Everything Conceivable : How Assisted Reproduction Is Changing Men, Women, and the World

Skyrocketing infertility rates and the accompanying explosion in reproductive technology are revolutionizing the American family and changing the way we think about parenthood, childbirth, and life itself. In this riveting work of investigative reporting, Liza Mundy, an award-winning journalist forThe Washington Post,captures the human narratives, as well as the science, behind what is today a controversial, multibillion-dollar industry, and examines how the huge social experiment that is assisted reproduction is transforming our most basic relationships and even our destiny as a species. Based on in-depth reporting from across the nation and around the world, using riveting anecdotal material from doctors, families, and childrenmany of them now adultsconceived through in vitro fertilization, Mundy looks at the phenomena created by assisted reproduction and their ramifications. Never before in the history of humankind has it been possible for a woman to give birth to an infant who is genetically unrelated to her. Never before has it been possible for a woman to be the genetic parent of children to whom she has not given birth. Never before has the issue of choice had such kaleidoscopic implications. If you support reproductive freedom, does that mean you support everything being offered in the reproductive marketplace? Thawing frozen embryos and letting them expire? Selecting the sex of your baby? Conceiving triplets and "reducing" the pregnancy down to twins?Everything Conceivableexplores the personal impact on individuals using assisted reproduction to conceive, and the moral, ethical, and pragmatic decisions they make on their journey to parenthood. It looks at the vast social consequences: for hospital neonatal wards, for family structure, for schools, for our notion of genetic relatedness and whether it matters, for adoption; for our nation as a whole, and how we think about the earliest human life-forms. The book explores questions of social justice: the ethics of buying or borrowing some part of the reproductive process, as with egg donation and surrogacy. It looks at entirely new family structures being created by families who have conceived using sperm donors, so that children may have half-siblings around the country with whom they are, or are not, in contact. And it looks toward the future, to the impact today's technology may have on coming generations. Fascinating, commanding, keenly observed and reported, rich in personal drama as well as in the science of evolution and reproduction, Liza Mundy'sEverything Conceivableis a groundbreaking consideration of the changes sweeping through our culture and the world.

Chapter One: The New Reproductive Landscape

"Eye Hoop They All Have Babies"

Every industrial convention has its own eccentric flavor, and the 2005 gathering of the American Society for Reproductive Medicine was no exception. That year the annual meeting of American fertility doctors was held in conjunction with the annual meeting of Canadian fertility doctors; the massive conference, which took place in Montreal over five days in October, was attended by emissaries from North America as well as from England, France, Europe, Japan, China, Africa, India, Asia, Israel: anywhere that humans live and wish, as humans usually do, to be fruitful and multiply. So numerous were the babymakers that airport immigration was bogged down and the city's downtown was transformed; the hospitality rooms of the Fairmont Queen Elizabeth were booked for events like "Cocktails with the Middle East Fertility Society." Converging on the downtown convention center, reproductive endocrinologists, embryologists, andrologists, urologists, therapists, and psychologists attended courses in packed seminar rooms. But the real action was in the cavernous exhibition hall, where an array of twenty-first century conception technology was on display, rivaling anything unveiled by the military-industrial complex.

At the entrance to the hall, unavoidable to all who entered, was a booth maintained by Scandinavian Cryobank, a subsidiary of Cryos, one of the world's largest sperm banks. As one might expect, Scandinavian Cryobank specializes in Scandinavian sperm donors: specifically Danish donors enrolled in graduate programs at "major Scandinavian universities," men so mentally and physically superior that they passed "some of the most exacting genetic testing in the industry." Deliberately recalling another era when northern European men inflicted their genes on women of other nations, sales staff were distributing wry little buttons announcing "Congratulations! It's a Viking!" underneath which was a photo of a very blond, very sturdy-looking baby. A banner advertisement noted that the company caters to gay and straight, black and white, male and female. Under the happy we-are-the-world tableau of patients, it added that it serves patients "as energetically as our ancestors once grabbed countries."

Not far away, one of the other principal players in the realm of international genetic redistribution, Los Angeles-based California Cryobank, was advertising its sperm bank by means of an indoor hockey game. It was not clear what hockey was supposed to symbolize. Maybe it was an homage to Canada. Maybe it was supposed to underscore the importance, in this crowd, of being deft and competent enough to shoot a small, frenetically moving object into a stationary target. No matter: setting down the espressos and Belgian chocolates that were being freely dispensed, the medical men and women lined up to whack away at the puck, cheering whenever a colleague, you know, scored.

Nearby, Cryogenic Laboratories was hoping to edge out this competition by offering a service called Lifetime Photos. For a price, clients can obtain photos of a sperm donor, from infancy to adulthood, and thereby see how their child's own appearance might unfold if they select that donor's genetic product to conceive their baby.

