IVF and Assisted Reproduction: A Global History [1st ed.] 9789811578946, 9789811578953

Table of contents :
Front Matter ....Pages i-vii
IVF and Assisted Reproduction: Global Visions, Local Stories (Sarah Ferber, Nicola J. Marks, Vera Mackie)....Pages 1-26
Towards the Two 1978 Births (Sarah Ferber, Nicola J. Marks, Vera Mackie)....Pages 27-70
The Foundations of Global Assisted Reproduction (Sarah Ferber, Nicola J. Marks, Vera Mackie)....Pages 71-110
Regulation and Risk (Sarah Ferber, Nicola J. Marks, Vera Mackie)....Pages 111-158
Oocytes, Surrogacy and Cross-Border Reproduction (Sarah Ferber, Nicola J. Marks, Vera Mackie)....Pages 159-200
Testing Boundaries, Finding Limits (Sarah Ferber, Nicola J. Marks, Vera Mackie)....Pages 201-237
Thresholds of the Future: New Directions in Assisted Reproduction (Sarah Ferber, Nicola J. Marks, Vera Mackie)....Pages 239-273
Back Matter ....Pages 275-361

Citation preview

IVF and Assisted Reproduction A Global History

Sarah Ferber · Nicola J. Marks · Vera Mackie

IVF and Assisted Reproduction

Sarah Ferber • Nicola J. Marks Vera Mackie

IVF and Assisted Reproduction A Global History

Sarah Ferber University of Wollongong Wollongong, NSW, Australia

Nicola J. Marks University of Wollongong Wollongong, NSW, Australia

Vera Mackie University of Wollongong Wollongong, NSW, Australia

ISBN 978-981-15-7894-6    ISBN 978-981-15-7895-3 (eBook) https://doi.org/10.1007/978-981-15-7895-3 © The Editor(s) (if applicable) and The Author(s) 2020 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and ­transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Cover illustration: Workers operate on “The Miraculous Journey”, an art installation at Sidra Medical & Research Centre in Qatar © Damien Hirst and Science Ltd. All rights reserved, Copyright Agency & DACS 2019/DACS. Copyright Agency, 2020. Photo by STRINGER / AFP This Palgrave Macmillan imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Acknowledgements

The research for this monograph was supported by an Australian Research Council Discovery Project grant (DP150101081). We thank the Victorian Assisted Reproductive Treatment Authority (VARTA) for access to its archives and for the advice of staff. We acknowledge the Comité consultatif national d’éthique pour les sciences de la vie et de la santé for their welcome during a trip to Paris. Glen Menzies of Copyright Agency, Sydney, provided generous assistance in securing our use of the cover image. Our colleagues at the University of Wollongong library have provided continued support for the requirements of the project. We are very grateful for the advice and assistance we received from Rebecca Albury, Raphaël Benhamou, Megan Brayshaw, Leigh Dale, Simon Flanagan, Samantha Hollingworth, Anna Kotarba-Morley, Robyn Morris, Ian Stewart and Chris Tiffin. Special thanks are due to Carol Hetherington. We extend our thanks to the interviewees who generously gave us their time and insights. All interpretations of the material, along with any errors, are the responsibility of the authors. Finally, we wish to express our gratitude to Joshua Pitt at Palgrave for his unwavering support throughout the process.

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Contents

1 IVF and Assisted Reproduction: Global Visions, Local Stories  1 2 Towards the Two 1978 Births 27 3 The Foundations of Global Assisted Reproduction 71 4 Regulation and Risk111 5 Oocytes, Surrogacy and Cross-Border Reproduction159 6 Testing Boundaries, Finding Limits201 7 Thresholds of the Future: New Directions in Assisted Reproduction239 Bibliography275 Index341

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In 1978, two children came into the world as a result of laboratory fertilisation techniques (in vitro fertilisation, or IVF). Louise Joy Brown was born in the UK on 25 July, and Kanupriya Agarwal, or ‘Baby Durga’, was born in India on 3 October.1 In Oldham, near Manchester, Patrick Steptoe, an obstetrician and gynaecologist, and Robert Edwards, a reproductive physiologist, led the clinical and scientific work that facilitated Lesley and John Brown’s attempt to have a child. Steptoe and Edwards achieved instant international fame; Jean Purdy, a nurse and scientist, is now acknowledged as having been a crucial member of the team.2 In Kolkata, the key figure was Subhas Mukerji, a clinician, reproductive physiologist and endocrinologist. With colleagues Saroj Bhattacharya, an obstetrician and gynaecologist, Sunit Mukherjee, a cryobiologist, and two nurses unnamed in reports, he used laboratory and clinical techniques quite different from those of Steptoe, Edwards and Purdy.3 Remarkably, after decades of research and experimentation, two disparate sets of clinical and laboratory techniques in the UK and India succeeded within a few months of each other in producing a living child. In ‘a race in two different corners of the world’, the British team relied on Lesley Brown’s natural ovulatory cycle, using just one egg for fertilisation; © The Author(s) 2020 S. Ferber et al., IVF and Assisted Reproduction, https://doi.org/10.1007/978-981-15-7895-3_1

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Mukerji’s used fertility drugs to increase the number of ova available for fertilisation.4 Where Patrick Steptoe used the surgical technique of laparoscopy to reach the sole egg, the Kolkata team used a transvaginal technique (colpotomy) to access multiple ova for laboratory fertilisation. The British team used a fresh embryo; Mukerji froze the embryos for fifty-­ three days prior to implanting three of them.5 These two teams came in ahead of other scientist-clinician groups in the United States and Australia, who had also been trying for years to facilitate a human IVF birth.6 Reports of both births went rapidly around the world, giving rise to excitement, apprehension and even, to varying degrees, scepticism about the authenticity of the claims. Colleagues peppered Steptoe and Edwards with requests for more clinical details before they would credit them with having achieved an IVF birth, some still expressing doubt years after the fact.7 Tragically, institutional scepticism led Subhas Mukerji to take his own life in 1981, after three years in which he had been unable to convince medical authorities of his claims, now vindicated, to have achieved IVF in India more or less concurrently with the British team.8 Today an estimated ten million people have been born following the use of IVF and assisted reproduction (AR).9 More than forty years after the first two births, providers have built on, modified or set aside the original successful techniques, creating new kinds of assisted reproductive treatment for an expanded range of clinical indications and fertility goals. As at 2018, the International Federation of Fertility Societies (IFFS) estimated that AR was available in 132 countries.10 In most countries with established programs, the proportion of AR births annually is around 1–4% of the total number of births.11 In Israel and Japan, the figure is closer to 5%, while in Denmark reports suggest around 10% of births result from some form of assisted reproduction.12 A significant proportion of AR offspring, perhaps as many as 50%, belong to sets of twins, triplets or even higher-order multiple births.13 An individual or a couple who want to obtain a child through AR can now create an embryo using either their own gametes (oocytes, ova or, colloquially, eggs, and sperm), or those of a donor provider, while clinics can source gametes and embryos from across the world.14 Someone about to undergo a major medical treatment or a gender transition can have

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gametes frozen in anticipation of later use, while women hoping to use their own eggs to become pregnant in the future can have oocytes removed, frozen and stored. Techniques of preimplantation genetic testing (PGT) of embryos extend AR to cases in which a potential child is at risk from a genetic or chromosomal defect.15 If people who seek a child through AR are ineligible to use a technique for legal reasons, or, if they find their local clinics in some way unsuitable, they might travel across borders for treatment. Regulatory differences resulting from ‘laws and religious bans [and] denial of treatment to certain categories of persons’, in particular, have been a major reason for people to opt for reproductive travel; cost and quality factors, as well as a desire for privacy, are among the others.16 According to the European Society of Human Reproduction and Embryology (ESHRE), one in six male-female couples will ‘experience some form of infertility problem at least once during their reproductive lifetime’.17 Infertility can be the result of factors in the female, the male or both partners, while 10–20% of cases are unexplained, termed ‘idiopathic infertility’.18 These statistics relate to heterosexual couples, but infertility is now understood more broadly as the unmet desire to parent a child: sexual preference, marital status or an event such as early bereavement can lead people to seek AR. Several subcategories of infertility have at different times been identified, including primary infertility—the physical inability to establish a first clinical pregnancy—and secondary infertility, meaning the physical inability to establish a second or subsequent pregnancy.19 Subfertility, meaning a ‘reduced fertility with a prolonged time of unwanted non-conception’, is now covered by the term ‘infertility’.20 ‘Social infertility’, arising principally from social factors, such as single status or a same-sex partnership, is a more contested but still widely used term.21 Assisted reproduction is expensive and ‘more common in the rich world’.22 Denmark, for example, uses AR at twenty-eight times the rate per million of population than does India.23 The highest prevalence of infertility,  however, is to be found  in South Asia, sub-Saharan Africa, North Africa, the Middle East, Central and Eastern Europe, and Central Asia.24 In a place such as the United States, with high availability of AR treatment, ‘fertility financing’ schemes exist for the many clients without

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insurance support who are prepared to take out a debt to obtain treatment.25 A constellation of global fertility treatment ‘hotspots’ reflects regulatory diversity, geographical suitability and recognised expertise. At present, Belgium is the go-to nation for the increasingly sought-after procedure of intracytoplasmic sperm injection (ICSI), a technique that has outstripped the use of IVF, originally being used for cases of male infertility but now often  used instead of IVF. Spain and Romania are major sites for egg provision, and Denmark for sperm.26 The volatile surrogacy industry is constantly adapting to regulatory changes: India, Thailand, the United Arab Emirates (Dubai) and Mexico have been major fertility treatment destinations at different stages, but new laws have reduced treatment availability, notably for international visitors. In several well-publicised cases, women providing children through surrogacy, the children themselves and fertility clients have faced social dislocation when new laws have come into being.27 As some markets have shut down, they have left a vacuum that other markets try to fill. There are around 6000 AR clinics currently in operation worldwide. India has the largest number, with an estimated 1500, but China, with fewer officially registered clinics, may provide more treatments than any other country.28 Israel has the highest number of clinics per head of population.29 In Japan, where there are 574 clinics, subsidies to AR patients reflect government fears about a declining national birth rate.30 High-end investment, high-tech products and international fertility companies are now standard for AR.31 International investment advisors expect that the global fertility services market will grow beyond US$25 billion by 2026.32 (Such market estimates may alter due to the impact of the COVID-19 pandemic, which was in its early months as this book went to press.) The global reproductive landscape, or ‘reproscape’, as it is sometimes called, is thus a very different place from the British and Indian ‘cottage industries’ of 1978.33 This book tells the story of how AR has linked together the worlds of human reproduction, medicine and politics.34 As a synoptic contribution to what social scientists Sarah Franklin and Marcia Inhorn refer to as the ‘new interdisciplinary field of reproductive studies’, it explores the

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multiple cultural components that go together to create the current global reproscape.35 It builds on the work of numerous scholars, who have over decades painstakingly interpreted the significance of AR technologies for users, social groups and nations, and established the importance of media and the power of narrative in this history. Their work—in fields such as science and technology studies (STS), anthropology, literature, sociology, history, and studies of media, gender, sexuality and family—is now being enhanced by interdisciplinary collaborations with AR clinicians and scientists, and provides many of the interpretive models and much of the factual detail presented here.36 Each country in which AR is practised would merit a full-length history and these national histories are now being written.37 Standard medical histories most often identify the discoveries and breakthroughs that led a field up to a certain point in history. Contrastingly, our focus is the social contexts of new developments, and the impact of AR on individuals, groups and nations.38 The book’s findings are based on a wide range of sources, including original interviews with key AR figures, archival materials, extensive mainstream media reportage and fertility blogs, as well as the relevant specialist literatures in medicine and science.39

Chapter Outline and Historical Overview Chapter 2 shows how clinicians and scientists developed IVF for human reproduction in the lead-up to 1978.  Chapter 3 examines the ways in which providers then worked to create the global phenomenon of AR today. Chapters 4 and 5 consider the regulatory restrictions that came into being starting in the 1980s and their effects on the international fertility trade, particularly the market for oocytes and surrogacy. Chapter 6 explores the implications of AR for people’s experience of infertility, and the cultural issues that have arisen as new patient groups have sought fertility treatment. Chapter 7 outlines some of the new directions of AR technologies, showing where they are now and where they might be in

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future, with a final reflection on the period from 1978 to 2020. What follows here is a brief overview of the history of AR. Cooperation and exchange across medical and scientific disciplines were from the mid-twentieth century crucial to the research that led to the first IVF births. Specialists in clinical medicine, such as obstetrics and gynaecology, and the new field of endocrinology (the study of hormones) worked together with researchers in scientific fields such as embryology and cryobiology (the study of freezing of biological material). Breakthroughs were pivotal, but the role of the imagination, informed in part by science fiction, also played a part in the ways the science developed. Aldous Huxley’s 1932 Brave New World startled millions of readers with nonchalant descriptions of babies hatched in factories, programmed to fulfil specific functions in a global totalitarian regime, all in a world where sex was divorced from reproduction. Yet some scientists and clinicians saw social value in aspects of reproductive engineering, as a means for ‘the improvement of the human species, and finally the emancipation of mankind’.40 From the 1930s, on the clinical front, women undergoing surgical interventions, such as hysterectomy, as well as those experiencing difficulty having children, showed a willingness to provide reproductive material or undergo procedures to facilitate research. Often with no clinical benefit to themselves, they helped to build a knowledge base for IVF as a fertility treatment.41 Making IVF possible was also contingent on propitious funding and regulatory environments. The initial funding for IVF was for projects focused on population control, a preoccupation of wealthy countries in the mid-twentieth century, which somewhat ironically yielded new knowledge for fertility research. A relatively unformed regulatory environment, ill-equipped to contemplate the specific issues posed by AR, proved to be another enabling factor. At every point, from the steps which led to the first creation of an embryo in vitro in 1969 to the first births in 1978, the creation of children through IVF and gaining recognition for doing so were never assured: they came about through a mix of intention and opportunity. Beginning in the early 1980s, fertility treatment providers engaged in a process of expansion, to build on, accelerate and redirect existing treatments. They embedded a new industry within or alongside established

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institutions: they set up new associations and journals and made crucial links with the pharmaceutical and medical devices industries. Successful clinicians and scientists provided training to international colleagues, in person and through textbooks, and new programs in hospitals and private clinics brought in established providers to teach them. In some cases, local initiatives came to reflect not just the goals of providers, but the reproductive agendas of nations. Making AR possible in more places required new money. Funds came from sources such as private donors, clients, venture capital, and industry, as well as from public and private health insurance schemes. Assisted reproduction providers knew a positive public profile was essential. Without favourable reportage in the mainstream media, they faced an uphill battle to convince their colleagues, and religious and government authorities, of the value of their work. Mainstream media, including active public relations efforts by providers, celebrated milestones measured in years since 1978 or in numbers of live births, anticipated breakthroughs and highlighted increased success rates. Increasingly, fertility brokers such as surrogacy agencies mediated relationships between client and provider, even across national borders. In the 1990s, the internet began to turn most clinics into international providers, with their own online presence sitting alongside the emerging fertility blogs of their clients. As the industry consolidated, a new politics emerged around AR, taking its cue in many instances from conservative religion, patients’ and consumers’ rights, and diverse strands of feminism. Assisted reproduction became the subject of laws and religious decrees, amid significant conflict about how and why, if at all, AR technologies should be regulated. New techniques focused the sights of theological activists on embryo research and a perceived threat AR might pose to the institutions of marriage and family; for its part, the AR industry sought the autonomy offered by peer regulation. Debates about these issues preoccupied legislatures from the 1970s and continue to the present day. Some AR clinicians and scientists voiced concern about medical risk to patients and future children, as well as warning of the risks to the reputation of medicine and the industry overall from over-commercialisation and unwarranted optimism about success rates. Now, discussions of medical and social risk are gaining in

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prominence. Reducing the risk posed by multiple births to mother and child is a new focus of both medical and state regulation, while many fertility providers are paying greater attention to avoidance of ovarian hyperstimulation syndrome (OHSS), ‘the most common complication related to ART’, brought about by hormonal stimulation to increase egg numbers.42 Success rates, too, have come under greater scrutiny. Regulators, along with many of the more reputation-minded clinicians, have tried repeatedly to enforce stricter criteria for claims of success, in the interests of transparency and patient welfare. And people born as a result of donor conception are actively seeking change to laws about access to donor identities. The fertility globe now shifts constantly on its regulatory axis, as a consequence of new and changing laws. For example, state regulation of AR injected a new dynamic into the gamete and surrogacy markets. Today, local legal systems shape the options of clients, of fertility service providers and of people providing reproductive material or children through surrogacy. It is now possible to seek legal, cheaper, more private or more varied treatments beyond borders, and to compare options with the assistance of online consumer communities and fertility brokers. As Melinda Cooper and Catherine Waldby express it, the ‘patchwork nature of national and provincial regulation creates distinctive geographies of permission and prohibition, so that intending parents may elude national regulatory restrictions and travel to a jurisdiction where oocyte or surrogacy markets are permitted’.43 The story of global AR is for that reason not only one of expansion: it is also one of contraction and redirection, often with profound social consequences. The present reproductive bio-­ economy, particularly in relation to international surrogacy and egg selling, has ‘stratified’ reproduction, making it possible to both ‘generate and exploit global inequalities’.44 Cross-border gamete selling, in particular oocyte sale, and surrogacy, for both providers and prospective parents, raises major concerns in relation to competing notions of ‘rights’ and ‘choice’, in feminist and legal analyses in particular. Groups previously outside the reproductive world can now see themselves as having a right to pursue the same reproductive freedoms as others. Assisted reproduction has expanded former boundaries of family-building, for example, in provision of fertility treatment to

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same-­sex couples and single people. It has challenged conventional views of gender roles in reproduction, with increased recognition of male infertility and a concomitant rise in the use of ICSI. Women using AR beyond the former limits of reproductive age, and families seeking to use the gametes of deceased relatives to procreate, have tested prior assumptions about where the limits to human reproduction should lie. A recently revised industry glossary of infertility has  extended its definition  to include same-sex couples and single potential parents.45 Providers disagree, however, on how far patients’ wishes should be accommodated and, especially, on whether offering so-called add-ons, or adjuvant treatments, serves commercial gain more than medical need.46 Twenty-first-century AR is characterised by intensifying commercial alignments, continued laboratory and clinical research—including into controversial embryo ‘gene editing’—as well as the development of cheaper techniques to expand AR into poorer countries and lower-income areas of affluent countries. As it has done since its early days, the future of AR relies on expansion and diversification at laboratory and geographical levels, and on the maintenance of a positive public profile.

