do people delay childbearing in the first place? Tomas Sobotka, a Senior Researcher from the Vienna Institute of Demography, has described the different social and economic reasons for fertility postponement in developed countries, including prolonged education, increased economic insecurity and less stable relationships. Thus, while it is biologically optimal for women to start a family when they are in their early or mid-20s, this does not always match their social circumstances. Moreover, previous studies have shown that fertility intentions have not changed much over the past decades, as the two-child family norm remains strong. What has changed though, is the proportion of 35 year old women without children who intend to have children in the future. Up to the 1990s, there has been a decline in the proportion of births to women aged 35 or above, which was mainly due to the decline in family size. However, since then, this proportion has increased back again as a result of births postponement.
What is therefore the contribution of ART to fertility levels? Overall, it is quite low according to Sobotka. Nevertheless, the level of impact varies considerably across countries and age groups; in Europe, between 2 and 3 percent of births occur after ART use and in countries with higher public funding of ART the share of birth following the use of these techniques may reach 5-6 percent. On the other hand, in the United States, where there is no public funding of fertility treatments, just over 1% of births occurred following use of ART. It is also important to bear in mind that the net effect of ART is somewhat lower, since some of these births would have occurred naturally. Nonetheless, ART has a much greater contribution to birth rates of women aged 40 and above, as a tenth of all births and one fifth of first births to women at that age group occur following the use of assisted reproduction. Another major impact is the increase in the proportion of twin births and triplets, since the likelihood of a multiple birth rises significantly following the use of ART, while also posing potential health risks to the mother and babies.
These presentations raise many questions regarding, among other things, the slippery concept of infertility, the extent to which the timing of childbirth is a matter of choice and what should be the appropriate policy response to these issues?
Some of the forum participants have questioned the WHO’s definition of infertility, which applies to couples who have been trying to conceive for one year or more, as some of these couples may still manage to conceive naturally after one year. At the same time, the definition of fertility postponement may be shaped by different social norms about the right time to conceive. Even the biological age when it becomes “too late” for childbearing is vague according to Schmidt. This is because on average, a woman cannot have children around 10 years prior to menopause, but we don’t know when exactly that happens.
The questions of reproductive choice and control over our reproduction are prominent to the discussion of ART and infertility. Peter Braude, an Emeritus Professor of Obstetrics and Gynaecology at King’s College London suggested that women potentially have different choices in relation to the timing of childbearing and can also choose to put childbearing on hold by using egg freezing. On the other hand, as other participants have commented, these choices are highly constrained. According to Zeynep Gürtin, a Research Associate in ReproSoc, one can think of ART as technological fixes representing increased reproductive choice and reproductive control. However, within a society in which women (and many men) still experience insufficient control over the environments within which they enact their reproductive choices (e.g. employment, childcare possibilities etc.), the concept of choice obfuscates what is going on, and places accountability squarely on the shoulders of individual women for delaying childbearing.
Similar arguments were made as part of the discussion over prevention of infertility and what would be the appropriate format of such prevention programmes. Tomas Sobotka has expressed his doubts about the utility of fertility education that warns young people about the risks of delayed fertility, since people avoid early childbearing for very concrete and rational reasons (e.g. not finding a partner, economic instability etc.). In addition, Wendy Sigle, a Professor of Gender and Family Studies at the London School of Economics and Political Sciences, maintained that it is mainly highly educated women who delay childbearing and that prevention of age related infertility must take into account the necessary institutional conditions to support early family formation.
In the public lecture following the panel discussion, Professor Alison Bashford provided eye-opening insights into the historical and geopolitical context of the debate over human reproduction. In her talk, entitled “Julian Huxley’s Reproductive Futures”, Bashford described the meeting between Julian Huxley, an evolutionary biologist and a keen supporter of eugenics, with other biologists and reproductive physiologists, including Crick, Pincus and Muller in a conference on “Man and his Future” in London, 1963. The concepts and terminology used by Julian Huxley and his contemporaries to talk about reproduction had a very different meaning from current ideas about this issue. Whereas the present debate over assisted reproductive technologies involves the right to family formation and equal access to fertility treatment, Huxley was mainly interested in these technologies as means of enhancing human potential. Back in the 1950s, Huxley has coined the term ‘transhumanism’, envisioning a utopian future without boundaries between humans and ‘super-humans’ and seeing embryology and reproduction technologies as a promising route for achieving this purpose. Contraception and assisted fertility were tied together in the eyes of Huxley and his colleagues in striving toward ‘fulfilment’. However, their notion of fulfilment was about improving mankind by correcting and perfecting biology, while the idea of self-realization through parenthood was completely absent from their conversations.
In this context, it is interesting to reflect on the social and political settings of the current forum and the ideas and perspectives that were at the focus of the discussions there. The forum has provided a stage to different approaches to infertility and insights on the relative contribution of ART in overcoming fertility problems. One of the main propositions stressed in the forum was that infertility should be addressed from a more structural and holistic viewpoint, taking into account the process in which reproductive decisions are made and the factors that affect these decisions. Therefore, delayed childbearing should be understood not only as a private matter, but as a socially and economically dependent choice, which requires change at the institutional level.