The conference was dominated and underwritten by the pharmaceutical industry. Standing everywhere were cheerful representatives from Ferring Pharmaceuticals, Organon USA, Serono Inc., Wyeth Pharmaceuticals, and others, who together do an estimated $3 billion a year business selling the drugs and medical devices that are an integral part of childbearing through assisted reproduction technology (ART). By now, ART comprises a spectrum of procedures of varying levels of sophistication. They include the fertility drugs that control and stimulate ovaries to produce more eggs; artificial insemination, or the injection of washed and treated sperm directly into a woman's cervix or uterus; in vitro fertilization, the more high-tech laboratory procedure in which sperm and egg are removed from the body and brought together in a culture dish; and a host of speedily developing related technologies such as genetic testing of embryos.

There were booths operated by the companies that make products to facilitate these procedures—sometimes all of them at once—there were booths operated by the companies that make media (Life Global: The ART Media Company!) for culturing embryos; flexible catheters for removing eggs and transferring embryos into uteruses; and long, terrifying surgical scissors for—one didn't want to think what. There were companies that make specialized petri dishes (test-tube babies are never made in test tubes); incubators for keeping developing embryos warm; freezers for keeping frozen embryos cold. There were software programs with names like BabySentry, for keeping track of the contents of all those dishes and incubators and avoiding that most dreaded of laboratory mishaps: the wrong embryo going into, oops, the wrong uterus.

There were microscopes with joysticks controlling hollow needles that enable lab technicians to suck a single cell out of a three-day-old, eight-cell human embryo. That cell can then be fixed onto a slide and sent off to a lab so that its chromosomes might be tested for any one of almost a thousand genetic diseases. After the testing is done, embryos that carry a genetic disease can be discarded and only unaffected embryos used, with the hope that these will grow into healthy children. "Cystic Fibrosis Testing: There is a difference!" said the advertisement for one of the labs that weeds out defective embryos. "RMA Genetics: Technology for New Beginnings, Offering Power through Knowledge!" said another.

Nearby was a booth run by the Genetics and IVF Institute, a Fairfax, Virginia-based fertility clinic that was distributing pink or blue M&Ms, scooped into urine specimen cups, as a way of advertising a patented sperm-sorting technique called Microsort(r), which offers parents a way to select the sex of their baby.

The hall was an enormous rectangle. The biggest and most profitable entities were located prominently at the front, where they lured passersby with everything from sperm-shaped pens to ice cream pellets (a favorite way to advertise any technology involving cryopreservation). But equally interesting were the smaller outfits located toward the back of the hall, jostling to attract browsers to their bunting-covered folding tables, and often not prosperous enough to be offering freebies. There were support groups for women with endometriosis and polycystic ovarian syndrome. There were general advocacy groups for the infertile. There were cutting-edge groups dedicated to helping women find ways to delay childbearing and still bear children. One of these is Fertile Hope, run by a cancer survivor named Lindsay Nohr Beck, whose mission is to help cancer patients preserve their fertility during treatment. One of Beck's mentors is a businesswoman named Christy Jones, a former dot-commer who now runs a for-profit company called Extend Fertility, which offers career women the chance to freeze their eggs with the hope of becoming pregnant later, when relationships and/or work schedules permit.

Since egg freezing is in its infancy, however, what the modern woman often needs to conceive—if things have been left too long—are the eggs of a younger woman. Snuggled against the back wall were egg-donation agencies, none of them as large or gleaming as the front-of-the-room sperm banks, since it is not—yet—possible to stockpile human eggs in the mass-market, quasi-industrial way in which human sperm can be stored and shipped. Egg-donation agencies are a sort of cross between a real estate brokerage and a dating service: for a fee, they connect infertile patients with live, real-time egg donors, and manage what is, legally, a property transfer. Egg donation is an invasive, time-consuming medical procedure, requiring physical risk on the donor's part. Which is not to say you can't build up a decent inventory: all of the banks were offering databases of winsome yet wholesome, sexy yet motherly young women, with profiles that detailed their height, weight, SAT scores, and lifetime goals. You could see how hard the agencies had to work to recruit them. One booth belonged to Global ART, an international outfit with a branch in Richmond, Virginia, that procures egg donors from Romania. Circumventing those aspects of reproductive technology (like egg freezing) that do not work reliably yet, and taking advantage of those (like sperm freezing) that do, Global ART rather ingeniously conducts transactions by shipping a prospective father's frozen sperm to the lab in Bucharest, where it is thawed and used to fertilize the eggs of a Romanian donor. The resulting human embryos—half-American, half-Romanian—are then frozen and shipped back to the United States, where they are thawed and transferred into the prospective American mother, all for much, much cheaper than can be done with a U.S. donor, in part because Romanian egg donors are paid so much less than U.S. donors are. And you don't even need a passport for the embryos!

Also there was an L.A.-based agency, Fertility Futures International, which does a brisk trade in providing egg donors to gay men, another rapidly growing customer base. Surrogacy agencies were also there, catering to straight and gay alike.

There were also, of course, lawyers. Not so long ago, running a "family-building" legal practice meant handling adoptions, foreign and domestic. Increasingly, attorneys are called upon to negotiate scenarios that involve a transfer of sperm or egg—part of the babymaking process—rather than the entire baby. "Half adoptions" you could call them: adoption of half the child's genetic makeup.