Language, Narrative and Media Now in its fifth decade, the practice of AR continues to revolve around what Aditya Bharadwaj refers to as the ‘media/medicine’ nexus.47 Language, narrative and media create the way people see the reproductive world and their place in it, positive portrayals of AR positioning readers and listeners as having a stake in the success of research and treatment. The ‘reproductive imaginary’ takes its form through the use of particular words, metaphors and stories. Since the 1970s, many of these have become normalised through the mainstream media. Fertility news has virtually been a sub-genre of journalism, as reporters and editors have created a recognisable vocabulary through which consumers read, hear and make sense of their own experiences using the stories of others.48 Headlines about AR that refer to ‘miracle’ births or the invocation of the ‘brave new world’ are now so routine as to be shorthand for what to expect in a news story. The miracle birth will be one couple’s quest for a

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child through AR, often found in the ‘women’s’ or lifestyle pages, while ‘brave new world’ implies a faceless big science, beyond the control of individuals, and potentially in the wrong hands. ‘Brave new world’ has been used at least 670 times in English-­language print media reports using the term ‘IVF’; ‘playing God’ features 757 times; ‘designer babies’ 7133 times.49 Rather than taking seriously the standard tabloid provocation ‘Are these people playing God?’, the question might be better put this way: why does it make sense to talk about ‘playing God’? Indeed: on what basis is the ‘miracle’ of assisted reproduction measurably more miraculous than that of natural birth?50 A habit of characterising early AR providers as ‘pioneers’ similarly distracts from seeing them foremost as professionals—talented and dedicated ones, to be sure—pursuing their goals, going to work every day, adjusting and improving existing technologies. Seen in these ways, AR is actually part of a quite mundane history: a story of private and professional life from the late twentieth century. Many of the debates that have emerged since 1978 have explicitly concerned the question of what word to use: does the fusion of an egg and sperm create an embryo? A fertilised egg? A pre-embryo? A ‘pre-syngamy’ embryo?51 Such distinctions might seem arcane, but these questions were central to the anti-abortion-linked politics of early IVF. As specific terms gain traction as the natural way to speak, they authorise a specific understanding. Assisted reproduction has many definitions, but this book uses the wide ranging ‘application of laboratory or clinical technology to gametes and/or embryos for the purposes of reproduction’.52 The term ‘IVF’ is often used as a shorthand for several kinds of assisted reproduction, and it will sometimes be used that way here. At times in the history of AR, hyperbole has made complex issues opaque, not least because some terms have become so conventional as to seem the natural way to speak of AR. The word ‘revolutionary’, for example, has been used so often to describe AR that even twenty years ago reports referred to the IVF technique as ‘once-revolutionary’.53 The ‘revolution’ can be inspected through an historical lens, to identify its component parts and to understand the individuals, professions, types of media, local cultures and institutions that led new fertility technologies to create a distinctive global marketplace. In what precise ways might IVF have

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been revolutionary, and for whom? If we consider, for example, that many new technologies to some extent defy the ‘laws of nature’, air travel being the most obvious, perhaps the fact that one stage of human reproduction has been replicated outside the body might not be such a dramatic development.54 For people who access AR, if the means seem revolutionary, the ends are likely to be the opposite, offering a stake in normality and a chance to blend in; to set the world to rights, not upend it. From the early 1980s, surveys in Australia, for example, showed that the public readily accepted IVF technology as a new way to create children.55

The Power of Analogy History, both as it is made and as it is recounted, is among other things the search for new stories that accommodate innovation by making it recognisable according to older stories. As Marilyn Strathern has observed: ‘There is no vacuum in people’s practices and habits of thought; there are only existing practices and habits of thought on which the new will work’.56 A crossroads between continuity and change is often marked by choices of analogy, and a struggle over analogies has been part of the politics of AR.57 Were the changes that might come wholesale departures from precedent, or were they assimilated comfortably into reproductive traditions? Deciding one way or the other was paramount to the politics of early AR. As early as 1970, when Robert Edwards’ Cambridge team had not long before succeeded in creating a human embryo in vitro for the first time, the medical journal Lancet sought to limit reaction to the news by claiming that the birth of children following IVF would be continuous with, not a departure from, any other kind of fertility treatment.58 It argued: The treatment of infertility by in-vitro fertilisation of the ovum and implantation of the fertilised egg in the patient’s uterus is not so new or so alarming a prospect as recent utterances and criticisms imply. … Surely this treatment would simply be an extension of earlier work in an area where other aids to conception have long been accepted but have not always been

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successful. Forebodings about ‘test-tube babies’ and ‘genetic engineering’ are unjustified.59

In this way, Lancet staked a claim for IVF as medicine as usual. There are human consequences to the choice of analogy, and advocacy is built around such usages. Depicting surrogacy as directly analogous to a form of traditional baby-giving, found in some past and present societies and purportedly a norm from Old Testament times, has, for example, become a standard platform for advocates of commercial IVF surrogacy. In relation to the donation or selling of eggs, is the clinical procedure more closely analogous to the donation of blood, or of a kidney? The answer to such a question affects estimates of risk, and hence the parameters of regulation of gamete provision.60 On donor conception, one AR practitioner has argued that programs providing eggs or sperm should be seen as the equivalent of casual sex, saying: ‘Just as in the normal population a one-night stand ends up with a pregnancy. That child never finds their father. Donor children are not any different’.61 In such a case, the choice of analogy has a human and personal significance. In all cases, analogy lays down the interpretive tracks along which the practices and assumptions of the future are reached.62

Rights and Needs Assisted reproduction has also stretched the language of medical needs and rights. The asserted ‘right’ of the client seeking a child implies in turn a ‘need’ for the new fertility technology, sometimes in the face of a ‘shortage’ of provider eggs, sperm or surrogacy. These naturalised terms rely on an innovative mix of familiar rights arguments with the language of medical need, working to generate a rhetoric of urgency within a new supply-­ chain model of human reproduction. The recently gained right of some women to choose to have an abortion inadvertently paved the way for an argument for a right to ‘access’ the range of options available in AR.63 The word ‘access’ itself implies a simple right to a social good, which can elide to suggest a right to obtain a child through access to another person’s ‘clinical labour’, notably in the form of eggs or surrogacy.64

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Words Unsaid What is even sayable or unsayable also matters. In her 2006 book The Baby Business, political economist Debora Spar urged that the commercial realities of AR should be made explicit. She identifies the very intensity of feeling that surrounds reproduction and parenthood as the reason for a general unwillingness to speak of AR as a money-making enterprise. This hesitancy, she argues, has led to an unwillingness to regulate the business side of AR, exposing clients, as well as providers such as egg donors and surrogacy workers, to personal and legal risk.65 A US television series titled ‘How to Buy a Baby’ relies on the same shock factor, speaking about AR in the language of commerce.66 The idea of literally ‘buying children’ through surrogacy might seem offensive, for example, to people who see themselves as trying to make a family through now widely accepted commercial channels. ‘Health service provision’ is a more neutral term, while, at the other end of the spectrum, the legal offence of ‘human trafficking’ has been used in relation to surrogacy cases, and the activities of some fertility agents.67 As authors, academic commentators are not immune to scrutiny for our choice of words. In the social sciences and humanities, the ideal is that these choices are made with an awareness of their implications. A range of terms exist to describe reproductive travel, for example, such as ‘cross-border reproductive tourism’ and ‘procreative tourism’.68 The word ‘tourism’ seems unsuitable to describe journeys of such great emotional moment as those involved in making a child. ‘Cross-border reproductive care’, however, seems to over-accentuate the role of the providers. Using ‘cross-border reproductive treatment’ or ‘travel’ (CBRT) better captures the main activities involved, including the journey of the client to a reproductive service, or the journey of a provider of tissue or reproductive services.69 Men and women who provide sperm and oocytes for AR treatments are often referred to as ‘donors’. Historically, there were reasons for this: medically facilitated sperm donation began without donors being paid, and one woman in an IVF program giving an egg to another was also referred to rightly as a donation. The widespread commercialisation of

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these processes, however, means the term ‘donor’ can often be inaccurate, or can obscure the commercial basis of a transaction for legal reasons. ‘Provider’, the term used most often here, covers both donors and sellers, and takes into account the genuine human care that often goes into a decision to supply reproductive tissue or clinical labour, even for payment. In this light, is ‘surrogate’ (meaning substitute) really the right word for a woman providing so significant a service as the birth of a child for relinquishment? The term ‘gestational carrier’, currently used in the medical field to refer to a woman who provides a child following the use of another woman’s egg, is an example of an alternative that recognises the work of pregnancy and labour, over the more problematic ‘surrogate’. Most would-be parents engage with the AR industry through an initial medical appointment, but the word ‘patient’ is not always the best way to describe them. ‘Client’ might be more accurate. It can cover both the clinical and contractual nature of many AR arrangements and leaves room for providers of biological labour, particularly in the form of eggs or children, to be referred to as patients. ‘Candidate health care recipients’ is a useful if cumbersome industry term for those seeking to obtain children via AR; ‘IPs’, for ‘intended parents’, is more widely used.70 The terms used in this book are the outcome of a constant process of sorting by the present authors and others.

Assisted Reproduction: An Intimate Industry In a 1980 essay in Time magazine, ‘The Baby in the Factory’, Roger Rosenblatt observed that an industry that helps to create human beings is unlike any other. He argued that ‘technological parenthood may have the trappings of business, but it is not big business; it is the answer to someone’s most personal prayers’.71 In fact, AR is both: it is a set of global commercial ventures in which deep emotions and countless personal journeys are implicated, each one in a chain of multi-layered institutional, cultural and financial engagements. The term ‘intimate industry’ best sums up this aspect of AR.72 A powerful engine of finance, politics and medicine surrounds the personal space of family-making, which is at the same time the emotional and the financial source of the energy that

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drives a vast global market. Not only does the industry create the desired ‘product’—a newborn human—it leads each client to their next life phase as a parent, or as childless.73 As one fertility clinic expresses it, clients can make their transition there from ‘patients to parents’; another encourages people to arrive as a couple and leave as a family.74 Who has a stake in the birth of a child through AR? At its starting point, AR is about what takes place between people seeking to have children and their clinical provider. Then the circles of investment in the birth of children widen: AR links the person or couple who wants the child, their extended family, friends or immediate community, religious groups or nations, with a major industry comprised of specialist clinicians and scientists, counsellors, fertility agencies who find gamete or surrogacy providers, along with manufacturers of pharmaceuticals and medical devices. Many people who are not actively involved in accessing or providing AR services are also part of the story, as venture capitalists, shareholders, taxpayers in public health systems, or as members of public and private medical insurance programs. Beyond them lie journalists, academics, students and consumers of media. With the growth of AR as a transnational industry, people accessing treatments are part of a global reproductive ecology, in which actions affecting their life experiences can occur far away from them. Understanding how such compelling global forces have intersected and helped to shape the experience of reproduction in the IVF era is the main goal of this book.

Notes 1. P. C. Steptoe and R. G. Edwards, ‘Birth after the Reimplantation of a Human Embryo’, Lancet 312, no. 8085 (1978): 336; AAP, ‘Deep Freeze Key to Indian Miracle Birth’, Sydney Morning Herald, 8 October, 1978. 2. Martin H. Johnson and Kay Elder, ‘The Oldham Notebooks: An Analysis of the Development of IVF 1969–1978. V.  The Role of Jean Purdy Reassessed’, Reproductive BioMedicine & Society Online 1, no. 1 (2015): 46–57; Yvonne Collins, ‘Plaque to Finally Honour Snubbed IVF Pioneers’, BioNews, no. 1006, 15 July, 2019, https://www.bionews.org.uk/

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3. T.  C. Anand Kumar, ‘Advent of Medically Assisted Reproductive Technologies (MART) in India’, in The Art and Science of Assisted Reproductive Techniques, ed. Gautam N.  Allahbadia and Rita Basuray Das (London: Taylor & Francis, 2004), 3–7, 5. See also Aditya Bharadwaj, ‘The Indian IVF Saga: A Contested History’, Reproductive BioMedicine & Society Online 2 (2016): 54–61. For what appear to be reasons of transliteration from Bengali, Mukerji is sometimes spelt Mukherjee, as well as in other ways. T. C. Anand Kumar, ‘Architect of India’s First Test Tube Baby: Dr. Subhas Mukerji, 16 January 1931 to 19 July 1981’, Current Science 72, no. 7 (1997): 526–31; Sandra Bärnreuther, ‘Innovations “Out of Place”: Controversies over IVF Beginnings in India between 1978 and 2005’, Medical Anthropology 35, no. 1 (2016): 73–89. 4. Ranjan Gupta, ‘Jibes Put Test-Tube Baby Pioneer on Path to Suicide’, Sydney Morning Herald, 26 June, 1981. 5. Steptoe and Edwards, ‘Birth after the Reimplantation of a Human Embryo’; Anand Kumar, ‘Architect’, 527. See also K.  S. Jayaraman, ‘India Reveals Deep-Frozen Test-Tube Baby’, New Scientist 80, no. 1125 (1978): 159. The terms ‘implantation’ and ‘reimplantation’ refer to the insertion of an embryo into the uterus of a woman having IVF. These are common terms that will, at times, be used here. Implantation is also, however, what occurs when an embryo attaches to the lining of the uterus,  without IVF, so ‘insertion’ is a more apt word when referring to IVF. 6. One Australian clinic still advertises that it was responsible for the first IVF pregnancy (uncompleted), in 1973, https://monashivf.com/aboutus/history/ 7. According to Richard Marrs, an infertility specialist, ‘Edwards and Steptoe would talk to nobody’. Jennie Smith, ‘IVF Pioneers: Field Marked by Competition, Innovation’, Ob. Gyn. News 51, no. 9 (1 September, 2016). See also Associated Press, ‘Methods Called into Question: “Test-Tube Baby” Doctor Not to Get Award’, Globe and Mail (Toronto), 31 October, 1978 and scepticism in 1980 expressed by the first Australian team to bring about an IVF birth there: ‘How the Medical Team Succeeded’, Australian Women’s Weekly, 20 February 1980, 4–5. 8. Gupta, ‘Jibes Put Test-Tube Baby Pioneer on Path to Suicide’. 9. Tim Lee, ‘IVF Pioneer Alan Trounson’s Work Started with Sheep Fertility, Helped Forge New Research into Stem Cells’, ABC Landline, 15 February, 2020, https://www.abc.net.au/news/2020-02-14/landline

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10. International Federation of Fertility Societies (IFFS), ‘International Federation of Fertility Societies’ (IFFS) Surveillance 2019: Global Trends in Reproductive Policy and Practice, 8th Edition’, Global Reproductive Health 4, no, 1 (2019): e29, 2. 11. Bart C. Fauser and Robert G. Edwards, ‘The Early Days of IVF’, Human Reproduction Update 11, no.5 (2005): 437–38, 438; ‘Fertility Blog: IVF by the Numbers’, 14 March, 2018. https://www.pennmedicine.org/; Kate Aubusson, ‘Australia’s IVF Rates Revealed: One in Every 25 Births an IVF Baby’, Sydney Morning Herald, 9 September, 2018, https://www. smh.com.au/ 12. ‘IVF Accounts for 5% of Babies Born in Japan in 2015: Survey’, Japan Times, 12 September, 2017, https://www.japantimes.co.jp. Israel has the highest per capita use of any country and in 2013, its rate for IVF births was 4.3%. Daphna Birenbaum-Carmeli, ‘Thirty-Five Years of Assisted Reproductive Technologies in Israel’, Reproductive BioMedicine & Society Online 2 (2016): 16–23, 17 and Jerusalem Post Staff, ‘Successful Fertility Treatments on the Rise in Israel—New Data’, Jerusalem Post, 10 June, 2019, https://www.jpost.com/; Lucy Proctor, ‘Why Is IVF So Popular in Denmark? The Changing Face of Procreation’, BBC World Service, 21 September, 2018, https://www.bbc.com/news/world-europe-45512312. Comparative figures can sometimes require investigation.  Denmark’s figures might, for example, include sperm donation, or the figure for international users whose children do not show up in the population statistics. 13. Peter R. Brinsden, ‘Thirty Years of IVF: The Legacy of Patrick Steptoe and Robert Edwards’, Human Fertility 12, no. 3 (2009): 137–43, 141–42. 14. ‘Oocyte’ and ‘egg’ or ‘ovum’ are often used interchangeably in descriptions of the IVF process. The 2017 industry glossary uses ‘oocyte’ and ‘egg’ interchangeably, tending not to use ‘ovum’, which is the Latin for ‘egg’. Fernando Zegers-Hochschild, G.  David Adamson, Silke Dyer, Catherine Racowsky, Jacques de Mouzon, Rebecca Sokol, Laura Rienzi, Arne Sunde, Lone Schmidt, Ian D.  Cooke, Joe Leigh Simpson, and Sheryl van der Poel, ‘The International Glossary on Infertility and Fertility Care, 2017’, Human Reproduction 32, no. 9 (2017): 1786–801. For a discussion of the IVF process, see Geoffrey Sher, ‘Egg Maturation in IVF: How Egg “Immaturity,” “Post-Maturity,” and “Dysmaturity” Influence IVF Outcome’, 10 April, 2017, https://drgeoffreysherivf.com. On gamete provision, see, e.g., World Egg Bank, http://www.theworl-

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deggbank.com/; Mamamia  Team, ‘New Deal Will Allow Australians Using IVF to Import Eggs from America’, 10 March, 2013, https:// www.mamamia.com.au/; HunterIVF, ‘Need a Sperm Donor?’, https:// www.hunterivf.com.au/; Victorian Assisted Reproductive Treatment Authority (VARTA), ‘Guidelines for the Import and Export of Donated Gametes and Embryos Formed Using Donated Gametes’, https://www. varta.org.au/resources/publications 15. ‘PGT—Preimplantation Genetic Testing’ and ‘PGT-A—Preimplantation Genetic Testing for Aneuploidy Screening’, https://monashivf.com. See also: ‘Preimplantation Genetic Screening (PGS) and Preimplantation Genetic Diagnosis (PGD) Now Have New Names’, 27 March 2018, Fertility Centers of New England, https://www.fertilitycenter.com 16. Marcia C.  Inhorn and Pasquale Patrizio, ‘The Global Landscape of Cross-Border Reproductive Care: Twenty Key Findings for the New Millennium’, Current Opinion in Obstetrics and Gynecology 24, no. 3 (2012): 158–63, 161. See also Nicola J. Marks, Vera Mackie, and Sarah Ferber, ‘Modes of Mobility: Tracing the Routes of Reproductive Travel in the Asia-Pacific Region’, in The Reproductive Industry: Intimate Experiences and Global Processes, ed. Vera Mackie, Nicola J. Marks, and Sarah Ferber (Lanham, MD: Lexington, 2019), 145–74. 17. ESHRE, ‘ART Fact Sheet’ 2020, https://www.eshre.eu/Press-Room/ Resources 18. ‘20–30% of infertility cases are explained by physiological causes in men, 20–35% by physiological causes in women, and 25–40% of cases are because of a problem in both partners’. ESHRE, ‘ART Fact Sheet’. For an earlier, more detailed overview, see Jacky Boivin, Laura Bunting, John A.  Collins, and Karl G.  Nygren, ‘International Estimates of Infertility Prevalence and Treatment-Seeking: Potential Need and Demand for Infertility Medical Care’, Human Reproduction 22, no. 6 (2007): 1506–12. 19. Zegers-Hochschild et al., ‘The International Glossary on Infertility and Fertility Care, 2017’. 20. C. Gnoth, E. Godehardt, P. Frank-Herrmann, K. Friol, Jürgen Tigges, and G. Freundl, ‘Definition and Prevalence of Subfertility and Infertility’, Human Reproduction 20, no. 5, (2005): 1144–47, 1144; Zegers-­ Hochschild et al., ‘The International Glossary on Infertility and Fertility Care, 2017’, 1800.

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21. Anna Louie Sussman, ‘The Case for Redefining Infertility’, New Yorker, 18 June, 2019, https://www.newyorker.com. ‘Involuntary childlessness’ now includes the condition of ‘a person with a child wish, who … has never been a legal or societally-recognized parent to a child’ and also covers some of these social aspects of infertility. Zegers-Hochschild et al., ‘The International Glossary on Infertility and Fertility Care, 2017’, 1798; 1799. 22. ‘IVF Rates and Safety around the World’, Economist (London), 31 August, 2016, https://www.economist.com/ 23. ‘IVF Rates and Safety around the World’. 24. Maya N. Mascarenhas, Seth R. Flaxman, Ties Boerma, Sheryl Vanderpoel, and Gretchen A.  Stevens, ‘National, Regional, and Global Trends in Infertility Prevalence since 1990: A Systematic Analysis of 277 Health Surveys’, PLOS Medicine 9, no. 12 (2012): e1001356. 25. Laura Briggs, How All Politics Became Reproductive Politics: From Welfare Reform to Foreclosure to Trump, Reproductive Justice: A New Vision for the 21st Century 2 (Oakland: University of California Press, 2018), 115; ‘Infertility Financing Programs’, resolve.org 26. Inhorn and Patrizio, ‘Global Landscape’, 160. 27. See Chap. 5. 28. IFFS, ‘International Federation of Fertility Societies’ Surveillance (IFFS) 2019’, 8; ESHRE, ‘ART Fact Sheet’. IFFS notes that both India and the People’s Republic of China are difficult to document, in the absence of ‘comprehensive registries and validation mechanisms’. IFFS, ‘International Federation of Fertility Societies’ Surveillance (IFFS) 2019’, 4. 29. Birenbaum-Carmeli, ‘Thirty-Five Years of Assisted Reproductive Technologies in Israel’, 17. 30. IFFS, ‘International Federation of Fertility Societies’ Surveillance (IFFS) 2019’, 7; ‘IVF Accounts for 5% of Babies Born in Japan in 2015: Survey’. 31. Kate Hampshire and Bob Simpson have referred to the present time in the history of IVF as a ‘third phase’, characterised by ‘an extension of access and availability that further integrates ARTs into infertility treatment across the globe [and] the move to recognise infertility as a disease (rather than mere misfortune) and to mobilise treatments to address it as such in developing world settings’. Assisted Reproductive Technologies in the Third Phase: Global Encounters and Emerging Moral Worlds, ed. Kate Hampshire and Bob Simpson (New York: Berghahn Books, 2015), 3.