And then were the companies that have evolved to deal with the problematic presence of the frozen embryo. Though it's still pretty hard to freeze and successfully thaw human eggs, it is strangely easy to freeze and thaw human embryos. Embryos don't get freezer burn. Unlike, say, hamburgers, human embryos can be frozen, and thawed, and frozen, and thawed again, and used. There are about a half-million frozen embryos in storage in the United States alone. These embryos present terrible moral difficulties for patients, and for doctors, who for fear of lawsuits are reluctant to destroy or thaw frozen embryos, even when patients divorce or move or disappear or otherwise fail to pay "storage fees." Enter ReproTech: standing by one display was a man named Russell Bierbaum, who operates a company that for a fee will take over a practice's frozen embryos, and also is willing, collection-agency style, to track down delinquent patients and persuade them to make what has come to be known as the "disposition decision."

"There are ways of getting people to respond," said the affable Bierbaum, who declined, for proprietary reasons, to reveal how he locates patients and encourages them to decide what to do with their frozen embryos. He did not seem to recognize the menacing significance of any phrase beginning "There are ways." Keeping things upbeat, Bierbaum would say only that "the Internet is a wonderful tool for finding people." Also nearby was the National Embryo Donation Center, one of a number of brokerages that help one couple "donate" surplus human embryos to another. Really good quality embryo batches are sometimes passed among three or four families before they get all used up, or born, or both.

Standing in yet another cubicle was—could it be true?—Professor Robert Edwards, the Bob Edwards, the British scientist who with his partner, the gynecological surgeon Patrick Steptoe, enabled the birth of the first IVF child in Oldham, England, in 1978. The very man who set this elaborate reproductive machinery into motion. Edwards was wearing a tan suit jacket, pale gray slacks that did not match the coat, and beige slip-on shoes. He was grayer but otherwise little changed from the photos that show him and Steptoe celebrating the birth of the infant Louise Joy Brown almost three decades ago. There was the same voluminous, side-parted haircut, the same big rectangular glasses, the same stout and genial look, more like a satisfied fly fisherman, or a Rotarian, than the scientific visionary he is.

Robert Edwards, who is probably the most knowledgeable embryologist in the world, now edits a Web publication called Reproductive BioMedicine Online, a British-based journal that publishes scientific papers and essays on the many ethical issues raised by the field he helped create. He was standing in the RBM Online cubicle for the purpose of saying hello to a long line of visitors, and, when possible, to sign them up as subscribers. Edwards was also, it emerged, brooding. I stood in line with the vague hope of asking whether back in 1978 he had had any idea of the array of services and situations that would arise from his work. I knew the answer in part: Edwards has a reputation for having been remarkably prescient. He had an early fascination with genetics and is widely credited with having foreseen that science someday would be able not only to produce embryos but to diagnose their genetic makeup before placing them in the womb.

Still, it would be interesting to hear what the man himself had to say.

As it turned out, the man had a lot to say and not much time to say it: Edwards, who was raised in the north of England, speaks in a wonderfully non-establishment, workingman's burr. He had been standing in the RBM Online cubicle for two days and needed to leave to catch a plane. An assistant was meaningfully clasping a rolling suitcase. Nevertheless, almost before I had finished my question Edwards began by commenting on a speech given by a prominent stem-cell scientist. "Did you hear the talk this morning?" he wanted to know, smoldering over an assertion that embryonic stem-cell research—one of the most promising, and controversial, realms of modern medicine—was an unforeseen consequence of IVF.

Unforeseen? Edwards wanted to correct the record here. Well before Louise Brown was perking along in her dish, he had indeed envisioned that the cells of the human embryo might be coaxed into making a medical therapy. And so many other things! Babies, period! Millions of babies! "Four percent of the babies in Finland are from IVF!" pointed out Edwards with a kind of defensive glee. It seemed that he, Bob Edwards, had seen coming much of what surrounded us, and found it, for the most part, good. Not just babies but delighted parents, of all stripes and varieties and ages. "Eye hoop they all have babies!" Edwards called out as he was being pulled away by his assistant, leaving behind a line of disappointed pilgrims who had hoped to shake his hand. "What coood be better than a baby?"

"Cancer Patients Aren't as Motivated as Infertility Patients"

What indeed? Through the displays wandered doctors, male and female, young and old, many of whom find it hard to believe that Steptoe and Edwards never received a Nobel Prize for what they did. What they did, after all, was conceive human life—human life—outside the womb. What they did was create a situation in which millions of human beings would be born who otherwise never would have existed. What they did was find the first effective treatment for infertility, an ancient affliction as old as humankind itself, and for most of history one of the most dreaded and untreatable; if you don't believe that, why are fertility totems found among the earliest human artifacts? According to more than one doctor, what Steptoe and Edwards accomplished in 1978 was one of the medical breakthroughs of the twentieth century, ranking with the discovery of penicillin and Christiaan Barnard's first human heart transplant.

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Excerpted from Everything Conceivable: How Assisted Reproduction Is Changing Men, Women, and the World by Liza Mundy
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