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Sarah Franklin sees the latest ‘phase’ as a time of increased acceptance of embryo research, without direct clinical use in reproduction. Sarah Franklin, Review of Louise Brown: My Life as the World’s First Test-Tube Baby, by Louise Brown and Martin Powell, Reproductive BioMedicine & Society Online 3 (2016): 142–44, 142. 32. Allied Market Research, ‘IVF Services Market to Garner $26.38 Billion by 2026 at 9.8% CAGR: AMR’, 1 July 2019, https://www.globenewswire.com/news-release/2019/07/01/1876671/0/en/IVF-ServicesMarket-to-Garner-26-38-Billion-by-2026-at-9-8-CAGR-AMR.html 33. Inhorn and Shrivastav use ‘reproscape’ to refer to ‘moving people, technologies, finance, media, ideas, and gametes, pursued by infertile couples in their “quests for conception.”’ Marcia C. Inhorn and Pankaj Shrivastav, ‘Globalization and Reproductive Tourism in the United Arab Emirates’, supplement, Asia-Pacific Journal of Public Health 22, no. 3 (2010): 68S–74S, 68S. 34. Several major studies have investigated the personal experience of fertility treatment. Sarah Franklin, Embodied Progress: A Cultural Account of Assisted Reproduction. (Abingdon, UK: Routledge, 1997). Individual memoirs and more recently online blogs tell of the emotional impact of the experience of trying to become a parent through AR. On memoirs, see Robyn Morris, ‘IVF and the “Promise of Happiness”’, in The Reproductive Industry, ed. Mackie, Marks, and Ferber, 97–107. Sarah Franklin provides details of overviews of feminist debates around IVF. Sarah Franklin, Biological Relatives: IVF, Stem Cells, and the Future of Kinship (Durham, NC: Duke University Press, 2013) 327, n3. 35. Sarah Franklin and Marcia C.  Inhorn, ‘Introduction’ (Symposium: IVF—Global Histories), Reproductive Biomedicine & Society Online 2 (2016): 1–7. 36. Examples of collaborative work include: Martin H.  Johnson, Sarah B.  Franklin, Matthew Cottingham, and Nick Hopwood, ‘Why the Medical Research Council Refused Robert Edwards and Patrick Steptoe Support for Research on Human Conception in 1971’, Human Reproduction 25, no. 9 (2010): 2157–74 and Marcia C.  Inhorn and Pasquale Patrizio, ‘Infertility around the Globe: New Thinking on Gender, Reproductive Technologies and Global Movements in the 21st Century’, Human Reproduction Update 21, no. 4, (2015): 411–26. Special issues of major journals have contributed to the ongoing conversation, such as Z. B. Gürtin and M. C. Inhorn, eds., ‘Symposium: Cross-

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Border Reproductive Care’, Reproductive BioMedicine Online 23, no. 5 (2011) and Sarah Franklin and Marcia C. Inhorn, eds., ‘Symposium: IVF—Global Histories’, Reproductive Biomedicine & Society Online 2 (2016). On the research of the Feminist International Network of Resistance to Reproductive and Genetic Engineering (FINRRAGE), see Stevienna de Saille, Knowledge as Resistance: The Feminist International Network of Resistance to Reproductive and Genetic Engineering (London, Palgrave Macmillan 2017). 37. See Aditya Bharadwaj, Conceptions: Infertility and Procreative Technologies in India, (New York: Berghahn Books, 2016); Elizabeth F. S. Roberts, God’s Laboratory: Assisted Reproduction in the Andes (Berkeley: University of California Press, 2012); Sandra P.  González-Santos, A Portrait of Assisted Reproduction in Mexico: Scientific, Political, and Cultural Interactions (Cham: Palgrave Macmillan 2020); Margaret Marsh and Wanda Ronner, The Pursuit of Parenthood: Reproductive Technology from Test-Tube Babies to Uterus Transplants (Baltimore: Johns Hopkins University Press, 2019) and Robin Marantz Henig, Pandora’s Baby: How the First Test Tube Babies Sparked the Reproductive Revolution (Cold Spring Harbor, NY: Cold Spring Harbor Laboratory Press, 2006). Major theses include: Christina Corinna Weis, ‘Reproductive Migrations: Surrogacy Workers and Stratified Reproduction in St Petersburg’ (PhD diss., De Montfort University, 2017); Ingvil Hellstrand, ‘Passing as Human: Posthuman Worldings at Stake in Contemporary Science Fiction’ (PhD diss., University of Stavanger, 2015); Jane Adams, ‘Fertility Factors: Infertility, Medicine and the Law in New Zealand, 1950–2004’ (PhD diss., University of Otago, 2017) and Burcu Mutlu, ‘Transnational Biopolitics and Family-making in Secrecy: An Ethnography of Reproductive Travel from Turkey to Northern Cyprus’ (PhD diss., Massachusetts Institute of Technology, 2019). Thematic studies include Michi Knecht, Stefan Beck, and Maren Klotz, Reproductive Technologies as Global Form: Ethnographies of Knowledge, Practices, and Transnational Encounters, Ethnographies of Knowledge, Practices, and Transnational Encounters 19 (Frankfurt: Campus Verlag, 2012); Ann V.  Bell, Misconception: Social Class and Infertility in America (New Brunswick, NJ: Rutgers University Press, 2014) and Laura Mamo, Queering Reproduction: Achieving Pregnancy in the Age of Technoscience (Durham, NC: Duke University Press, 2007). Other major studies will be referred to in the relevant chapters.

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38. Fittingly, the first such history was a  memoir: Robert Edwards and Patrick Steptoe, A Matter of Life: The Story of a Medical Breakthrough (New York: William Morrow, 1980). Cambridge University Press published a commemorative volume on the fortieth anniversary of the first IVF births: Gabor Kovacs, Peter Brinsden, and Alan DeCherney, eds., In-Vitro Fertilization: The Pioneers’ History (Cambridge, UK: Cambridge University Press, 2018). See also John Leeton, Test Tube Revolution: The Early History of IVF (Clayton, Vic.: Monash University Publishing, 2013); John Leeton, ‘The Early History of IVF in Australia and Its Contribution to the World (1970–1990)’, Australian and New Zealand Journal of Obstetrics and Gynaecology 44, no. 6 (2004): 495–501; Peter R. Brinsden, ‘The Evolution of ART’, in Principles and Practice of Fertility Preservation, ed. Jacques Donnez and S. Samuel Kim (Cambridge, UK: Cambridge University Press, 2011), 1–10; Jacques Cohen, ‘A History of Clinical Embryology and Therapeutic IVF: From Pythagoras and Aristotle to Boveri and Edwards’, in Infertility: Diagnosis, Management and IVF, ed. Anil K.  Dubey (New Delhi: Jaypee Brothers Medical Publishers, 2012), 3–19; Martin H.  Johnson, ‘A Short History of  In Vitro Fertilization (IVF)’, International Journal of Developmental Biology 63 (2019): 83–92 and Joyce C. Harper, ‘Background: Introduction to Preimplantation Genetic Diagnosis’, in Preimplantation Genetic Diagnosis: Second Edition, ed. Joyce C.  Harper (Cambridge, UK: Cambridge University Press, 2009), 1–10. Gayle Davis and Tracey Loughran have edited an important overview collection, The Palgrave Handbook of Infertility in History: Approaches, Contexts and Perspectives (London: Palgrave Macmillan, 2017). 39. Interviews were carried out in accordance with protocols approved by the University of Wollongong Human Research Ethics Committee (HREC), 10 February 2016 (approval HE16/028). 40. Franklin, Biological Relatives, 245, quoting Susan Merrill Squier, Babies in Bottles: Twentieth-Century Visions of Reproductive Technology (New Brunswick, NJ: Rutgers University Press, 1994), 73. 41. ‘Biologist Miriam Menkin Recalls Pioneer Efforts’, Morning Call (Allentown, PA), 30 July, 1978; Loretta McLaughlin, The Pill, John Rock, and the Church: The Biography of a Revolution (Boston: Little, Brown, 1982), 62–66. See Chap. 2 on the patients of Steptoe and Edwards. 42. ESHRE, ‘ART Fact Sheet’.

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43. Melinda Cooper and Catherine Waldby, Clinical Labor: Tissue Donors and Research Subjects in the Global Bioeconomy, Experimental Futures (Durham, NC: Duke University Press, 2014), 63. 44. Charlotte Faircloth and Zeynep B.  Gürtin, ‘Fertile Connections: Thinking across Assisted Reproductive Technologies and Parenting Culture Studies’, Sociology (Oxford) 52, no. 5 (2018): 983–1000, 984. Shellee Colen coined the term ‘stratified reproduction’ in 1986, in a context not directly related to assisted reproduction. See Shellee Colen, ‘“Like a Mother to Them”: Stratified Reproduction and West Indian Childcare Workers and Employers in New York’, in Conceiving the New World Order: The Global Politics of Reproduction, ed. Faye D. Ginsburg and Rayna Rapp (Berkeley: University of California Press, 1995), 78–102. 45. Zegers-Hochschild et al., ‘The International Glossary on Infertility and Fertility Care, 2017’. 46. Richard Kennedy, ‘Back to Basics: Improve Access to Fertility Care by Subtracting the “Add-Ons”’, BioNews, no. 942, 19 March, 2018, https:// www.bionews.org.uk 47. Bharadwaj, ‘The Indian IVF Saga’, 55. 48. An important early work on the role of media is José Van Dyck, Manufacturing Babies and Public Consent: Debating the New Reproductive Technologies (Houndmills: Macmillan, 1995). 49. Authors’ all-dates search of print media since the 1980s, using the Factiva search engine. 50. Sarah Franklin, ‘Postmodern Procreation: A Cultural Account of Assisted Reproduction’, in Ginsburg and Rapp, Conceiving the New World Order, 323–45, 332. 51. ‘Syngamy’ is the term used to describe the fusion of oocyte and sperm prior to the commencement of cell division in the early embryo. In Australia, the word came to betoken a time limit of around twenty-two hours, beyond which experimentation on embryos became, in the eyes of some, unacceptable. John Porter, ‘Infertility Researchers Are Not Initiating Human Engineering’, Age (Melbourne), 4 March, 1988. 52. Definition of assisted reproductive technology (ART), National Health and Medical Research Council (Australia), Ethical Guidelines on the Use of Assisted Reproductive Technology in Clinical Practice and Research (Canberra, National Health and Medical Research Council, 2017), 3. The Victorian Assisted Reproductive Treatment Authority (VARTA) has

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an even broader definition: ‘Assisted reproductive treatment (ART), also known as assisted reproductive technology, refers to treatments used to assist people in achieving a pregnancy. ART covers a wide spectrum of treatments’. VARTA, ‘Types of Assisted Reproductive Treatment’, https://www.varta.org.au. Assisted reproduction is also referred to as ‘assisted conception’; ART can stand for assisted reproductive technology/technologies or treatment(s); MAR is medically assisted reproduction, and MART stands for medically assisted reproductive technology/ technologies or treatment(s). Intrauterine insemination (IUI) of sperm took place clinically before the advent of IVF: today, IUI usually entails the use of fertility drugs, leading clinicians to argue for going direct to IVF, to control the number of embryos created. As with IVF, sperm are tested and prepared in the laboratory. Readers are referred to the 2017 industry glossary for the latest use of acronyms and definitions. ZegersHochschild et al., ‘The International Glossary on Infertility and Fertility Care, 2017’. 53. People Staff, ‘Miracle Babies’, People, 12 October, 1998, https://people. com/archive 54. Franklin, Biological Relatives, 4–6. 55. Gabor T. Kovacs, Gary Morgan, Michele Levine, and Julian McCrann, ‘The Australian Community Overwhelmingly Approves IVF to Treat Subfertility, With Increasing Support over Three Decades’, Australian and New Zealand Journal of Obstetrics and Gynaecology 52, no. 3 (2012): 302–04. 56. Marilyn Strathern, ‘Displacing Knowledge: Technology and the Consequences for Kinship’, in Ginsburg and Rapp, Conceiving the New World Order 346–63, 348. Franklin builds on a similar point from Raymond Williams, Biological Relatives, 4. 57. Susan Merrill Squier addresses the importance of analogy extensively in the history of reproductive biology in Babies in Bottles. 58. Robert G.  Edwards, Barry D.  Bavister, and Patrick C.  Steptoe, ‘Early Stages of Fertilization In Vitro of Human Oocytes Matured In Vitro’, Nature 221, no. 5181 (1969): 632–35. 59. ‘Extracorporeal Fertilisation’, Lancet, 7 March 1970, 510. 60. Naomi Pfeffer, ‘Eggs-Ploiting Women: A Critical Feminist Analysis of the Different Principles in Transplant and Fertility Tourism’, Reproductive BioMedicine Online 23 (2011): 634–41.

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61. Quote attributed to Professor Michael Chapman, of IVF Australia, in James Purtill, ‘A Daughter’s Search for Anonymous Sperm Donor RMRi084’, Triple J Hack, 26 February, 2016, http://www.abc.net.au/ triplej/programs/hack/ 62. See also Sarah Franklin, ‘Analogic Return: The Reproductive Life of Conceptuality’, Theory, Culture & Society 31, no. 2–3 (2014): 243–61; Sonja van Wichelen, ‘Private International Law and Cross-Border Surrogacy: The Role of Analogy’, in Mackie, Marks, and Ferber, The Reproductive Industry, 109–24. 63. Sarah Franklin, ‘Transbiology: A Feminist Cultural Account of Being after IVF’, The Scholar and Feminist Online 9, no. 1–2 (2010–2011), http://sfonline.barnard.edu/reprotech/franklin_01.htm. The ‘right to life’ movement has to a significant extent countered ‘reproductive rights’ arguments by imputing in turn equal rights to the embryo. 64. Cooper and Waldby, Clinical Labor, 61. 65. Debora L.  Spar, The Baby Business: How Money, Science, and Politics Drive the Commerce of Conception (Boston: Harvard Business Review Press, 2006). 66. ‘How to Buy a Baby’, https://www.cbc.ca/mediacentre/program/ how-to-buy-a-baby 67. Franklin, Biological Relatives, 55; Kari Points, ‘Commercial Surrogacy and Fertility Tourism in India: The Case of Baby Manji’. Institutions in Crisis Series (Kenan Institute for Ethics at Duke University, September 2009), http://www.duke.edu/web/kenanethics/, 6. 68. Michal Rachel Nahman, ‘Reproductive Tourism: Through the Anthropological “Reproscope”’, Annual Review of Anthropology 45 (2016): 417–32. 69. See Marcia C.  Inhorn and Pasquale Patrizio, ‘Procreative Tourism: Debating the Meaning of Cross-Border Reproductive Care in the 21st Century’, Expert Review of Obstetrics & Gynecology 7, no. 6 (2012): 509–11; ESHRE, ‘ESHRE Fact Sheets 1, January 2017: Cross Border Reproductive Care’. https://www.eshre.eu/Press-Room/Resources 70. Françoise Shenfield, ‘Cross Border Reproductive Care: The Facts from the ESHRE Study’ (European Society for Human Reproduction and Embryology (ESHRE), Strasbourg, 2018). 71. Roger Rosenblatt, ‘Essay: The Baby in the Factory’, Time, 14 February, 1983, 94–95.

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72. See Rhacel Salazar Parreñas, Hung Cam Thai, and Rachel Silvey, eds., ‘Intimate Industries: Restructuring (Im)Material Labor in Asia’, special issue, positions: asia critique 24, no. 1 (2016), especially Daisy Deomampo, ‘Race, Nation, and the Production of Intimacy: Transnational Ova Donation in India’, 303–32. 73. Charis Thompson, Making Parents: The Ontological Choreography of Reproductive Technologies (Cambridge, MA: MIT Press, 2005). 74. ‘Dr. Rama Fertility & IVF Center: Come as Couple … Leave as a Family’, Dr. Rama Fertility & IVF Center, http://fertilityindia.com

2 Towards the Two 1978 Births

The birth of Louise Brown in 1978 is often portrayed as the revolutionary outcome of the dedication of two pioneers working against incredible odds and with little support. An article in London’s Daily Mail from 27 July 1978, for example, describes the ‘happiness that shines in the faces of Lesley and John Brown’ as a ‘triumphant reward for years of effort by the scientists who made the birth possible’. It credits Patrick Steptoe and Robert Edwards with fighting ‘both man and nature for more than a decade’.1 This heroic story of assisted reproduction (AR) focuses on how these two men’s personal characteristics and technical abilities overcame adversity, and how their work then spread to the rest of the world. Louise Brown’s birth is also at times portrayed as the confluence of the right scientific and technical elements needed to treat infertility, enabled by a long list of trail-blazers, culminating in victory in a scientific race to achieve the world’s first in vitro fertilisation (IVF) birth—a race that could have been won by others, but was inevitably going to be won somehow.2 An examination of the pre-1978 history of IVF suggests that several elements of these stories need addition or revision. The first story omits the key role of Jean Purdy in the team, not least in patient care and basic © The Author(s) 2020 S. Ferber et al., IVF and Assisted Reproduction, https://doi.org/10.1007/978-981-15-7895-3_2

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research.3 It also fails to explain the parallel achievements happening around the world, in particular the birth of Kanupriya Agarwal (under the pseudonym ‘Baby Durga’) in India ten weeks after Louise Brown, as a result of the work of Subhas Mukerji, with colleagues Sunit Mukherjee and Saroj Kanti Bhattacharya.4 The second story, of the inevitability of IVF, is too linear, for it fails to show how conditional IVF ‘success’ was. Some technical inaccuracies were accepted and led the way to other developments, while some technical accomplishments, especially those of Mukerji, came to be ignored. To understand how and why teams in some places were working on IVF in the lead-up to the births of Louise Brown and Kanupriya Agarwal, and how only one of these two births came to be heralded as a landmark feat in science and medicine, it is important to consider a range of factors that either sustained or hindered the development of IVF.  As scholars such as Susan M.  Squier and Sarah Franklin have underlined, the complexities of IVF history belong not only to the innate technical challenges of the procedures, but also to the socio-­ cultural dimensions of human reproductive biology that IVF has reflected, recapitulated and refashioned.5 This chapter first discusses how, across the middle decades of the twentieth century, IVF technology built on several medical and scientific disciplines, and cultural imaginaries. The next section highlights that IVF developed in a staccato fashion, bringing together diverse research materials and ideas with some inventive problem-solving. Global and national conditions are subsequently examined, especially concerns about perceived overpopulation, since they affected IVF research and funding. The chapter then argues that IVF was not just the next technical step that emerged effortlessly and inevitably from previous research and scientific knowledge as the best way to respond clinically to infertility. Rather, IVF had to be ‘made’—made possible, made imaginable and made acceptable. For this, researchers did their job, but also expanded what their job involved, and patients, especially women, were key participants. Nor was IVF definitively established as a treatment as soon as the first live births were announced. Once this ‘technical’ outcome had been achieved, IVF was not automatically accepted and taken up around the world. As the final section shows, the ‘success’ of IVF was not inevitable but contingent.

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Disciplines and Imaginaries Clinical and Scientific Disciplines IVF as a laboratory practice and clinical application relies on knowledge and expertise from several key disciplines, including embryology, clinical medicine, endocrinology, reproductive physiology and developmental biology. Each of these disciplines has slightly different modes of operation, research tools and animal models, thus contributing to what Franklin calls the ‘thick genealogies of IVF’.6 Recognition of the importance of knowledge and ideas from both clinical medicine and laboratory research meant that many of the early IVF teams included a clinician and a scientist. In the United States, from the late 1930s, clinician John Rock and scientist Miriam Menkin worked together, as did husband-and-wife team Howard Jones and Georgeanna Seegar Jones, from the 1940s.7 The Joneses were both clinicians, but Georgeanna conducted much endocrinological research and has been recognised as ‘one of the foremost female scientists in the twentieth century’.8 Landrum Shettles, who was one of the first to attempt IVF clinically in 1973, had a medical degree and a PhD in zoology.9 Other teams were: clinician Patrick Steptoe and scientist Robert Edwards in the UK; clinician René Frydman and scientist Jacques Testart, as well as clinician Jean Cohen with scientists Michelle Plachot and Jacqueline Mandelbaum, in France; clinicians Carl Wood, John Leeton and Ian Johnston, with scientists Alex Lopata (also a medical graduate) and Alan Trounson in Australia.10 In India, Subhas Mukerji was another of the relatively few individuals qualified in both clinical medicine and science, holding a medical degree and two doctorates (in reproductive physiology and reproductive endocrinology). He worked with a clinician, Saroj Kanti Bhattacharya, as well as a cryobiologist (an expert in biological freezing), Sunit Mukherjee.11 Many of these collaborations ran up against insular views of disciplinary roles and competencies that might have precluded a pure scientist from being actively involved in devising clinical responses to human reproductive issues. Australian obstetrician-gynaecologist Carl Wood recalled the difficulties he had installing Alan Trounson in the medical

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faculty at Monash University: ‘I got him by having the Dean of Medicine put him on his personal staff and ultimately got him a job as senior lecturer’.12 Robert Edwards felt this suspicion, too, since IVF as a branch of medicine touched some sensitive nerves in the medical fraternity.13 Such professional divisions might be among the reasons why IVF emerged as the province of some very energetic and entrepreneurial personalities. A number of the key figures of early human IVF had backgrounds in research on animal breeding, including Robert Edwards, Alan Trounson and Jacques Testart. After starting out in agriculture, Edwards moved into zoology in his last year of study at the University College of North Wales, Bangor. He then studied animal genetics and embryology as a postgraduate at the University of Edinburgh.14 Trounson obtained a doctorate in ovine embryology at the University of Sydney, before taking up a Postdoctoral Fellowship at the Agricultural Research Council’s Unit of Reproductive Physiology and Biochemistry at the University of Cambridge. He developed human ovulation induction protocols in the 1980s, building on techniques initially developed for sheep.15 Jacques Testart worked on animal reproduction at France’s INRA (Institut national de la recherche agronomique [national agronomic research institute]) before researching human IVF. Testart’s superior at INRA was Charles Thibaud, whose team in 1954 had provided the earliest convincing evidence of mammalian (rabbit) IVF, to be followed by Min Chueh (M. C.) Chang in the United States (in 1959).16 Artificial insemination (AI) and IVF intersect. Not only did many scientists who worked on AI, in both humans and animals, go on to research human IVF, but researchers adopted insights from research on AI and cryopreservation of sperm in humans and animals, and later applied them to human embryos and eggs.17 The first published report of successful AI in humans was by medical doctor Louis Girault, in 1838, while the first successful human births using AI and frozen sperm were reported in 1953–1954  in the United States, and the first live mouse births from cryopreserved embryos came in 1972 in the same country.18 France also saw the early establishment of a sperm bank in 1973 at the CECOS (Centre d’étude et de conservation des oeufs et du sperme humains [research and conservation centre for human eggs and sperm]), which still plays a role in determining who has access to donations for AR, and

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under what conditions.19 Kanupriya Agarwal is now recognised as the first human baby born from a cryopreserved embryo.20 Cryopreservation is important today in enabling embryos, sperm and eggs to be transported around the world. Endocrinology (the study of hormones) and embryology have been central to IVF, in clinical, research and agricultural settings. According to science and technology studies scholar Nelly Oudshoorn, the idea that the human body could be understood as a ‘hormonal body’ became established during the twentieth century.21 Many of the key figures in endocrinology are known for their work on IVF and contraception, as well as early embryo development. These include John Rock who, with his collaborator Miriam Menkin, conducted a famous series of experiments on human embryos in the 1940s. Rock also investigated the hormones responsible for ovulation and later collaborated with Gregory Pincus; together they made important contributions to the development of the contraceptive pill in the 1940s and 1950s.22 Hormonal compounds such as gonadotrophins could make laboratory animals as well as women superovulate, thus speeding up research on ovulation, oocyte maturation and fertilisation. Gonadotrophins were used in animals from the 1920s, and in women perhaps as early as the 1930s.23 Ideas for IVF also came from beyond scientific disciplines and practitioners.

The IVF Imaginary The creation of babies outside the body was discussed in both scientific and cultural realms for many decades. Already in 1863, Charles Kingsley had published The Water-Babies in support of Darwin’s evolutionary ideas. It included an illustration of a baby in a bottle and inspired biologist Julian Huxley’s work in both science and science fiction.24 Aldous Huxley, Julian’s brother, who authored Brave New World (1932), discussed ectogenesis (fertilisation and gestation outside the body) with Julian and with Gregory Pincus.25 Ectogenesis combined with genetic selection had been described by geneticist John Burdon Sanderson (J. B. S.) Haldane in a futuristic lecture to the Cambridge Heretics in 1923 that was published as Daedalus; or, Science and the Future (1923).26

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The familial and social networks of some major scientists reinforced the significance of modern science through a process of public exposition in both scientific and fictional forms. Aldous Huxley was one among many science fiction writers of the time, including thenprominent feminist writers Charlotte Haldane (J. B. S. Haldane’s wife) and Naomi Mitchison (a geneticist, and Haldane’s sister).27 Historian Fran Bigman identifies Brave New World as part of an important body of literature ‘about how technological change, both real and imagined, might reshape sex, reproduction, gender roles, and the family’.28 Although these fictions were mostly written in the UK between the two world wars, they were particularly influential later on the global scene. Historian Angus McLaren has remarked that the interwar period laid the basis, both cultural and technical, for a broad range of twenty-firstcentury controversies and discussions, including those surrounding AR and contraception.29 It is not clear, though, whether these ideas made research on IVF more, or less, controversial. On the one hand, dystopian science fiction framed IVF in a negative light, and such dystopic imagery has been invoked in subsequent discussions about embryo research and cloning.30 On the other hand, these fictions make AR using IVF conceivable and imaginable: a range of scientists and members of the public could envisage the possibility of embryos being created outside the body. In addition, the dystopian or ambivalent suggestions of science fiction may be ignored by scientists when they refer to such works.31 John Rock appears to have read Huxley’s deeply ambivalent work as positive when he penned, in 1937, an anonymous New England Journal of Medicine editorial entitled ‘Conception in a Watch Glass’, suggesting that the ‘“Brave New World” of Aldous Huxley may be nearer realization’.32 Besides their contemplation of embryos growing outside the body, the work and discussions of these influential thinkers were permeated with anxieties about ‘good’ birth. Julian Huxley and many of his peers were members of the Eugenics Society which, although not favouring the compulsory sterilisation that characterised policies in both Germany and the United States, was deeply elitist.33 The potential to create babies in bottles opened up the possibility of choosing supposedly more desirable children, as envisioned by Haldane in Daedalus:

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The small proportion of men and women who are selected as ancestors for the next generation are so undoubtedly superior to the average that the advance in each generation … is very startling. Had it not been for ectogenesis there can be little doubt that civilisation would have collapsed.34

These cultural and scientific imaginaries were essential in creating a future for assisted reproduction using IVF.  So too were a range of biological materials, laboratory methods and instruments, alongside some inventive problem-solving.

Bringing Together Ideas and Materials Materials, Tools and Techniques A wide diversity of animals was used in the disciplines that contributed to IVF, in embryology in particular, but also artificial insemination and animal husbandry. The choice of animal depended on availability, researcher preference, and type of experiment. They included chicks, worms, fruit flies, sea urchins, frogs, rabbits, axolotls, flatworms, cows, dogs, horses, sheep and a blue whale.35 Different animals made visible different aspects of development and enabled different kinds of experiments, thus shaping how the scientific knowledge evolved. In the decades prior to 1978, much IVF work was at the edge of technical knowledge and capabilities, with researchers devising innovative practices while building on established ones. They designed their own recipes for laboratory culture media, as well as using commercially available products, such as purified hormone extracts. Steptoe, Edwards and Purdy, for example, used their own culture medium, as well as commercially available hormones from Dutch company Organon.36 Researchers also used new tools. The recently developed laparoscope, for instance, was hugely influential in the work of Steptoe, Edwards and Purdy. Steptoe first learnt how to use it from two leaders in the field in the late 1950s and early 1960s: Frenchman Raoul Palmer and German Hans Frangenheim. Steptoe went on to become world renowned in laparoscopy, initially for sterilisation, later, for egg retrieval with Edwards and

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Purdy.37 The team also obtained eggs from ovarian tissue derived during the surgical work of gynaecologist Molly Rose, who had delivered two of Edwards’ five daughters.38 Human eggs were essential materials, but difficult to use. Miriam Menkin recalled that ‘working with eggs was a delicate and frustrating business … it was like handling a handful of mercury’.39 Embryos were also tricky, so researchers had to tinker with their protocols to enable their growth. They needed to be cared for in particular ways and, at one point, Edwards wondered if they would develop only when implanted into women’s bodies in the calm hours of the night.40 Testart looked back fondly on those times, saying that ‘no-one comes in at night anymore, dreaming about this embryo’, with implantation of an embryo by a doctor no longer being ‘a magical ceremony’, having become ‘a technical act’.41 It might seem unbelievable today, but not only were researchers unclear on the best protocols for using human eggs and embryos in the 1960s, in the 1930s many simply did not know what early human embryos looked like. This is why Rock and Menkin’s embryo experiments were so important. Arthur Hertig, who collaborated with Pincus and also with Rock and Menkin, recalled: No-one knew what a human embryo looked like during the first two weeks of life, nor exactly when conception took place, or where … We looked at an enormous amount of eggs that weren’t eggs, just cellular debris, because none of us had seen a fertilised egg.42

Despite these difficulties, Rock and Menkin worked with nearly 800 human eggs, for contraception and IVF research. The eggs were usually obtained from excised single follicles, and some from the ovarian tissue of patients undergoing hysterectomies.43 In the UK a few years later, Steptoe and Edwards reported on the use of fifty-six human eggs preliminary to their first in vitro fertilisation, and of 133 eggs in their research on hormonal treatments to improve laparoscopic egg retrieval.44 In total, they are thought to have worked with at least 1361 eggs between 1969 and 1978.45 Bringing together these materials and tools was no simple feat, and the research that led to the births of Louise Brown and Kanupriya Agarwal did not move along a simple linear path.

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Tortuous Paths to IVF Devising the right protocols to create and maintain live embryos in the laboratory was particularly difficult and led to some early claims of success later being disproved. From the late 1800s, researchers had been attempting the fertilisation in vitro of human and other mammalian gametes. The most famous of these include Leopold Schenk (in 1878, Austria), Gregory Pincus and Ernst Enzmann (in 1934, United States) working on mammalian IVF, Rock and Menkin (1944) and Shettles (1954), working on human IVF in the United States.46 Many of their once-recognised claims were later found to be overstated because the publications did not demonstrate essential steps such as egg maturation or sperm capacitation (the latter is described as ‘a final maturation process which spermatozoa undergo physiologically in the uterus and that is essential for the acquisition of fertilizing competence’).47 Yet these claims were important at the time in furthering IVF research and making fertilisation outside the body seem attainable. According to reproductive biologist John Biggers, the findings of Pincus and Enzmann ‘were accepted by the scientific community for many years as the first demonstration of IVF’.48 In one sense, it mattered a great deal that these early reports made misleading claims, because later scientists wasted time trying to replicate the protocols. Talking of egg maturation times, Edwards recalled: ‘Pincus’s error cost me 2 years’.49 In another sense, though, the reports made fertilisation outside the body seem more achievable and pushed research onwards. Even once oocyte and sperm could be isolated in the laboratory and brought together in a Petri dish, achieving their fusion to create an embryo remained an obstacle. Capacitation is still poorly understood despite much research. It seems particular to mammals and is evidenced in part by a morphological change in the sperm called the ‘acrosome reaction’; capacitation is essential for individual spermatozoa to bind with and then enter the oocyte, enabling fertilisation to occur.50 In 1951, Australian Colin Russell ‘Bunny’ Austin and Chinese-born American M. C. Chang independently found that mammalian sperm need to spend some time in the female reproductive tract before they are capable of

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fertilising an egg.51 In 1963, Japanese-born American Ryuzo Yanagimachi reported with Chang the successful fertilisation of hamster eggs by in vitro-capacitated sperm.52 Replicating this in humans was not straightforward and embryologist Christopher De Jonge comments that for nearly twenty years ‘efforts were underway to fertilize human oocytes in vitro but with no fundamental understanding of how human sperm acquire “fertilizing capacity”’.53 Edwards, Bavister and Steptoe succeeded in creating the first human embryo in vitro in 1969, an event arguably as crucial for the history of biology as the resultant use of their techniques to bring about the first IVF birth.54 Edwards had tried to capacitate sperm in a range of ways, including using a nylon basket to hold them inside women’s bodies before attempting IVF.55 He and his team eventually succeeded in 1969 by washing and suspending sperm in a modified version of a culture medium developed by his student Barry Bavister for hamster IVF—also dubbed ‘Barry’s magic culture fluid’—itself based on a commercially available culture fluid called ‘Tyrode’s solution’. The sperm were also ‘pre-­incubated’ in follicular fluid (from the ovary). The protocols led to the birth of Louise Brown.56 Many teams had also used this modification of Tyrode’s solution, including Wood’s Australian team in their world-first human IVF pregnancy in 1973, a ‘chemical pregnancy’, which lasted nine days. (A chemical pregnancy is detected by hormonal changes in the woman’s body but results in early miscarriage before the foetus is big enough to be detected by ultrasound.57) Subhas Mukerji’s team washed and suspended sperm in ‘modified Tyrode’s solution’, but then transferred oocytes and sperm into ‘freshly collected nontoxic heparinized cervix-uterine fluid drops’—a fluid from the female body also known to contribute to capacitation.58 There were other media available later, including Ménézo’s B2 medium, developed at INRA by Yves Ménézo in 1976 and subsequently patented, which was used by French, American and Australian researchers; it was colloquially referred to as ‘French champagne’ and is still used by some groups today.59 Resourcefulness was at a premium. As the first clinician to bring about an IVF conception resulting in a birth in Japan, in 1983, Masakuni Suzuki recalled his team ‘using various available agents’ including ‘water used at a whisky distillery in Scotland, which

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allowed us to formulate the media necessary for achieving a certain level of results’.60 The complicated stories of capacitation and culture fluids highlight that researchers moved forwards, despite very incomplete knowledge. Capacitation also underscores the  difficulties in translating knowledge between humans and model animals.61 As Bavister argues, ‘hamster IVF paved the way for human IVF’, but human IVF overtook hamster IVF— the live birth of an IVF hamster was not reported until 1992.62 Edwards, Bavister and Steptoe modified their culture medium in 1970 to more closely resemble human follicular fluid.63 This bodily fluid improves sperm penetration in humans, although it does not seem to lead to capacitation in hamsters.64 They used similar protocols for Louise Brown, but also in their many failed attempts at fertilisation.65 Steptoe, Edwards and Purdy noted in 1980 that fertilisation rates ‘should be improved as more information accrues on capacitation’.66 Today, many culture media have replaced biological fluids with serum albumin (a protein found in blood, and that was present in Bavister’s fluid), but the capacitating function of this protein is still not understood in full detail.67 Not only were there advances and reversals within research programs, but different teams addressed similar problems in different ways, again highlighting that IVF did not come about in a linear fashion. One example concerns the complexity of using hormones in live organisms. Researchers found that the use of gonadotrophins, while inducing multiple ovulations to increase the chance of creating embryos, prevented pregnancy upon implantation into the woman’s body because her cycle was shortened, which brought about early menstruation. Different teams found different solutions. Steptoe, Edwards and Purdy opted to abandon hormonally induced ovulation, going back to using women’s natural cycles. In India, Mukerji solved the problem by using drugs to induce ovulation and then freezing the embryo before implanting it during a subsequent (unshortened) menstrual cycle, while the Australian and US teams used complex hormonal protocols to support pregnancies.68

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Global Contexts, National Priorities The paths towards IVF were also shaped by a range of conditions outside the laboratory and hospital. Local and global political, economic and socio-cultural conditions affected where and how IVF research could take place. In particular, concerns about post-war global overpopulation on the part of governments and philanthropic organisations played an important role in the funding landscape, especially from the 1950s onwards. Another important factor enabling IVF research in some countries was a broadly supportive and lightly regulated research culture. In most places only the 1964 Declaration of Helsinki, which set out ethical principles, guided but did not control scientific research practices on humans.69 These trends shaped national research priorities in different ways. In the 1940s, fertility was on the social as well as scientific agenda. Science and technology studies scholar Adele Clarke argues that in the United States, by 1945, there had been a ‘strategic’ shift by birth control advocates away from women’s rights and towards family planning, in order ‘to provide something for everyone—even the infertile and Roman Catholics—within the broader planned-parenthood frame’.70 In 1946, for example, John Rock gave a talk on alleviating infertility at a luncheon sponsored by the Planned Parenthood Federation of America (PPFA).71 One reviewer described Rock’s 1949 book Voluntary Parenthood, co-­ authored with David Loth of the PPFA, as being published ‘at a time when infertility is an increasingly important problem to many couples who want and can afford several children’.72 Similarly in the UK there had been an increase in the number of women seeking medical help for infertility during the Second World War and later there was public and political interest in the reconstruction of Britain, improved fertility and ‘positive eugenics’.73 The post-war baby boom, however, reassured worried British elites about their nation’s fertility, and the National Health Service (NHS), set up in 1948, did not include fertility treatment in its remit.74 By the late 1940s and early 1950s, scientists, social scientists, birth-­ control advocates and charitable as well as commercial foundations spread

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concerns of overpopulation from the United States towards the UK and around the world, calling for ‘population control’ as a response.75 One outcome was that in the 1960s funding became available for research on ‘endocrinological contraception’.76 This was targeted particularly at populations thought excessively numerous and over-fertile, and was accompanied by policy measures to discourage so-called hyper-fertility.77 This research could in turn serve as a basis for infertility research, because many of the same hormones needed to be understood and managed. As Franklin highlights: It may be one of the chief ironies of the history of IVF that it is in many ways the identical twin of the contraceptive Pill, both technologies having been gestated in the same womb of highly charged post World War II anxiety about the ‘population bomb’.78

Institutions such as the Ford Foundation and the Rockefeller Foundation, through the founding of the Population Council, aimed to reduce fertility in regions including Africa, Asia and South America, in part by funding research into contraception.79 These institutions provided money to a range of important IVF researchers. The Population Council, for example, provided extensive funding in the 1960s to Masakuni Suzuki in Japan.80 The Council had also supported some of Edwards’ work through a ‘modest fellowship’ when he conducted research in California in 1958.81 His work in Cambridge in the 1960s was ‘generously’ funded by the Ford Foundation but, according to Edwards, ‘they pulled out in the mid-seventies, worried by the ethical controversy surrounding in-vitro fertilisation in the USA’.82 Carl Wood recalled similarly that the Ford Foundation did not want to be credited if an IVF birth eventuated from his work with Alan Trounson that it funded.83 The UK taxpayer-funded Medical Research Council (MRC) rejected Steptoe and Edwards’ application for long-term funding in 1971. One of the reasons given was that infertility research should not be prioritised over population control.84 The global population scare and associated redirection of research funding combined with local factors to influence which countries would intensify IVF research in the 1950s, 1960s and 1970s.

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The United States was home to much early IVF research and also welcomed scientists from around the world. Researchers in Japan, for example, had tackled many of the difficult issues of IVF, such as culture media, but some had had to move overseas to advance their work.85 This included Yanagimachi, who conducted key work on sperm capacitation and collaborated with M.  C. Chang.86 Yanagimachi had gone to the United States because of a lack of opportunities in Japan.87 Infertility research slowed in the 1970s in the United States, however, due in part to concerns about overpopulation and in part to broad ‘anti-technological sentiments’.88 There were also controversies about what forms families and reproduction should take, maintained through vigorous feminist debate and accelerated by the decriminalisation of abortion in 1973.89 The National Institutes of Health (NIH) announced in 1973 that they would not fund research involving embryos outside the body.90 That same year, Landrum Shettles had secretly attempted the first implantation of a human embryo created in vitro, but his department chair was concerned that this experiment contravened Columbia University’s undertaking to conduct ethical federally funded research, based on the 1964 Declaration of Helsinki.91 IVF research in the United States relied on private donations until public support for clinical IVF gained some momentum after the birth of Louise Brown, although it should be noted that private funding was always a key aspect of embryo research funding in the United States. Brown’s birth led the NIH to put funds on hold for oocyte research linked to IVF, because of concerns over the creation of extra-corporeal embryos.92 In Australia, researchers actively published on a range of IVF topics including hormone protocols and culture media.93 In 1956, Wesley K. Whitten described a mouse culture medium that made possible many later successes in IVF and other areas.94 This ‘Father of Embryo Culture Medium’ was driven by an interest in contraception and addressing overpopulation.95 Wood and Leeton, who established the AR program in Melbourne, had also conducted research into contraception before moving into infertility research.96 Amongst a number of factors, Leeton attributes demand for AR in the 1970s to policy changes that reduced the number of babies available for adoption.97

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In Mexico, as a result of international and local political pressure, the professional association addressing infertility slowly shifted its focus in the 1960s towards overpopulation and contraception, particular attention on infertility treatment not resuming until the 1980s.98 In Singapore, there was little interest in IVF in the 1970s, but a strong state focus on reducing population through family planning provisions, including support for abortion, was followed by support for some population expansion in the 1980s, initially along eugenic lines.99 In the People’s Republic of China, it was not until the end of the Cultural Revolution in 1976 that infertility research became possible. Clinician Zhang Lizhu, whose research would underpin the birth of China’s first IVF baby in 1988, had been made to work as a janitor in the 1960s and early 1970s.100 In continental Europe, IVF research took place in the 1970s despite minimal funding. In France, research on infertility had been undertaken at least since the 1940s, and IVF research began in earnest in the late 1970s, with encouragement from Edwards.101 Testart soon started working with Frydman in a labo de fortune [a makeshift lab] with assistants who were not always paid.102 Research was conducted in Germany, where, in contrast to strong regulations preventing abortions (the law was reformed in 1973), extra-corporeal embryo research was lightly regulated.103 In Scandinavian countries, too, some research occurred in the mid-1970s, notably on improving techniques for obtaining oocytes.104 There were also active teams in Spain, Belgium and Austria.105 Italian IVF research was impeded for religious reasons, and a number of promising scientists left the country to conduct their experiments in France, the United States or Australia.106 Nonetheless, research on boosting the fertility of married women did take place in Italy, in particular in collaboration with Israeli scientists. In Israel, the context was quite different to elsewhere as, since the creation of the country in 1948, ‘infertility treatments were considered as almost a basic right’.107 There was much research on hormonal stimulation. Bruno Lunenfeld (born in Austria, educated in Israel) investigated a hormone called human menopausal gonadotrophins (hMG), used to induce ovulation.108 This would not have been possible without collaboration with the pharmaceutical company Serono, headquartered in Rome, which is said to have obtained large quantities of hMG from the

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urine of retired nuns, with the support of the Pope (the Vatican owning 25% of Serono).109 This collaboration led to the world’s first hMGinduced pregnancies, reported in 1962, at the Sheba Medical Center at Tel Hashomer.110 Ovulation induction using hMG became widely available and free of charge in Israel, prompting the Sheba Center to publish a detailed report on this kind of fertility treatment, which would become a cornerstone of IVF; it also reported for the first time in detail on ovarian hyperstimulation syndrome (OHSS), and some of its serious complications.111 In India, after Independence and Partition in 1947, there was great hope for a new ‘“modern”, free India’ that could move beyond its colonial past. The key areas of interest for Indian governments in the 1950s and 1960s were agricultural reform and economic development, as well as controlling its growing population.112 Early hopes for a better future waned, with poverty and ill health rampant, and the 1970s were labelled at their close ‘a decade of disillusionment’.113 In West Bengal, where Subhas Mukerji worked, a Left Front Government with clear priorities for land reform was elected in 1977.114 In this context, there were few opportunities to pursue research into infertility, which might seem to be a condition affecting only a few people, in contrast to ill health and poverty affecting millions. Across the scientific world, then, public funding was not widely available to conduct research into AR using IVF.  If, as Andrea Whittaker wryly observes, money can be ‘the critical culture medium making [assisted] reproduction possible’ there was nothing in its early history that guaranteed the continuity of IVF research.115 The British team obtained funds unexpectedly from several local donors and, for ten years leading up to the birth of Louise Brown, received substantial funding from a private US donor. As Sarah Franklin remarks: ‘Contributing the equivalent in today’s currency of half a million pounds over the course of the crucial decade between 1968 and 1978, the modest Californian philanthropist Lillian Lincoln Howell (1921–2014) is as responsible for the birth of Louise Brown as Steptoe or Edwards’.116 Funding fragility, combined with some complex technical issues and the potentially socially disruptive nature of fertilisation outside the body, meant that IVF, although already in people’s imaginations, was not inevitably possible and desirable; it needed to be made so.

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‘Making’ IVF ‘Right’: Technical Promises, Ethical Issues and Women Pioneers117 IVF was and is about human infertility, but it was never just about infertility. Before the 1978 births, the promise of IVF seemed to lie more in its potential as a laboratory tool than as a clinical treatment.118 When outlining the aims of a research program into IVF in 1965, Edwards suggested eleven uses for IVF, only one of which directly related to infertility treatment.119 He was particularly interested in using IVF embryos to better understand early embryo development and ‘even control the genetic disorders of man’.120 He also collaborated with tissue culture specialist John Paul in Glasgow in the mid-1960s to create stem cells from rabbit embryos. Embryonic stem cell research would be key to the global expansion of research using IVF embryos in the decades to come.121 (Stem cells give rise to all the different tissues in the body. There is a range of stem cell types, including specialised stem cells such as blood stem cells that give rise to different blood components, as well as stem cells that can be obtained from IVF embryos and which can be coaxed into developing into any of the different cell types of the body.) According to Cambridge reproductive scientist Martin Johnson (Robert Edwards’ former doctoral student), Edwards’ main goal when using IVF was to avert genetic diseases. This changed when he met and collaborated with Steptoe, who had a long-standing interest in fertility treatment.122 Sarah Franklin has noted that Patrick Steptoe believed it was ‘a fact that there is a biological drive to reproduce’ and that ‘women who deny this drive, or in whom it is frustrated, show disturbances in other ways’.123 IVF could enable a fertility treatment that was more appealing than existing options, including surgery for tubal disease. This is partly because IVF was new and exciting and partly because it might ultimately provide children to people beyond the initial cohort of couples in which the woman’s fertility was affected by damaged fallopian tubes.124 Clinicians such as René Frydman in France were focused on IVF to help women have children from early on; research scientists, such as Alan Trounson in Australia, also came to share with Robert Edwards an appreciation of the import of this application of their science.125

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IVF could not be ‘made’ into the ‘right tool’ simply by being useful technically, whether in the clinic or in the laboratory; it had to be ‘right’ socially, ethically and culturally, too.126 Conception outside the body had already attracted both utopian and dystopian connotations and thus public support for it could not be assumed. Some medical professionals had in the past sidelined other techniques of AR, in particular artificial insemination by donor, because they had been deemed too socially disruptive.127 Individual scientists also had different views on elements of IVF.  Some of the British medical establishment, for instance, greeted Steptoe’s descriptions of the great promises he saw in laparoscopy with doubt and at times derision.128 The potential application of IVF for selective reproduction was especially divisive. Early on, Edwards had discussed the possibility of combining IVF with pre-implantation selection methods to choose biological sex or avoid particular diseases.129 Testart, however, renounced IVF work in the 1980s, shortly after enabling with Frydman the birth of the first French IVF baby. Testart raised concerns about various aspects of IVF, including the potential for genetic selection of embryos.130 One part of making IVF for AR possible was to expand what could be considered acceptable—some researchers, Edwards and Howard Jones in particular, were active participants in ethical discussions about their work, promoting it through lay-friendly publications and discussions.131 Another part required the careful consideration of the ethical issues raised by IVF. There is evidence that some researchers cared deeply about the ethics of what they were doing. Martin Johnson and Kay Elder argue that Steptoe, Edwards and Purdy keenly felt their ethical responsibilities, even if they did not commonly detail ethics procedures in their publications.132 Edwards, for example, acknowledged the dilemma in deciding whether to implant successfully fertilised oocytes back into women (perhaps for pregnancy) or whether to destroy them in the course of doing research to improve understanding.133 Ethical reflection influenced scientific practice and considerations of which technical solutions were deemed acceptable. When the UK team realised that gonadotrophins could induce multiple ovulation, but then prevent implantation of the IVF embryo in the superovulated woman’s body, Steptoe suggested to Edwards and Purdy that they could consider

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egg donation to an infertile couple from a third-party provider. They could use gonadotrophins to hyperstimulate the donor, fertilise the resulting egg with the husband’s sperm and then implant the resulting embryo into the body of his wife—who would not have received the cycle-shortening drugs and so would be more likely become pregnant. The team rejected this early suggestion for egg donation, however, on the grounds that the woman would be giving birth to a child genetically related to her husband, but not to her. Edwards later reflected: ‘we did not know enough about the psychological relationships between parents, recipients, and children. There could be legal as well as moral problems too. It was much too complicated’.134 IVF research was and remains complex to navigate socially and ethically, with many practices at the edge of acceptability—in particular, the recruitment of research volunteers. A scientist from the UK recalls for early IVF research: ‘It was a little bit of a bribe. “If you will agree to take part in this research, you will go up the list and get your sterilisation done earlier”’.135 A number of practices used at that time would not be allowed in more regulated environments. Frydman states that ‘it is obvious that we couldn’t do today what we did thirty years ago … [but] we need to find a balance between respect for people and innovation’.136 Similarly, a recent account of John Rock’s career has argued that he was firmly committed to consent procedures, although the standards of informed consent and gamete-tracking were not the same then as they are today.137 Rock’s extensive embryo work would be very difficult to reproduce: It is highly unlikely that women could be found, who were in need of a hysterectomy, but could and would be willing to delay surgery for a few months and spend that time charting their ovulatory cycles, for the sake of an uncertain experiment.138

So, we see that women themselves, both hysterectomy and fertility patients, were central in enabling IVF to be possible: they played a key role not only in providing material for research, but also in supporting the idea of AR using IVF, even in the face of slow progress. Rock, who had an approachable manner and much media visibility, received many letters from women asking whether IVF could help them.

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His early responses to them were very optimistic, before becoming more cautious as he failed to achieve IVF.139 In Melbourne, before the first IVF birth in 1980, it was reported that ‘more than 1000 women were involved in the program’ and between 1975 and 1978, ‘as many as 50 patients each year underwent IVF attempts’ though ‘none was successful and research continued’.140 Many of the women suffered heartbreaking miscarriages. Louise Brown observed in her autobiography that another woman … seemed to be on course to be the first—but sadly there was a problem in the pregnancy and she lost the baby. It was pure chance that Mum happened to be the one lying on that operating table on July 25, 1978 and that I was the first successful baby conceived in that way.141

These women were not simply desperate or duped—they could be willing participants in what they saw as ground-breaking research, hoping for a take-home child, but knowing it might not happen. Steptoe and Edwards highlight the difficulty of asking women to participate in infertility research while not raising false hope of treatment.142 Several early IVF providers credited the commitment the women showed, accepting low expectations and little reward. Australian IVF clinician John McBain, who was involved in the birth of the first Australian IVF baby, Candice Reed, recalls the difficulties encountered by these patients: ‘women undergoing so-called natural cycle IVF in the late 1970s faced an arduous, rigorous and mostly unsuccessful process … Clearly, women such as Candice Reed’s mother were true pioneers’.143 Because women were writing letters to scientists and were volunteering to participate in IVF research, even though it had not received any official stamp of social approval, they can be thought of as what Rayna Rapp calls ‘moral pioneers’: ‘at once conscripts to technoscientific regimes of quality and normalization, and explorers of the ethical territory its presence produces’, they were ‘our moral philosophers of the private’.144 As we have seen so far, innovative thinking and complex problem-­ solving enabled IVF to develop, but there was never one solution, nor one clear path to follow. Researchers and clinicians were working with old and new scientific ideas, some of which turned out to be correct, and some of which turned out to be incorrect. A number of elements needed

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to be brought together, but technical achievement was not a guarantee of recognition and acceptance.

‘Assembling’ for ‘Success’ in the UK and India Those wishing to bring about IVF for AR were of necessity entrepreneurial. They can be thought of as what scholars in the field of science and technology studies refer to as ‘heterogeneous engineers’ who ‘assembled’ previously unconnected people, financial support, biological materials, patients, media and ethical discussions to enable their research.145 Both Edwards and his colleagues and Mukerji and his colleagues became adept at this, although in the end, the British team more so than the Indian one. Edwards, Steptoe and Purdy brought together new technologies such as laparoscopy and egg and embryo maturation, refined their protocols for many years before the birth of Louise Brown and obtained financial and institutional support from a range of sources, including the Ford Foundation, and Oldham District and General Hospital.146 Similarly, Subhas Mukerji conducted ground-breaking technical work, bringing together the insights he had gained from his research at Calcutta University on pregnancy with those gained during his second PhD on reproductive endocrinology under John Loraine, a renowned researcher in the field of human gonadotrophins, undertaken at the University of Edinburgh. These insights combined with what Trichnopoly Chelvaraj Anand Kumar, the researcher later credited with India’s first ‘scientifically documented’ IVF baby in 1986, referred to as Mukerji’s ‘innovative gynaecological surgery’, ‘considerable technical skills’ and ‘fertile mind’.147 Mukerji assembled complex ovulation induction protocols with the relatively low-tech measuring of cervical fluid viscosity to determine optimum embryo implantation time, and the delicate task of slowly freezing and thawing embryos with that of conserving them in a scientifically advanced freezer that he kept at his home. He worked in public (hospital) and private (home) spheres, using his own money or that received from private donations.148 Both Edwards and Mukerji were aware of the need to navigate complex ethical issues. Even in scientific publications, they explicitly referred

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to sperm as being provided by ‘the husband’, pointing to the heteronormative nature of the reproductive imaginary at that time.149 Mukerji was working with patients from what one report referred to as ‘conservative Hindu society’ in which childlessness was frowned upon.150 He conducted research and saw patients in his home in order to shield his work from government interference and to protect the privacy of his patients.151 Even though Sunit Mukherjee later quoted Kanupriya Agarwal’s father as stating that ‘a deformed child is better than no child’, the team worried about the risk of delivering an unhealthy child and was concerned that their experiments would be controversial.152 Unlike Edwards, though, Subhas Mukerji is not known to have participated in public discussions to make IVF more acceptable before it became a reality. The births of Louise Brown and Kanupriya Agarwal were both initially greeted with a mixture of awe and scepticism. There were news reports of the British birth as an ‘historic achievement’ and of the Indian one as a ‘feat’ that ‘might be considered one step higher than that of the Edwards-­ Steptoe team’.153 The Indian birth was accepted by some internationally and was still counted as the second IVF birth in 1980, when the Australian team announced their first—and the world’s fourth—IVF birth (although the Indian birth was not included in an Australian report of IVF successes in early 1979).154 At the same time, the ‘Indian medical community’ was reported as ‘somewhat sceptical’ of the Indian birth and some scientists in Japan called for ‘restrictions’ on the UK’s ‘unnatural experiments’.155 At least one newspaper suggested that other IVF births had happened before Louise Brown’s and another was doubtful that Louise was truly the result of in vitro fertilisation.156 Religious and legal commentators also saw IVF as socially very disruptive.157 Given the comparable mixed initial reactions, how did awe come to dominate the British story, whilst scepticism dominated the Indian one? Despite some strong and at times isolating ‘professional hostility’, Steptoe, Edwards and Purdy were recognised by many peers as leaders in their field, partly because they belonged to a network of people exchanging ideas and partly because they had established their credentials through extensive publication.158 Edwards benefitted from working with Georgeanna Seegar Jones and Howard Jones when they were based at Johns Hopkins University.159 Much of Edwards’ research was done in

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Cambridge, where others, including Alan Parkes, M.  C. Chang and Bunny Austin, had conducted important work. Not everyone was welcome in Cambridge, however, and its inability to support Steptoe’s clinical work was one of the reasons he stayed in Oldham, near Manchester.160 Steptoe, Edwards and Purdy were also working in a country that had a self-image of being at the forefront of scientific innovation, and in which the hospital and research system had accepted protocols and consent procedures.161 After Louise Brown’s birth, the team shared some details of their methods (but not all, especially initially) with colleagues, including visiting Australians Alan Trounson and Alex Lopata. Jacques Testart, however, spoke, in an interview, of Edwards’ reluctance to share too many technical details until the French team had successfully enabled their own IVF baby.162 Steptoe and Edwards also had a generally positive, if sometimes fraught, relationship with the press. Their 1969 publication announcing human egg fertilisation in vitro was promoted thanks to the editor of Nature, who was a supporter of their work and organised a tie-in with the London Times. Yet the publicity itself created difficulties as the MRC did not like this sort of media attention, one of the reasons the team’s research was not initially funded.163 Steptoe was also accused of selling an exclusive story on the birth of Louise Brown, leading the Barren Foundation to withdraw an award they had offered him late in 1978.164 Edwards and Steptoe both strongly maintained that the team never accepted money for stories around the time of Louise’s birth.165 On balance, the British press favoured the project, but the media reported concerns and criticisms as well as the good news stories about IVF.166 The British team could also show their IVF success. A film of Louise Brown’s birth, via caesarean section, made visible the fact that Lesley Brown had no fallopian tubes, thus making it impossible for her to conceive without medical help.167 The overall acceptance of Louise Brown as an IVF success can perhaps best be illustrated by a swift, and arguably ‘evidence-light’, change of policy on the part of the MRC: by the time they published their 1978/79 annual report to support embryo research, they termed IVF an ‘experimental treatment’ rather than ‘a research procedure’.168 This smoothed the way for potential future funding. By 1980, Steptoe, Edwards and  Purdy had achieved a total of four pregnancies,

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with two full-term live births from thirty-two embryo implantations: in addition to Louise Brown, there was a second pregnancy that ended in an early miscarriage at twelve weeks; the third resulted in premature delivery at twenty weeks of a live child who sadly died one hour later; the fourth led to the birth of Alastair MacDonald on 14 January 1979 in Glasgow.169 After that, the team relocated to Bourn Hall near Cambridge, where their efforts would lead to many more births. Unlike Edwards, Mukerji was not well recognised by his global scientific peers. He was educated in the UK, having received a Colombo Plan scholarship to study in Edinburgh, not long after Edwards left that city.170 He also attended a symposium in 1971 in Bombay (now Mumbai) for the inauguration of the Institute for Research in Reproduction, which Edwards also attended, at the height of Indian research into population control. There is no evidence, however, that Edwards and Mukerji met and it seems, as Anand Kumar has suggested, that the British and Indian groups were initially ‘oblivious of each other’s work’.171 In interviews four decades later, Testart and Frydman both stated that they were unfamiliar with the details of Mukerji’s research.172 He had published only in India, in an ‘obscure’ technical journal in 1978, with Sunit Mukherjee and Bhattacharya, describing their protocol, but providing very little technical detail. This was similar to the initial British publication, but the British team had the opportunity to publish further details the following year.173 Yet Subhas Mukerji had worked on IVF for fifteen years.174 In addition, Sunit Mukherjee, who provided crucial expertise on cryopreservation, was nonetheless vulnerable, being ‘neither a medical doctor nor a reproductive biologist’—one sceptical doctor undermined his work by referring to it disparagingly as a ‘miracle’.175 The Indian team also lacked local support. Tellingly, the editors of the Indian Journal of Cryogenics accompanied the brief letter of Mukherjee (sic), Mukherjee and Bhattacharya announcing the IVF birth with a comment describing it as ‘basically an experimental work’, as yet not supported ‘by further data’.176 Senior colleagues disrespected Subhas Mukerji for having ‘openly criticize[d] a senior and powerful gynaecologist for conducting too many caesarean sections’ and there was ‘professional jealousy’ at successes Mukerji had enjoyed earlier in his career.177 When scientist John Biggers visited India from the United States for a conference,

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a US National Institutes of Health (NIH) official asked him to look into Mukerji’s work. Biggers interviewed Mukerji on 2 November 1978 and was convinced by the protocol used, which was in line with contemporary scientific practice. He says, ‘we were not inclined to dismiss the claim out of hand’. Biggers adds, ‘Nevertheless, the Indian doctors we talked to unanimously regarded the claim as fraudulent’.178 In addition, Sunit Mukherjee says that the team had not sought formal approval for their research, as that was not part of the research culture in India at the time; they were working ‘quietly and secretively’.179 So, when questions started to be asked about their research, they received little backing from colleagues and had no clear paper trail to support their claims. The Government of West Bengal, later accused of having ‘targeted and destroyed the standards of excellence in Bengal academia often with the weapon of political appointments’, set up a committee to investigate Kanupriya Agarwal’s birth.180 It was headed by a radiophysicist, an expert little suited to judge Mukerji’s work, and concluded that Mukerji had not achieved what he claimed. In addition, Mukerji had not submitted all the details of his protocols, in part due to lack of time, in part because he wanted to publish them in a peer-reviewed journal. He also had no proud parents to testify to his endeavours because, although Kanupriya’s parents’ names did appear in newspapers, they shied away from publicity.181 Mukerji was able to present his work at a few Indian scientific gatherings and meet some international researchers, but on 28 December 1978, the West Bengal government, through the Department of Health Services, barred him from attending conferences without specific permission, which they then systematically withheld. They also denied his requests for a leave of absence to write up his results. He was therefore unable to share his findings after the birth of Kanupriya Agarwal. He was eventually transferred to the Regional Institute of Ophthalmology on 5 June 1981, where he could not conduct his work. Isolated and humiliated, Subhas Mukerji took his own life on 19 July 1981, leaving a note making direct reference to the criticism he had faced.182 Mukerji’s team had conducted much of their work outside the hospital and the laboratory, as well as in a country not recognised globally as a scientific power; as anthropologist Sandra Bärnreuther argues, their achievement can be thought of as an ‘innovation out of place’, and

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therefore easier to reject for so long.183 The 1978 Indian birth was not widely recognised until 1997, when Anand Kumar, the man responsible for the first publicly acknowledged IVF birth in India, reviewed Mukerji’s notes and correspondence, and argued that Mukerji had indeed achieved what he claimed.184 Mukerji’s work was formally honoured by the Indian Council of Medical Research at a public meeting in 2004, attended by Mukerji’s wife Namita and Kanupriya Agarwal’s father Prabhat.185 A number of current chronologies listing world first IVF babies still do not recognise Mukerji’s work.186

Conclusions By the end of 1978, there were two healthy babies born following the use of IVF. Louise Brown was the first live baby resulting from natural cycle IVF.187 Kanupriya Agarwal was the second IVF baby, and the world’s first resulting from a hormonally induced cycle and a cryopreserved embryo.188 Patrick Steptoe and Robert Edwards, and later, Jean Purdy, received the greater global recognition for their achievement, but not simply because they worked harder, were smarter or were using more advanced technology. They did work tirelessly and innovatively, but they were also working in the right places, with support from the right quarters. Subhas Mukerji, Sunit Mukherjee and Saroj Kanti Bhattacharya, by contrast, were not afforded recognition, despite their similar technical and medical achievement. In some ways the births of Louise Brown and Kanupriya Agarwal are the climax of similar stories: both were built on a vast range of scientific ideas that were understood and reinterpreted in contemporary and local ethico-cultural contexts, and shaped by historically contingent ideas and imaginaries. Neither birth was the result of a concerted, state-supported push for infertility treatment, and both took place with little high-level regulation. The births were made possible by assembling technological artefacts, low-tech and high-tech practices, biological materials, professional interests, funding, researchers, clinicians, research volunteers and would-be parents. This tells us that many ingredients besides driven and gifted individuals are important for successful IVF, and shows that IVF

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was at once mundane and ground-breaking, working within but also reshaping science and medicine. In other ways, these two births proceed from very different stories. First, they are technically quite different. One relied on natural cycles, hormonal dosage for ovulation timing and high-tech laparoscopy for single egg retrieval. The details of these procedures, including those of the parents and a video of the birth by caesarean section, were deliberately made visible to the scientific community, the media and the public. The second relied on a hormonally induced cycle, mucosal viscosity assessment for ovulation timing, colpotomy (transvaginal incision) for multiple egg retrieval and cryopreservation of the embryos, the details of which did not appear for decades. They were also different in that Edwards and Steptoe were widely recognised by their peers and their claims were mostly accepted. By contrast, Mukerji and his colleagues were working with a higher degree of secrecy, were not well known in influential scientific circles and were met with greater local hostility. These differences between Edwards and Mukerji and the contexts in which they were working partly explain why in the end Louise Brown’s birth was accepted, contributing to Edwards’ Nobel Prize, but Kanupriya Agarwal’s was not, contributing to Mukerji’s suicide.189 Assisted reproduction using IVF is so normalised now, as both a treatment of choice and a scientific and medical career option, that it is hard to imagine how little it could be taken for granted in the early years. Even after 1978 there was no guarantee that such potential would grow into a medical industry, or that stories of the precariousness of resources, and consequent innovation and workarounds, would characterise the folklore of most major programs. It is clear, however, that markets for AR had, from the start, a capacity to expand vastly. As with the initial success of IVF, a delicate awareness of cultural context was essential to the continued clinical work and market expansion of what were once referred to as the ‘new reproductive technologies’.

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Notes 1. Cited in Katharine Dow, ‘“The Men Who Made the Breakthrough”: How the British Press Represented Patrick Steptoe and Robert Edwards in 1978’, Reproductive BioMedicine & Society Online 4 (2017): 59–67, 63. 2. James Le Fanu, The Rise and Fall of Modern Medicine (New York: Carroll & Graf, 2000), 127–46; John Leeton, Test Tube Revolution: The Early History of IVF (Clayton: Monash University Publishing, 2013), 1, 11–17. 3. Steptoe and Edwards mention the involvement of Jean Purdy throughout their first memoir, but she is often forgotten by others despite her essential role. Robert Edwards and Patrick Steptoe, A Matter of Life: The Story of a Medical Breakthrough (New York: William Morrow, 1980); Martin H. Johnson and Kay Elder, ‘The Oldham Notebooks: An Analysis of the Development of IVF 1969–1978. V. The Role of Jean Purdy Reassessed’, Reproductive BioMedicine & Society Online 1, no. 1 (2015): 46–57; Roger Gosden, ‘Jean Marian Purdy Remembered— The Hidden Life of an IVF Pioneer’, Human Fertility 21, no. 2 (2018): 86–89. 4. There are multiple spellings for the names of Subhas Mukerji and his colleagues (see Chap. 1). On the announcement of the first Indian birth, see K.  S. Jayaraman, ‘India Reveals Deep-Frozen Test-Tube Baby’, New Scientist 80, no. 1125 (1978): 159. For a critique of the assumptions that innovations like IVF ‘diffuse’ from Global North to the rest of the world, see Sandra Bärnreuther, ‘Innovations “Out of Place”: Controversies over IVF Beginnings in India between 1978 and 2005’, Medical Anthropology 35, no. 1 (2016): 73–89. 5. Sarah Franklin, Biological Relatives: IVF, Stem Cells, and the Future of Kinship (Durham, NC: Duke University Press, 2013); Susan Merrill Squier, Babies in Bottles: Twentieth-Century Visions of Reproductive Technology (New Brunswick, NJ: Rutgers University Press, 1994). 6. Franklin, Biological Relatives, 132. 7. Margaret M. Marsh and Wanda Ronner, The Fertility Doctor: John Rock and the Reproductive Revolution (Baltimore: Johns Hopkins University Press, 2008), 30–43, 75–76.

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8. Marian D. Damewood and John A. Rock, ‘In Memoriam: Georgeanna Seegar Jones, M.D.: Her Legacy Lives On’, Fertility and Sterility 84, no. 2 (2005): 541–42, 541. 9. Robin Marantz Henig, Pandora’s Baby: How the First Test Tube Babies Sparked the Reproductive Revolution (Cold Spring Harbor, NY: Cold Spring Harbor Laboratory Press, 2006), 20–22; citation for Landrum Brewer Shettles, ‘Response to Light in Peranema trichophorum with Special Reference to Dark-Adaptation and Light Adaptation’, in The Johns Hopkins University, Baltimore, Conferring of Degrees at the Close of the Sixty-First Academic Year, 1937, https://jscholarship.library. jhu.edu/ 10. Jean Cohen, Alan Trounson, Karen Dawson, Howard W. Jones, Johan Hazekamp, Karl-Gösta Nygren, and Lars Hamberger, ‘The Early Days of IVF outside the UK’, Human Reproduction Update 11, no. 5 (2005): 439–60; Leeton, Test Tube Revolution, 2–4, 11, 21–23. 11. T.  C. Anand Kumar, ‘Architect of India’s First Test Tube Baby: Dr. Subhas Mukerji, 16 January 1931 to 19 July 1981’, Current Science 72, no. 7 (1997): 526–31; Prithvijit Mitra and Arnab Ganguly, ‘Beautiful Mind’, Times of India, 13 June, 2009, https://timesofindia.indiatimes. com/; ‘India’s Test Tube Baby Doing Fine’, Sioux City Journal, 9 October, 1978; Bärnreuther, ‘Innovations’, 76. 12. Geoff Strong, ‘How Carl Wood Delivered Himself from His Own Anxiety’, Times on Sunday, 20 December, 1987. See also Leeton, Test Tube Revolution, 15. 13. Edwards and Steptoe, A Matter of Life, 47–49. 14. Edwards and Steptoe, A Matter of Life, 16–18. 15. Annette Alafaci, ‘Trounson, Alan Osborne’, 27 September, 2006, last modified: 1 August, 2007, in Encyclopedia of Australian Science, http:// www.eoas.info/biogs/P004778b.htm; Sarah Franklin, ‘“Crook” Pipettes: Embryonic Emigrations from Agriculture to Reproductive Biomedicine’, Studies in History and Philosophy of Science Part C: Studies in History and Philosophy of Biological and Biomedical Sciences 38, no. 2 (2007): 358–73, 367–68. 16. Jacques Testart, interview with Nicola J. Marks, 14 April, 2016; John D.  Biggers, ‘IVF and Embryo Transfer: Historical Origin and Development’, Reproductive BioMedicine Online 25, no. 2 (2012): 118–27. Interview protocols were approved by the University of Wollongong Human Research Ethics Committee (approval HE16/028).

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17. Lazzaro Spallanzani (1729–1799), for example, worked on animal IVF, AI and cryopreservation. Gary N.  Clarke, ‘ART and History 1678–1978’, Human Reproduction 21, no. 7 (2006): 1645–50; Iris Sandler, ‘The Re-Examination of Spallanzani’s Interpretation of the Role of the Spermatic Animalcules in Fertilization’, Journal of the History of Biology 6, no. 2 (1973): 193–223; R. H. Foote, ‘The History of Artificial Insemination: Selected Notes and Notables’, Journal of Animal Science 80, E-Suppl_2 (2002): 1–10. 18. Louis Girault, Étude sur la génération artificielle dans l’espèce humaine, (Paris: Aux bureaux de l’Abeille Médicale, 1869); Clarke, ‘ART and History’, 1649; J. K. Sherman, ‘Synopsis of the Use of Frozen Human Semen since 1964: State of the Art of Human Semen Banking’, Fertility and Sterility 24, no. 5 (1973): 397–412. 19. Sylviane Hennebicq, Jean-Claude Juillard, and Jean-Marie Kunstmann, ‘Le don de spermatozoïdes au sein des CECOS de 1973 à 2009 en France’, Médecine de la Reproduction, Gynécologie Endocrinologie 13, no. 3 (2011): 147–57; also Testart, interview. 20. T. C. Anand Kumar, ‘In Vitro Fertilization in India’, Current Science 86, no. 2 (2004): 254–56; see also Aditya Bharadwaj, ‘The Indian IVF Saga: A Contested History’, Reproductive BioMedicine & Society Online 2 (2016): 54–61; Aditya Bharadwaj, Conceptions: Infertility and Procreative Technologies in India (New York: Berghahn Books, 2016), 105–06. 21. Nelly Oudshoorn, Beyond the Natural Body: An Archaeology of Sex Hormones (London: Routledge, 1994), 9, 15–41. 22. Rock and Menkin’s publications include: John Rock and Miriam F.  Menkin, ‘In Vitro Fertilization and Cleavage of Human Ovarian Eggs’, Science n.s. 100, no. 2588 (1944): 105–07; Miriam F. Menkin and John Rock, ‘In Vitro Fertilization and Cleavage of Human Ovarian Eggs’, American Journal of Obstetrics and Gynecology 55, no. 3 (1948): 440–52; on Rock and hormone research, see Marsh and Ronner, The Fertility Doctor, 69–74. On Rock, Pincus and the contraceptive pill, see Marsh and Ronner, The Fertility Doctor, 146–160. On Pincus and the contraceptive pill, see Adele E.  Clarke, Disciplining Reproduction: Modernity, American Life Sciences, and the Problems of Sex (Berkeley: University of California Press, 1998), 193–94. 23. Bruno Lunenfeld, ‘Historical Perspectives in Gonadotrophin Therapy’, Human Reproduction Update 10, no. 6 (2004): 453–67. See also

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R.  G. Edwards, ‘The History of Assisted Human Conception with Especial Reference to Endocrinology’, Experimental and Clinical Endocrinology & Diabetes 104, no. 3 (1996): 183–204. Menkin worked with Pincus on the superovulation of rabbits in 1935–37, Marsh and Ronner, The Fertility Doctor, 76. 24. Squier, Babies in Bottles, 29. 25. Biggers highlights the importance of Pincus’ influence, while Squier emphasises that of Julian Huxley. Biggers, ‘IVF and Embryo Transfer’, 119; Squier, Babies in Bottles, 55. Dutch embryologist Jacques Cohen also mentions the important role of Haldane in imagining ectogenesis in ‘A History of Clinical Embryology and Therapeutic IVF: From Pythagoras and Aristotle to Boveri and Edwards’, in Infertility: Diagnosis, Management and IVF, ed. Anil K. Dubey (New Delhi: Jaypee Brothers Medical Press, 2012), 3–19, 11. 26. J. B. S. Haldane, Daedalus or Science and the Future; A Paper Read to the Heretics, Cambridge, on February 4th 1923 (London: Kegan Paul, Trench, Trubner, 1923). 27. Fran Bigman, ‘Pregnancy as Protest in Interwar British Women’s Writing: An Antecedent Alternative to Aldous Huxley’s Brave New World’, Medical Humanities 42, no. 4 (2016): 265–70. 28. Bigman, ‘Pregnancy as Protest’, 265. 29. Angus McLaren, Reproduction by Design: Sex, Robots, Trees, and Test-­ Tube Babies in Interwar Britain (Chicago: University of Chicago Press, 2012), 2–3. 30. Cultural tropes from science fiction have been used by proponents of the legalisation of embryo research to mock the concerns of those opposed to the research. Michael Mulkay, ‘Frankenstein and the Debate over Embryo Research’, Science, Technology, & Human Values 21, no. 2 (1996): 157–76; Clarke, Disciplining Reproduction, 248–50; Nicola J. Marks, ‘Science Fiction, Cultural Knowledge and Rationality: How Stem Cell Researchers Talk about Reproductive Cloning’, in The Body Divided; Human Beings and Human ‘Material’ in Modern Medical History, ed. Sarah Ferber and Sally Wilde (Farnham: Ashgate, 2012), 191–222. 31. Squier, Babies in Bottles, 55–56. 32. [John Rock], ‘Conception in a Watch Glass’, editorial, New England Journal of Medicine 217, no. 17 (1937): 678; Marsh and Ronner, The Fertility Doctor, 104.

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33. Squier, Babies in Bottles, 56–62. 34. Haldane, Daedalus, 66. 35. For discussions of the range of animals used in embryology see Nick Hopwood, ‘Approaches and Species in the History of Vertebrate Embryology’, in Vertebrate Embryogenesis: Embryological, Cellular, and Genetic Methods, ed. Francisco J.  Pelegri (New York: Humana Press, 2011), 1–20; Nick Hopwood, ‘Embryology’, in The Cambridge History of Science, Volume 6: The Modern Biological and Earth Sciences, ed. P. J. Bowler and J. V. Pickstone (Cambridge, UK: Cambridge University Press, 2009), 285–315; Frederick B.  Churchill, ‘The History of Embryology as Intellectual History’, Journal of the History of Biology 3, no. 1 (1970):  155–81. On AI see Foote, ‘The History of Artificial Insemination’. On how a blue whale was brought in for endocrinology research, see Oudshoorn, Beyond the Natural Body, 68. On axolotls, dogs and cows see Squier, Babies in Bottles, 35–38, 58. 36. Oudshoorn, Beyond the Natural Body, 65–81; Robert G.  Edwards, Barry D. Bavister, and Patrick C. Steptoe, ‘Early Stages of Fertilization In Vitro of Human Oocytes Matured In Vitro’, Nature 221, no. 5181 (1969): 632–35; P.  C. Steptoe, R.  G. Edwards, and J.  M. Purdy, ‘Human Blastocysts Grown in Culture’, Nature 229, no. 5280 (1971): 132–33; Testart, interview. 37. Grzegorz S.  Litynski, ‘Patrick C.  Steptoe: Laparoscopy, Sterilization, the Test-Tube Baby, and Mass Media’, JSLS: Journal of the Society of Laparoendoscopic Surgeons 2, no.1 (1998): 99–101. 38. Martin H. Johnson, ‘Robert Edwards: The Path to IVF’, Reproductive BioMedicine Online 23, no. 2 (2011): 245–62. 39. ‘Biologist Miriam Menkin Recalls Pioneer Efforts’, Morning Call (Allentown, PA), 30 July, 1978. 40. Edwards and Steptoe, A Matter of Life, 158. 41. Original for quotation: ‘Personne ne vient plus la nuit rêver sur cet embryon…’, in Jacques Testart, L’Œuf transparent (Paris: Flammarion, 1999), 92. 42. Loretta McLaughlin, The Pill, John Rock, and the Church: The Biography of a Revolution (Boston: Little, Brown, 1982), 62. 43. Menkin and Rock, ‘In Vitro Fertilization’, 441, 442, 443. 44. P. C. Steptoe and R. G. Edwards, ‘Laparoscopic Recovery of Preovulatory Human Oocytes after Priming of Ovaries with Gonadotrophins’,

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Lancet 295, no. 7649 (1970): 683–89; Edwards, Bavister and Steptoe, ‘Early Stages’, 633. 45. Kay Elder and Martin H.  Johnson, ‘The Oldham Notebooks: An Analysis of the Development of IVF 1969–1978. III.  Variations in Procedures’, Reproductive BioMedicine & Society Online 1, no. 1 (2015): 19–33, 26; Robert G. Edwards, ‘The Bumpy Road to Human In Vitro Fertilization’, Nature Medicine 7, no. 10 (2001): 1091–94, 1091; Johnson, ‘Robert Edwards’, 257. 46. Biggers, ‘IVF and Embryo Transfer’, 119, 121–22; Barry D. Bavister, ‘Early History of In Vitro Fertilization’, Reproduction 124, no. 2 (2002): 181–96; G.  Pincus and E.  V. Enzmann, ‘Can Mammalian Eggs Undergo Normal Development In Vitro?’, Proceedings of the National Academy of Sciences USA 20, no. 2 (1934): 121–22; Cohen et al., ‘Early Days’, 445; Rock and Menkin, ‘In Vitro Fertilization’. 47. Biggers, ‘IVF and Embryo Transfer’, 122; Bavister, ‘Early History’, 182–83. For the definition of capacitation, see Johnson, ‘Robert Edwards’, 254. 48. Biggers, ‘IVF and Embryo Transfer’, 120; see also Robert Bebbington, ‘Fertilisation In Vitro’, Lancet 293, no. 7592 (1969): 464. 49. Edwards, ‘Bumpy Road’, 1092. 50. Christopher De Jonge, ‘Biological Basis for Human Capacitation— Revisited’, Human Reproduction Update 23, no. 3 (2017): 289–99; Bavister, ‘Early History’, 183, 185, 187–88. 51. M. C. Chang, ‘Fertilizing Capacity of Spermatozoa Deposited into the Fallopian Tubes’, Nature 168, no. 4277 (1951): 697–98; C. R. Austin, ‘Observations on the Penetration of Sperm into the Mammalian Egg’, Australian Journal of Scientific Research B 4, no. 4 (1951): 581–96; C. R. Austin, ‘The “Capacitation” of the Mammalian Sperm’, Nature 170, no. 4321 (1952): 326. 52. R. Yanagimachi and M. C. Chang, ‘Fertilization of Hamster Eggs In Vitro’, Nature 200, no. 4903 (1963): 281–82. 53. De Jonge, ‘Biological Basis’, 292. 54. Edwards, Bavister and Steptoe, ‘Early Stages’. 55. Johnson, ‘Robert Edwards’, 254. 56. Main publications include Edwards, Bavister and Steptoe, ‘Early Stages’; R. G. Edwards, P. C. Steptoe, and J. M. Purdy, ‘Fertilization and Cleavage In Vitro of Preovulator Human Oocytes’, Nature 227, no. 5265 (1970): 1307–09. On pre-incubation of sperm in follicular fluid,

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see Edwards, Bavister and Steptoe, ‘Early stages’, 634. On ‘Barry’s magic culture fluid’, see Edwards and Steptoe, A Matter of Life, 80–82; B.  D. Bavister, ‘Environmental Factors Important for In Vitro Fertilization in the Hamster’, Journal of Reproduction and Fertility 18, no. 3 (1969): 544–45. See also Johnson, ‘Robert Edwards’, 256–57. On failed attempts at fertilisation, see R. G. Edwards, Roger P. Donahue, Theodore A. Barmki, and Howard W. Jones, Jr., ‘Preliminary Attempts to Fertilize Human Oocytes Matured In Vitro’, American Journal of Obstetrics and Gynecology 96, no. 2 (1966): 192–200. 57. D. De Kretzer, P. Dennis, B. Hudson, J. Leeton, A. Lopata, K. Outch, J. Talbot, and C. Wood, ‘Transfer of a Human Zygote’, Lancet 302, no. 7831 (1973): 728–29; David English, ‘Life Created in a Test Tube’, Age, 30 August, 1973. 58. Anand Kumar, ‘Architect’, 527. Heparinized means treated with heparin (a chemical originally isolated from liver cells) in order to avoid coagulation. Jay McLean, ‘The Discovery of Heparin’, Circulation 19, no. 1, (January 1959): 75–78. 59. Yves Ménézo, ‘Milieu synthétique pour la survie et la maturation des gamètes et pour la culture de l’œuf fécondé’, Comptes rendus hebdomadaires des séances de l’Académie des sciences 282 (1976): 1967–70. On B2 medium being patented, see Yves Ménézo, ‘Paternal and Maternal Factors in Preimplantation Embryogenesis: Interaction with the Biochemical Environment’, Reproductive BioMedicine Online 12, no. 5 (2006): 616–21. On the use of this medium by Australian and US teams and its name as ‘French champagne’, see Testart, interview. 60. Masakuni Suzuki, ‘In Vitro Fertilization in Japan: Early Days of In Vitro Fertilization and Embryo Transfer and Future Prospects for Assisted Reproductive Technology’, Proceedings of the Japan Academy. Series B, Physical and Biological Sciences 90, no. 5 (2014): 184–201, 190. 61. De Jonge, ‘Biological Basis’, 293. 62. Bavister, ‘Early History’, 184. 63. Edwards, Steptoe, and Purdy, ‘Fertilization and Cleavage’, 1307. 64. De Jonge, ‘Biological Basis’, 292; Edwards, Bavister and Steptoe, ‘Early Stages’, 633. 65. R. G. Edwards, P. C. Steptoe, and J. M. Purdy, ‘Establishing Full-Term Human Pregnancies Using Cleaving Embryos Grown In Vitro’, British Journal of Obstetrics and Gynaecology 87, no. 9 (1980): 737–56, 741. 66. Edwards, Steptoe, and Purdy, ‘Establishing Full-Term Pregnancies’, 753.

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67. Bavister, ‘Early History’, 188; Noritaka Hirohashi, ‘Site of Mammalian Sperm Acrosome Reaction’, in Sperm Acrosome Biogenesis and Function During Fertilization, ed. Mariano G.  Buffone (Cham: Springer, 2016), 145–58. 68. See Edwards and Steptoe, A Matter of Life, 122–24, on the shortening of menstrual cycle and use of further hormones. On the birth of Louise Brown after a natural cycle, see Edwards, Steptoe, and Purdy, ‘Establishing Full-Term Pregnancies’. 742–43. On Mukerji’s use of hMG and hCG, see Anand Kumar, ‘Architect’, 529. On the Australians’ development of IVF drugs clomiphene citrate  and hCG, see Cohen et al., ‘Early Days’, 441–42; John Leeton, ‘The Early History of IVF in Australia and its Contribution to the World (1970–1990)’, Australian & New Zealand Journal of Obstetrics & Gynaecology 44, no. 6 (2004), 495–501; Alexander Lopata, James B.  Brown, John F.  Leeton, John Mc. Talbot, and Carl Wood, ‘In Vitro Fertilization of Preovulatory Oocytes and Embryo Transfer in Infertile Patients Treated with Clomiphene and Human Chorionic Gonadotropin’, Fertility and Sterility 30, no. 1 (1978): 27–35. 69. Henig, Pandora’s Baby, 58–59. The Declaration of Helsinki was developed by the World Medical Association, adopted in 1964, and has been updated a number of times since. World Medical Association, ‘WMA Declaration of Helsinki—Ethical Principles for Medical Research Involving Human Subjects’, 9 July, 2018, https://www.wma.net 70. Clarke, Disciplining Reproduction, 174. 71. ‘Planned Parenthood Holds 25th Anniversary Meeting at Waldorf to Present Lasker Award’, New York Age, 26 January, 1946. 72. Eileen Murphy, ‘Self-Limited Population’, review of Voluntary Parenthood, by John Rock and David Loth, Oakland Tribune (CA), 23 October, 1949; see also ‘Young Couples Want Families but Better Ones, Experts Say’, Tampa Tribune (FL), 8 January, 1950, Main Edition. 73. Naomi Pfeffer, The Stork and the Syringe: A Political History of Reproductive Medicine (Cambridge, UK: Polity, 1993), 103–04, 108–09, 116. 74. Pfeffer, The Stork and the Syringe, 17, 109. 75. Pfeffer, The Stork and the Syringe, 18–21; Matthew Connelly, Fatal Misconception: The Struggle to Control World Population (Cambridge, MA: The Belknap Press of Harvard University Press, 2008), 115–54,

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161–63; Matthew Connelly, ‘Seeing beyond the State: The Population Control Movement and the Problem of Sovereignty’, Past & Present 193, no. 1 (2006): 197–233; Donald T.  Critchlow, ‘Birth Control, Population Control, and Family Planning: An Overview’, Journal of Policy History 7, no. 1 (1995): 1–21. 76. Clarke, Disciplining Reproduction, 194. 77. For example, Paige Whaley Eager, ‘From Population Control to Reproductive Rights: Understanding Normative Change in Global Population Policy (1965–1994)’, Global Society 18, no. 2 (2004): 145–73. 78. Sarah Franklin, ‘Response to Marie Fox and Thérèse Murphy’, Social & Legal Studies 19, no. 4 (2010): 505–10, 506. 79. See Clarke, Disciplining Reproduction, 225–29. 80. Suzuki, ‘In Vitro Fertilization in Japan’, 201. 81. Edwards and Steptoe, A Matter of Life, 34. 82. Robert Edwards, Life Before Birth: Reflections on the Embryo Debate (London: Century Hutchinson, 1989), 10. 83. Helen Szoke, ‘Social Regulation, Reproductive Technology and the Public Interest: Policy and Process in Pioneering Jurisdictions’ (PhD diss., University of Melbourne, 2004), 261. 84. Martin H.  Johnson, Sarah B.  Franklin, Matthew Cottingham, and Nick Hopwood, ‘Why the Medical Research Council Refused Robert Edwards and Patrick Steptoe Support for Research on Human Conception in 1971’, Human Reproduction 29, no. 9 (2010): 2157–74. 85. Yutaka Toyoda and Minesuke Yokoyama, ‘The Early History of the TYH Medium for In Vitro Fertilization of Mouse Ova’, Journal of Mammalian Ova Research 33, no. 1 (2016): 3–10. On the importance of Japanese researchers overseas, see M.  C. Chang, ‘My Life with Mammalian Eggs’, in Cellular and Molecular Aspects of Implantation, ed. Stanley R. Glasser and David W. Bullock (New York: Plenum Press, 1981), 27–36, 28. 86. Frederick Naftolin, Jennifer Blakemore, and David L. Keefe, ‘The American Roots of In-Vitro Fertilization’, in In-Vitro Fertilization: The Pioneers’ History, ed. Gabor Kovacs, Peter Brinsden, and Alan DeCherney (Cambridge, UK: Cambridge University Press, 2018), 21–27.

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87. R. Yanagimachi, ‘Germ Cells and Fertilization: Why I Studied These Topics and What I Learned along the Path of My Study’, Andrology 2, no. 6 (2014): 787–93. 88. Margaret Marsh, ‘Americans and Assisted Reproduction: The Past as Prologue’, in The Palgrave Handbook of Infertility in History: Approaches, Contexts and Perspectives, ed. Gayle Davis and Tracey Loughran (London: Palgrave Macmillan, 2017), 422–37, 428. 89. Marsh, ‘Americans and Assisted Reproduction’, 553–55. For an analysis of the interactions between feminisms, medicine and science in the 1970s and 1980s, see Michelle Murphy, Seizing the Means of Reproduction: Entanglements of Feminism, Health, and Technoscience (Durham, NC: Duke University Press, 2012). 90. Henig, Pandora’s Baby, 89–90. 91. Henig, Pandora’s Baby, 115–16, 155–69. 92. Biggers, ‘IVF and Embryo Transfer’, 125. See also Charis Thompson, ‘IVF Global Histories, USA: Between Rock and a Marketplace’, Reproductive BioMedicine & Society Online 2 (2016): 128–35. 93. Cohen et al., ‘Early Days’, 440–44; Leeton, ‘Early History’; Alex Lopata and Gabor Kovacs, ‘The Development of In-Vitro Fertilization in Australia’, in Kovacs, Brinsden, and DeCherney, In-Vitro Fertilization, 46–65. 94. W. K. Whitten, ‘Culture of Tubal Mouse Ova’, Nature, 177, no. 4498 (1956): 96; Hans Ingolf Nielsen and Jaffar Ali, ‘Embryo Culture Media, Culture Techniques and Embryo Selection: A Tribute to Wesley Kingston Whitten’, Journal of Reproductive and Stem Cell Biotechnology 1, no. 1 (2010): 1–29. 95. Nielsen and Ali, ‘Embryo Culture Media’, 2, 5. 96. Leeton, Test Tube Revolution, 4. 97. Leeton, Test Tube Revolution, 1. 98. Sandra P.  González-Santos, ‘From Esterilología to Reproductive Biology: The Story of the Mexican Assisted Reproduction Business’, Reproductive BioMedicine & Society Online 2 (2016): 116–27. 99. J. John Palen, ‘Fertility and Eugenics: Singapore’s Population Policies’, Population Research and Policy Review 5, no. 1 (1986): 3–14; John DiMoia, ‘Blastocysts and Family Planning: IVF and Tracking a Developmental Context for Biomedical Research in Singapore (1966–1994)’, Science, Technology & Society 18, no. 3 (2013): 275–89.

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100. Lijing Jiang, ‘IVF the Chinese Way: Zhang Lizhu and Post-Mao Human In Vitro Fertilization Research’, East Asian Science, Technology and Society 9, no. 1 (2015): 23–45. 101. René F.  Frydman, ‘The Development of In-Vitro Fertilization in France’, in Kovacs, Brinsden, and DeCherney, In-Vitro Fertilization, 102–03. 102. On laboratory assistants not being paid, see Testart, L’Œuf transparent, 53. On the low-tech status of the laboratory, see Violaine Kerbrat, Secrets de Sage-Femme (Paris: Calmann–Levy, 2010), 94. 103. Herbert Gottweis, ‘Stem Cell Policies in the United States and Germany’, Policy Studies Journal 30, no. 4 (2002): 444–69, 451. 104. Cohen et al., ‘Early Days’, 455–56; see also Lars Hamberger, Torbjörn Hillensjö, and Matts Wikland, ‘The Development of In-Vitro Fertilization in Scandinavia’, in Kovacs, Brinsden, and DeCherney, In-Vitro Fertilization, 111–19. 105. Cohen et al., ‘Early Days’, 440. On Austria specifically, see also Wilfried Feichtinger, ‘The Development of In-Vitro Fertilization in Austria’, in Kovacs, Brinsden, and DeCherney, In-Vitro Fertilization, 87–101. 106. Marsh, ‘Americans and Assisted Reproduction’, 552; Luca Gianaroli, Serena Sgargi, Maria Cristina Magli, and Anna Pia Ferraretti, ‘The Development of In-Vitro Fertilization in Italy’, in Kovacs, Brinsden, and DeCherney, In-Vitro Fertilization, 104–110. 107. Zion Ben-Rafael, ‘The Development of In-Vitro Fertilization in Israel’, in Kovacs, Brinsden, and DeCherney, In-Vitro Fertilization, 132–40, 132. 108. Ben-Rafael, ‘The Development of In-Vitro Fertilization in Israel’, 132–33. 109. Oliver Staley, ‘Holy Water: The Strange Story of a Fertility Drug Made with the Pope’s Blessing and Gallons of Nun Urine’, Quartz, 26 June 2016, https://qz.com/710516 110. B. Lunenfeld, S. Sulimovici, E. Rabau, and A. Eshkol, ‘L’induction de l’ovulation dans les amenorrheas hypophysaires par un traitement combiné de gonadotropins urinaires menopausiques et de gonadotropins chorioniques’, Comptes rendus de la Société française de gynécologie 32, no. 5 (1962): 346–51; Bruno Lunenfeld, ‘Gonadotropin Stimulation: Past, Present and Future’, Reproductive Medicine and Biology 11, no. 1

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(2011): 11–25; Neri Livneh, ‘The Good Father’, Haaretz, 30 May 2002, https://www.haaretz.com/1.5181405 111. Ben-Rafael, ‘The Development of In-Vitro Fertilization in Israel’, 133; E.  Rabau, A.  David, D.  M. Serr, S.  Mashiach, and B.  Lunenfeld, ‘Human Menopausal Gonadotropins for Anovulation and Sterility: Results of 7  years of Treatment’, American Journal of Obstetrics and Gynecology 98, no. 1 (1967): 92–98. 112. Barbara D.  Metcalf and Thomas R.  Metcalf, A Concise History of Modern India, 2nd ed., (Cambridge, UK: Cambridge University Press, 2006), 231 on modern India; 242–47, 250 on the Green Revolution; 256 on population. 113. ‘India in ’70s: A Turbulent and Testing Decade than Any Other in the Country’s History’ [sic], India Today, 23 December, 2014, https:// www.indiatoday.in 114. ‘Rise and Fall of Left-Front in West Bengal’, India Today, 14 May, 2011, https://www.indiatoday.in 115. Andrea Whittaker, ‘From “Mung Ming” to “Baby Gammy”: A Local History of Assisted Reproduction in Thailand’, Reproductive BioMedicine & Society Online, 2 (2016), 71–78, 77. 116. Sarah Franklin, Review of Louise Brown: My Life as the World’s First Test-­ Tube Baby, by Louise Brown and Martin Powell, Reproductive BioMedicine & Society Online 3 (2016): 142–44, 143. 117. Monica J. Casper and Adele E. Clarke, ‘Making the Pap Smear into the “Right Tool” for the Job: Cervical Cancer Screening in the USA, circa 1940–95’, Social Studies of Science 28, no. 2 (1998): 255–90. 118. Lawrence E.  Karp and Roger P.  Donahue, ‘Preimplantational Ectogenesis: Science and Speculation Concerning In Vitro Fertilization and Related Procedures’, Western Journal of Medicine 124, no. 4 (1976): 282–98. 119. Johnson, ‘Robert Edwards’, 251, 253; R. G. Edwards, ‘Maturation In Vitro of Human Ovarian Oocytes’, Lancet 286, no. 7419 (1965): 926–29. 120. Edwards, ‘Maturation In Vitro’, 929. 121. R.  J. Cole, R.  G. Edwards, and J.  Paul, ‘Cytodifferentiation and Embryogenesis in Cell Colonies and Tissue Cultures Derived from Ova and Blastocysts of the Rabbit’, Developmental Biology 13, no. 3 (1966): 385–407; R. G. Edwards, ‘IVF and the History of Stem Cells’ Nature 413, no. 6854 (2001): 349–51; Johnson, ‘Robert Edwards’, 251. For

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more, see US Department of Health & Human Services (HHS), National Institutes of Health (NIH), ‘Stem Cell Basics I’, https://stemcells.nih.gov/info/basics/1.htm 122. Johnson, ‘Robert Edwards’, 253, 259. 123. Sarah Franklin, Embodied Progress: A Cultural Account of Assisted Reproduction (London: Routledge, 1997), 153–54; see also Edwards and Steptoe, A Matter of Life, 11–15. 124. Jacques Cohen argues that ‘[t]ubal disease treatment using surgical intervention was well established and quite successful’, ‘A History of Clinical Embryology’, 11. On professionals’ desire to use the latest tools in reproductive medicine, see Judy Wajcman, Feminism Confronts Technology (Sydney: Allen and Unwin, 1991), 72. 125. René Frydman, Convictions: 30 ans de combats pour l’assistance médicale à la procréation (Paris: Bayard Presse, 2011), 38; Leeton, Test Tube Revolution, 1–2. 126. Casper and Clarke, ‘Making the Pap Smear’. 127. See Pfeffer, The Stork and the Syringe, 112–22; González-Santos, ‘From Esterilología’, 117, 119; Sebastian Mohr and Lene Koch, ‘Transforming Social Contracts: The Social and Cultural History of IVF in Denmark’, Reproductive BioMedicine & Society Online 2 (2016): 88–96. See also Jane Adams, ‘“A Cloak and Dagger Situation”: Artificial Insemination, Secrecy and Openness in New Zealand, 1950s to Early 2000s’, in The Reproductive Industry: Intimate Experiences and Global Processes, ed. Vera Mackie, Nicola J. Marks, and Sarah Ferber (Lanham, MD: Lexington Books, 2019), 51–68. 128. Robert G.  Edwards, ‘Patrick Christopher Steptoe, C.  B. E: 9 June 1913—22 March 1988’, Biographical Memoirs of Fellows of the Royal Society 42 (1996): 433–52; Peter R.  Brinsden, ‘The Story of Patrick Steptoe, Robert Edwards, Jean Purdy, and Bourn Hall Clinic’, in Kovacs, Brinsden, and DeCherney, In-Vitro Fertilization, 28–36. 129. Edwards, ‘Maturation In Vitro’, 929. 130. Testart, L’Œuf transparent. 131. For example, see R. G. Edwards and D. J. Sharpe, ‘Social Values and Research in Human Embryology’, Nature 231, no. 5298 (1971): 87–91; Edwards and Steptoe, A Matter of Life, 111–15. 132. Martin H.  Johnson and Kay Elder, ‘The Oldham Notebooks: An Analysis of the Development of IVF 1969–1978. IV. Ethical Aspects’, Reproductive BioMedicine & Society Online 1 no. 1 (2015): 34–45.

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133. Edwards and Steptoe, A Matter of Life, 96. 134. Edwards and Steptoe, A Matter of Life, 122. 135. The Lancet, ‘Eggs Shared, Given, and Sold’, editorial, Lancet 362, no. 9382 (2003): 413. 136. René Frydman, interview with Nicola Marks, 13 April, 2016. 137. Marsh and Ronner, The Fertility Doctor, 290–291; Thompson, ‘IVF Global Histories’, 131. 138. McLaughlin, The Pill, John Rock, and the Church, 64. 139. Marsh, ‘Americans and Assisted Reproduction’, 550–51. 140. ‘How the Medical Team Succeeded’, Australian Women’s Weekly, 20 February, 1980, 4–5. 141. Louise Brown and Martin Powell, Louise Brown: My Life as the World’s First Test-Tube Baby (Bristol: Bristol Books CIC, 2015), 21. 142. Edwards and Steptoe, A Matter of Life, 88; see also Leeton, Test Tube Revolution, 12 143. John McBain, ‘Children of a Fertile Revolution: IVF’, Australian, 19 June, 2010, https://www.theaustralian.com.au 144. Rayna Rapp, Testing Women, Testing the Fetus: The Social Impact of Amniocentesis in America (New York: Routledge, 1999), 306. Martin H.  Johnson, ‘IVF: The Women Who Helped Make It Happen’, Reproductive BioMedicine & Society Online 8 (2019): 1–6. 145. On ‘heterogeneous engineers’ see Donald Mackenzie, Inventing Accuracy: A Historical Sociology of Nuclear Missile Guidance (Cambridge, MA: MIT Press, 1990). On ‘assembling’, see Bruno Latour, ‘Why Has Critique Run Out of Steam? From Matters of Fact to Matters of Concern’, Critical Inquiry 30, no. 2 (2004): 225–48 and Maria Puig de la Bellacasa, ‘Matters of Care in Technoscience: Assembling Neglected Things’, Social Studies of Science 41, no. 1 (1 February 2011): 85–106. 146. Edwards and Steptoe, A Matter of Life, 131, 134–40; Elder and Johnson, ‘The Oldham Notebooks III: Variations in Procedures’; Johnson, ‘Robert Edwards’, 254. Martin H. Johnson and Kay Elder, ‘The Oldham Notebooks: An Analysis of the Development of IVF 1969–1978. VI.  Sources of Support and Patterns of Expenditure’, Reproductive BioMedicine & Society Online 1, no. 1 (2015): 58–70. 147. Anand Kumar, ‘Architect’, 526, 527. 148. Bärnreuther, ‘Innovations’, 80–83. 149. For example, see P.  C. Steptoe, R.  G. Edwards, and J.  M. Purdy, ‘Clinical Aspects of Pregnancies Established with Cleaving Embryos

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Grown In Vitro’, British Journal of Obstetrics and Gynaecology 87, no. 9 (1980): 757–68; De Kretzer et al., ‘Transfer’, 728; Subhas Mukherjee, Sunit Mukherjee, and S.  K. Bhattacharya, ‘The Feasibility of Long Term Cryogenic Freezing of Viable Human Embryos—A Brief Pilot Study’, Indian Journal of Cryogenics 3, no. 1(1978): 80. 150. AAP-Reuter-AP, ‘Father of Test-Tube Baby Wanted Anonymity’, Sydney Morning Herald, 9 October, 1978. 151. Bärnreuther, ‘Innovations’, 81. 152. Bärnreuther, ‘Innovations’, 81. 153. Cited in Dow, ‘The Men Who Made the Breakthrough’, 63; cited in Jayaraman, ‘India Reveals’, 159. 154. Associated Press, ‘4th Test-Tube Baby Born in Australia’, Miami News (FL), 23 June, 1980; ‘Australian Third “Test Tube” Mother?’, Sydney Morning Herald, 28 January, 1979. 155. Jayaraman, ‘India Reveals’; ‘New Ovum Implant; Disquiet Over Birth’, Age (Melbourne), 28 July, 1978. 156. AP-Reuter, ‘Test Tube Baby Not First?’, Sydney Morning Herald, 6 August, 1978; Associated Press, ‘Methods Called into Question: “Test-­ Tube Baby” Doctor Not to Get Award’, Globe and Mail (Toronto), 31 October, 1978. 157. Nancy Berryman, ‘Tube Baby: Legal Moral Row Just Starting’, Sydney Morning Herald, 30 July, 1978. 158. On ‘professional hostility’, see Martin H.  Johnson, ‘Professional Hostility Confronting Edwards, Steptoe, and Purdy in their Pioneering Work on In-Vitro Fertilization’, in Kovacs, Brinsden and DeCherney, In-Vitro Fertilization, 37–45. 159. Edwards and Steptoe, A Matter of Life, 53–55; Thompson, ‘IVF Global Histories’, 129. 160. Johnson, ‘Robert Edwards’, 251–53; Edwards and Steptoe, A Matter of Life, 98; Thompson, ‘IVF Global Histories’, 128. 161. Johnson and Elder, ‘The Oldham Notebooks IV.  Ethical Aspects’; Bärnreuther, ‘Innovations’, 74–75. 162. On sharing with Australian colleagues, see ‘Test Tube Mission’, Age (Melbourne) 30 January, 1979; on sharing with French researchers, see Testart, interview. 163. Johnson et  al., ‘Why the Medical Research Council Refused’, 2160, 2166.

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164. Associated Press, ‘Methods Called into Question’. The Barren Foundation was founded in 1960 to promote fertility research and education. 165. ‘Tempest in a Test Tube’, Miami News (FL), 3 November, 1978; Holland, John, ‘“Test Tube” Births: 100 Likely to Try’, Age (Melbourne), 22 February, 1979; Edwards and Steptoe, A Matter of Life, 182–83. 166. For example, Dow, ‘The Men Who Made the Breakthrough’; Peter R. Brinsden, ‘Thirty Years of IVF: The Legacy of Patrick Steptoe and Robert Edwards’, Human Fertility 12, no. 3 (2009): 137–43, 139. 167. Edwards and Steptoe, A Matter of Life, 179. 168. Johnson et  al., ‘Why the Medical Research Council Refused’, 2169, 2170. 169. Steptoe, Edwards, and Purdy, ‘Clinical Aspects’, 763–66. R. G. Edwards and P.  C. Steptoe, ‘Current Status of In-Vitro Fertilization and Implantation of Human Embryos’, Lancet 322, no. 8362 (1983): 1265–69, table VI. 170. Anand Kumar, ‘Architect’, 526, 527. 171. Anand Kumar, ‘Architect’, 526. 172. Testart, interview; Frydman, interview. Frydman knew of Mukerji’s suicide. 173. Anand Kumar, ‘Architect’, 530; Mukherjee, Mukherjee, and Bhattacharya, ‘Feasibility’, 80 174. Ranjan Gupta, ‘Jibes Put Test-Tube Baby Pioneer on Path to Suicide’, Sydney Morning Herald, 26 June, 1981. 175. Bärnreuther, ‘Innovations’, 81. 176. Mukherjee, Mukherjee, and Bhattacharya, ‘Feasibility’, 80. 177. Bärnreuther, ‘Innovations’, 82; Gupta, ‘Jibes’. 178. Biggers, ‘IVF and Embryo Transfer’, 124. 179. Our Bureau and AP, ‘Test Tube Triumph and Tragedy: Nobel for UK Scientist Stirs Memory of a Bengal Doctor’, Telegraph (Kolkata), 5 October, 2010, https://www.telegraphindia.com. For quotation, see Gupta, ‘Jibes’. 180. Our Bureau and AP, ‘Test Tube Triumph’. 181. AAP-Reuter-AP, ‘Father of Test-Tube Baby’; Anand Kumar, ‘Architect’, 531. 182. Anand Kumar, ‘Architect’, 530–31. ‘Test-Tube Doctor Kills Self ’, News Journal (Wilmington, DE), 21 June, 1981.

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183. Bärnreuther, ‘Innovations’; see also Bharadwaj, ‘The Indian IVF Saga’, 60. 184. Anand Kumar, ‘Architect’; Bharadwaj, Conceptions, 105. 185. Adhitya Gosh, ‘Late Honour for Test Tube Pioneer’, Times of India, 8 January, 2004, https://timesofindia.indiatimes.com 186. For a recent example, see Lopata and Kovacs, ‘The Development of In-Vitro Fertilization in Australia’, Table 6.5. 187. P. C. Steptoe and R. G. Edwards, ‘Successful Birth after IVF’, Lancet 312 (1978): 366. 188. Anand Kumar, ‘Architect’, 526. 189. Both Purdy and Steptoe had died by the time Edwards was awarded his Nobel Prize, meaning they were not eligible for it.

3 The Foundations of Global Assisted Reproduction

Between 1978 and 1981, the clinical field of assisted reproduction (AR) remained the province of ‘isolated groups of enthusiastic individuals’, most of whom were still working towards their first IVF births, sharing knowledge on an ad hoc basis.1 In 1979 Steptoe, Edwards and Purdy began a faltering move to take the Oldham program to Cambridge, Edwards’ university research base. Associated Newspapers, owner of the British Daily Mail, offered to purchase and fit out a new clinic there at Bourn Hall, an Elizabethan mansion.2 Notwithstanding that two ‘test-­ tube babies’ had been born in the UK in apparent good health, ‘fears that many abnormal babies would be born’ led the company to reverse its decision and withdraw funds.3 There was a hiatus of around one ‘wasted’ year, to quote Patrick Steptoe, with constant doubts about funding and without a suitable building.4 During this period of frustration for Edwards, he later noted with a hint of chagrin, ‘an IVF baby was born in Australia’.5 Candice Reed came into the world in June 1980 through the work of a large team at Melbourne’s Royal Women’s Hospital, becoming Australia’s first IVF baby.6 Eventually, new sources of funding enabled Bourn Hall to open as a private facility in October 1980.7

© The Author(s) 2020 S. Ferber et al., IVF and Assisted Reproduction, https://doi.org/10.1007/978-981-15-7895-3_3

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Over the four decades since that time, IVF-based AR has become available internationally in many forms, but a view that IVF was ‘perfected in Bourn Hall Clinic’ to then spread ‘around the world’ oversimplifies the story.8 As the early French IVF clinician Jean Cohen observed: ‘Let’s not forget that in 1978 very few doctors or biologists could predict the future of IVF in reproductive medicine’, adding that ‘those who were involved were motivated by a desire to succeed, innovate, understand the reasons for their failures and measure the progress of their competitors’.9 In view of low or, in many cases, zero success, nothing could be assumed. Up to the early 1980s, live births per treatment cycle were rare and the IVF procedure, successful or not, was costly, required numerous experts, and relied largely on patient payments. There was doubt even among providers about the viability of IVF as a treatment option, and scepticism in the wider medical profession about its ethics.10 The first AR practitioners maintained other research interests alongside IVF and few, if any, staked their careers exclusively on its success. Public interest, too, was patchy: the London Times in 1979 did not once mention IVF, even failing to report the birth in January of the Oldham program’s second IVF child, Alastair MacDonald.11 While the Observer thought a serialised memoir by Steptoe and Edwards in 1980 was worthwhile, publicly, the case for IVF was still to be made. A March 1980 Guardian article headlined ‘Birth of the Blues’ mused waspishly: ‘The chances are that unless you live in Cambridge or read the Observer, you will have forgotten all about test tube babies’.12 Yet in 1981, two of the world’s leading AR teams made confident claims that the future was bright. In March, Alan Trounson of the newly independent Monash University IVF program in Melbourne drew on the team’s latest clinical results to state that ‘I think the procedure has turned the corner’.13 In September, Robert Edwards echoed this sentiment in an article in Nature, entitled ‘Test-Tube Babies, 1981’. It began with the sentence: ‘This year should prove a turning point for the birth of children by the fertilization of human eggs in vitro’.14 Some key developments in 1981 pointed to the future direction of AR. The first was that the weight of opinion among teams working on IVF shifted to acceptance of fertility drugs to stimulate ovulation  and create multiple embryos. The second was that a self-conscious IVF-based fertility profession, addressing its

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work to a range of issues beyond tubal infertility, began to take shape. In the face of initial disagreement between key teams, particularly about the value of fertility drugs, and of criticism from the wider medical profession, providers came to identify ways to work internationally as a united front. Thus, if 1981, were the clinical turning point to which both Trounson and Edwards referred, the new direction of IVF nonetheless entailed the active nurturing and promotion of an incipient industry. This chapter outlines the key institutional means whereby AR became established worldwide. It begins with an account of the foundations of the new industry created by AR practitioners themselves, through the identification of new techniques and client groups, innovative professional meetings, new associations and journals, international peer training and cooperation with industry. It identifies some of the public criticisms of the industry, notably by fellow medical professionals and religiously motivated opponents. It describes government attitudes to the introduction of the new technology, including its symbolic significance as a marker of modernity, the potential role of IVF genetic screening as a public health measure, and the use of AR in relation to population policy. Throughout, the chapter draws attention to issues of financing and the role of news media, two key aspects of the development of the new industry.

Fertility Drugs and New Patient Cohorts Early IVF practitioners described the role of laboratory fertilisation as little more than a stand-in for the functions of a woman’s blocked fallopian tubes. The Royal Women’s Hospital team of obstetrician-­gynaecologist Ian Johnston, in Melbourne, depicted laboratory fertilisation as similar to the work of ‘an artificial fallopian tube’, comparable to a heart valve, pacemaker, artificial limb or ‘artificial kidney’ (referring to dialysis).15 Carl Wood, clinical leader of the Monash team, asserted similarly that ‘IVF is a method of copying the function of the tube but in the laboratory’.16 To characterise IVF as closely analogous to natural conception, aimed at overcoming tubal infertility, was at once a means of understating and of domesticating the technology’s full potential. The use of fertility drugs

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and the search for other clinical applications for expanding AR beyond the original patient cohort of women with tubal incapacity tended to subvert the elegant simplicity of these assertions that IVF was little different from natural conception.17 Once embryos were in the laboratory environment, the potential existed for their use with patients whose fertility was affected by conditions other than tubal blockage: for donation, for freezing and for investigations into embryonic development for both reproductive and non-reproductive uses. Where the gap lay in 1981 was between what the future might be and the still low number of live births. Creating more oocytes per cycle, with the use of either the drug clomiphene or human menopausal gonadotrophin (hMG), could lead to more births, especially if couples were willing to accept the implantation of more than one embryo. Timing of oocyte retrieval after administering human chorionic gonadotrophin (hCG) to trigger ovulation facilitated planning for the laparoscopic surgery the IVF process entailed. At this time, surgical tubal repair was still by percentage a more successful response to tubal infertility than IVF. If repair were not achievable, however, there would remain a substantial female clientele for whom IVF might be suitable.18 Had IVF remained solely a clinical response for women with tubal disorders, the story would have been a very different one. Expanded uses, enhanced by hormonal interventions, allowed for a crucial shift in public perception of IVF, opening the door to both greater acceptance and more significant challenges. The 1981 ‘IVF year’ began with the birth on 10 March of baby Victoria, the fourth credited IVF birth in the world and the first child born via IVF through the Monash program of Carl Wood, John Leeton and Alan Trounson. Melbourne’s original large team, of which these three were members, had split in June 1980 as a result of tensions over credit for the first Australian birth.19 Two weeks following the birth of Victoria, Trounson left Melbourne to attend the Third Congress on Human Reproduction in (then) West Berlin. A Melbourne newspaper characterised Trounson’s upcoming visits to the Berlin conference and to several leading universities as akin to a religious revival tour, with a front-page headline reading: ‘Scientist to Preach the Test Tube Baby Method’.20 Trounson stated that the ‘programme could now be set up in other

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countries because there’s an enormous number of clinics and patients who could profit by this’.21 In Berlin, Trounson presented a detailed and well-received account of how to carry out IVF. According to one clinician-­ scientist who was there, ‘People were standing outside because they couldn’t all fit in the room’.22 Trounson argued that fertility drugs could increase the chances of creating a child through IVF. He documented the team’s changes to almost every IVF protocol current at the time, which had implications for surgical choices, instruments to be used, ovulation testing and culture media, and the stage of embryo development prior to reimplantation, among other aspects of treatment.23 The two Melbourne teams and the Bourn Hall team all published studies in 1981 reporting intense clinical activity. Combined, they showed outcomes for more than 400 individual patients, some of whom had undergone more than one treatment cycle.24 Teams in the United States, Germany, Austria, France and Scandinavia were continuing their attempts, if at a slower rate.25 The Monash and Royal Women’s Hospital teams in Melbourne were both convinced of an increased likelihood of pregnancy from stimulating the production of multiple oocytes and the use of hCG, against Bourn Hall’s preference for the unstimulated cycle.26 Edwards conceded that ‘the regulation of ovulation is undoubtedly easier’, as well as being a ‘considerable help in organizing laboratory or surgical teams for oocyte recovery’, but identified clinical problems that could arise as a result of the stimulated cycle.27 Each team’s publications identified new client groups for which IVF might become the treatment of choice. All proposed that IVF could be a response to idiopathic (unexplained) infertility and to male infertility, notably arising from oligospermia, meaning low sperm count, and low sperm motility. They also referred to a range of problems in the female reproductive system, including in the endometrium and the cervix, as well as in the makeup of oocytes.28 At variance with colleagues, the Monash team also wrote that IVF was suitable for women over thirty-five (such as the mother of baby Victoria).29 The program excluded women over forty, but later raised that to forty-five.30 Notwithstanding Bourn Hall’s ambivalence about fertility drugs, Edwards noted that ovulation induction would lead to the creation of ‘spare embryos’, even if freezing embryos ‘still appears to be distant’.31 The Monash team were already

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offering embryo freezing, although the second birth using that process, after that of Kanupriya Agarwal in 1978, was still two years away.32 ‘In a single stroke’, Ian Johnston’s team argued, AR ‘has the potential for solving a multitude of reproductive disabilities’, reflecting that ‘when one realizes that the list virtually summarizes all the causes of infertility exclusive of intractable anovulation [an inability to ovulate] and those patients without a uterus or a husband, one realizes the full potential of this work’.33 Indeed, the potential was greater than even they allowed, as intractable anovulation could be countered in theory by oocyte donation, and the desire for parenthood in a woman without a uterus could in theory be addressed by IVF surrogacy, commercial or otherwise. For women ‘without … a husband’—solo women or lesbian couples—sperm donation was already technically possible. Providers knew of these avenues but at times differed on their social acceptability. Wood and Trounson were more prepared to comment speculatively on the use of IVF for egg or embryo donation, surrogacy, reproductive cloning, embryo manipulation and the sexing of embryos.34 The reservations of Johnston and colleagues were more a cultural assessment of what was acceptable to the wider public and the churches than a strictly medical opinion, as the barriers to which they pointed were social rather than technical. Indeed, Johnston elsewhere observed that ‘each society will have its own social standards and norms, and changes will be introduced at different rates according to the social outlook of each country’.35 Even within countries, diverse perspectives emerged. Wariness among non-IVF clinicians about the safety and utility of the techniques featured in the press, with views ranging from a mild collegial caution to calls for the work to be put on hold.36 In July 1981, the British Medical Association’s (BMA) ethics chair, Michael Thomas, warned of the potential risk to children born as a result of new kinds of AR procedure, arguing that if the medical profession did not discuss IVF urgently, it would be ‘completely overtaken’ by the practice.37 The Medical Research Council had expressed concern for the health of offspring years before, but for the MRC the question at least seemed to have been partially resolved by the birth of healthy children.38 In a warning on the societal implications of genetic manipulation, Thomas invoked the spectre of Brave New World, in which individuals would ‘conform to the party line

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before birth’.39 The BMA itself, however, did not seek a moratorium on IVF.40 Obstetrician-gynaecologist Robert Winston (later Lord Winston), of Hammersmith Hospital, London, was at the time a world leader in the use of tubal surgery, a procedure he saw as still superior to the use of IVF for tubal infertility. He had introduced IVF to the hospital in 1980, but his appraisal of its success rates was nonetheless blunt: ‘The procedure is very unsuccessful and could never be widely used’; his statement was reinforced by an Australian IVF clinician, who observed that ‘fellow gynaecologists … felt that [IVF] technology exceeded requirements and would never really catch on’.41 The IVF teams knew well that the live birth rate per treatment cycle was low and, for those wanting to have a child using the new treatments, could not have seemed encouraging. Yet it was encouraging enough. By the measure of a chance to create even one new human life, for the people concerned, the value appears to have been incalculable. Assisted reproduction, as what Sarah Franklin calls a ‘hope technology’, became increasingly entrenched as a fertility treatment choice when the total number of live births had scarcely exceeded single figures.42 To reiterate: there was no guarantee that the venture of AR would succeed, that there would be financiers or indeed support from within the ranks of the medical world. From all the evidence, however, one thing seemed sure: it appeared there would always be clients. Everywhere that providers set up programs there were long waiting lists. As early as 1982, for example, one Australian unit stated it had a waiting list of nearly 2000.43 To establish a record of successful procedures was vital for the credibility and viability of IVF as a treatment option. Robert Edwards wrote of the early period at Bourn Hall as a time when more births were crucial: ‘Starting with natural cycles, dozens of pregnancies were established within a month or so … It was essential to conceive as many children as possible, and the rooms and corridors of Bourn Hall soon filled up with patients from far and wide’.44 People travelled to the clinic from around the world—‘the USA, Canada, Greece, Yugoslavia and many other countries’—seeking a conception at Bourn Hall, with the aim of going home for the births.45 Positive publicity in the medical press in relation to different kinds of AR likely encouraged non-IVF clinicians to refer patients on to the new programs, while mainstream press versions of the same

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information could have reached potential patients and clients directly. If, as is often said, AR technology runs ‘ahead of medical ethics’, at the early clinics demand was running ahead of technology.46 For if IVF was something of a leap of faith, it was the clients who were making the leap. While on the one hand there were growing moves from wary medical professionals to oppose or at least constrain the practice of IVF, on the other, there was a guaranteed and growing market awaiting even the slightest advancement.47 Wood and Trounson believed, however, that if global collaboration did not soon take place to improve success rates, use of the new technique would lapse.48 In this crucial historical moment, leading IVF teams from across the world joined forces.

The First Bourn Hall Meeting In September 1981, Bourn Hall hosted an invitation-only meeting, the ‘first major meeting of IVF specialists’, of twenty-five clinicians and scientists from the UK, Australia, Switzerland, Sweden, Germany, France, Austria, and the United States, on the basis of their being well advanced in their programs.49 It appears that no one from India was present. Nothing could underline more clearly the precariousness of individual success than the tragic fact that just two months before this meeting, Subhas Mukerji had taken his own life.50 Bourn Hall and the two Melbourne programs were the clear leaders in the field, in terms of both the number of patients being treated and the number of live births.51 In 1981, the Monash team was forcing the pace, providing evidence to challenge the theories of rival programs at Melbourne’s Royal Women’s Hospital and Bourn Hall.52 According to a newspaper interview with Carl Wood on 5 September 1981, there had been thirteen IVF live births, eleven of them in Melbourne, including nine through the Monash program, which was housed in the Queen Victoria Hospital. Wood expressed the dominance of his team in sporting terms: ‘Queen Vic 9; rest of the world 4’. ‘Rest of the world’ for Wood by this point included not only the Bourn Hall team, but his Melbourne neighbours at the Royal Women’s Hospital.53 The US team of Howard Jones, an obstetrician-gynaecologist, and Georgeanna Seegar

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Jones, an obstetrician-gynaecologist and expert in endocrinology, were at that point awaiting the first birth from IVF in the United States, which took place in December 1981. Howard Jones referred to the Bourn Hall meeting whimsically as ‘a small IVF mafia type group’ that sought to ensure ‘communication of the current state of affairs could be transmitted quickly’.54 Many of those present at Bourn Hall had already actively cooperated with each other: Jean Cohen referred to the early years in France as being characterised by an ‘amicable—if competitive—atmosphere’ and René Frydman recalls collaboration between the French teams, and fruitful exchanges with Australian clinicians during a visit to Melbourne.55 Edwards had travelled to the United States to work with Jones and Seegar Jones, worked with the two rival French teams and taught the then sole Australian team (in his words) ‘all we knew’ prior to its 1980 success.56 The Bourn Hall gathering embodied an emergent sense of group identity, but Steptoe and Edwards had faced continued criticism from local and overseas colleagues for the lack of scientific detail in their public utterances. As one provider put it: ‘Bob and Patrick … only reported limited descriptive details’ and the Australian press depicted the meeting as a response to other providers’ sense of exclusion.57 Carl Wood commented at the time on the high cost of IVF at Bourn Hall, proposing mischievously that there be a counter-conference in London to which doctors who supported the use of British National Health Service (NHS) funding could be invited. At that time, Robert Winston at Hammersmith Hospital and Ian Craft of the Royal Free Hospital were advanced in their IVF work and both favoured NHS support for the process, but it appears neither was invited to the Bourn Hall meeting.58 The Bourn Hall meeting reflected the medical tradition of collaboration based on an awareness of the need to promote shared goals. Historically, medical, scientific and other professionals have established societies and colleges to claim a new terrain of innovation. Indeed, a similar but smaller culture-building group calling themselves ‘The G Club’ first met in 1953 to explore the use of gonadotrophin protocols in fertility treatment. One attendee had been leading endocrinologist John Loraine of the University of Edinburgh, who later trained Subhas Mukerji. Another was the New Zealand–born endocrinologist James

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Boyer Brown, an early collaborator with the first Melbourne IVF team.59 At the Bourn Hall meeting, the use of hormones that built on this history was a major talking point. Alan Trounson spoke of the value of using fertility drugs and, unsurprisingly, given that those present had publicly disagreed over the question, a ‘heated’ discussion arose.60 The meeting appears to have ended in a consensus that using fertility drugs was on balance the best approach, a clinical policy direction that became the norm, enabling important accretions on ‘basic IVF’.61 Ethics and politics were also prominent on the agenda. Attendees were aware of opposition to the treatments, including that from medical colleagues, but most notably from the anti-abortion lobby, which depicted embryo research as a form of abortion. Howard Jones addressed himself to these issues, having encountered significant opposition in the United States prior to establishing a unit at Norfolk hospital in the state of Virginia. Jones provided his colleagues with a kind of media-training exercise, rehearsing stock ‘rejoinders to frequent objections’, particularly relating to the moral status of the embryo. He rounded off his presentation with a general statement under the heading ‘The Separation of Secular and Religious Authority: A Most Serious Consideration’, arguing that to fail to adhere to that division was to ‘invite tyranny’.62 Jones prioritised response to religious activism; in citing religious opposition as the key threat to the incipient industry, Jones implicitly positioned as secondary medical colleagues’ anxieties about clinical aspects of IVF. This approach foreshadowed a tendency that came to characterise much of the future public policy debate about IVF. Bourn Hall moved quickly to publish the papers from what was to become the first of many meetings there. One participant saw the event as having provided the seedbed for the formal collaboration of the major European providers, under Edwards’ guidance, in the European Society of Human Reproduction and Embryology (ESHRE).63 Advancing the technology and ensuring that market expansion could occur entailed a self-conscious effort on the part of providers to optimise the available body of technical knowledge and client interest. Success came as the result of careful deliberation, considered initiatives and defensive strategies, as well as being an ongoing story of rivalry.

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Media Responses In early December 1981, the leading generic medical journal the Lancet condensed the year’s developments in a positive editorial entitled ‘Test-­ Tube Babies—Whatever Next?’64 The Lancet editorial picked up and digested for general medical readers several recent articles, two of which had first appeared in a prestigious, multi-disciplinary research journal: Nature for Edwards and Science for Trounson and colleagues. The Lancet came out in favour of the use of hormonal stimulation, noting that the views of Steptoe and Edwards were being superseded and that ‘criteria previously stated to be necessary for success are open to question’. It observed that the use of fertility drugs ‘probably increases a couple’s chance of eventual parenthood’. Mindful of the cost factor, the Lancet also argued that the chance to freeze multiple embryos from a single treatment could save patients money: ‘Economically, there would be advantages in superovulation coupled with cryopreservation’. The article referred to Edwards’ earlier abandonment of the use of drugs, while Australian groups were now using them with success. It noted that ‘Wood and others have shown that in-vitro fertilisation and embryo transfer may have applicability in certain forms of infertility other than obstructive tubal disease’. These developments led the author to speculate that IVF treatment ‘might even become first-line treatment for obstructive tubular disease [meaning the choice over tubal repair], unexplained infertility, and infertility associated with endometriosis, cervical hostility, or oligospermia’.65 The Lancet’s views then made their way into the public domain via a now standard route, transiting from the scientific and medical community to the daily press. By the time the Lancet story reached the London Times, four days after its initial publication, the headline seemed to invite prospective users of the technologies: ‘Wide Scope for Test Tube Baby Method’. The Times downplayed the challenges of the treatment, describing the potential of IVF to become a ‘simple, regular procedure’.66 Women unable to produce ova, the article stated, could benefit from donor ova ‘in much the same way that couples can benefit from artificial insemination by donor’. This framing of the question, itself possibly anticipating moral, rather than

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medical, objections, passed over the significant difference between women providing eggs and the usual way in which men provided sperm (through masturbation): at minimum, to undergo surgery, as well as the probable use of fertility drugs.67 For ‘a woman whose offspring would be at risk of an inherited disease’, the article proposed the use of donor eggs, or, in the case of infertility in both partners, ‘embryo adoption’.68 Preimplantation genetic diagnosis (PGD) to exclude embryos carrying heritable conditions (now one kind of preimplantation genetic testing or PGT), something Edwards had long considered, did not feature in the Times article, but over the next few months both that possibility and embryo freezing featured in the mainstream media.69 Perhaps inevitably, continued publicity for developments in AR left the door open for the expression of further medical concerns. The Royal College of Obstetrics and Gynaecology formed a working party to consider the implications of the technology.70 In the face of medical scepticism, and building on the Bourn Hall meeting, IVF providers positioned themselves as a self-­ conscious profession that drew on disciplinary diversity while being neither strictly laboratory science nor clinical medicine.

Institutionalising Assisted Reproduction: Associations, Meetings, Journals Medical societies primarily provide meeting grounds, both literal and figurative, at conferences and in the publication of academic journals or bulletins. Like many collegial institutions, they exist to give shape and direction to a field, to convey information and advice, and often to enforce discipline when members stray from agreed principles. They equally serve members by providing protection from outside criticism, notably from governments perceived as intrusive. In this instance, they further institutionalised AR through the creation of new groups, meetings and journals. The American Fertility Society (AFS) came into being in 1944—later becoming the American Society for Reproductive Medicine (ASRM)— and published the leading industry journal Fertility and Sterility from

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1950. From the early 1980s ESHRE, under the inspiration and guidance of Robert Edwards and Jean Cohen, moved quickly to establish a journal, Human Reproduction, as a direct rival to Fertility and Sterility.71 ESHRE’s membership grew at a rapid rate as the number of delegates to meetings rose ‘from almost 1000  in Milan in 1990, to 1600  in Thessaloniki in 1993, 2,178 in Maastricht in 1996 … reaching 3,700 in Bologna by the end of the decade’.72 ESHRE also undertook an active program to ‘export’ its meetings outside the countries of its north-west European origins. In 1991 alone, it held first a workshop in Moscow in May, then in September in Israel, where AR had been rapidly adopted, and later in Cairo in November.73 The official history of ESHRE makes clear that groups with overlapping interests jockeyed for position, as the industry expanded and new groups competed with or absorbed others.74 The Fertility Society of Australia (FSA) came into being in 1982 as the result of the merging of three groups: the Australian Obstetrical and Gynaecological Research Society, the Australian Society of Reproductive Biology and participants in a series of Artificial Insemination by Donor (AID) workshops.75 The FSA included New Zealand practitioners, reflecting an established tradition of cooperation across the Tasman Sea.76 Similarly, in Japan in 1982 IVF researchers inaugurated the Japan Society of Fertilization and Implantation, which was separate from the Japan Society of Fertility and Sterility that had been in existence since the 1950s. The newer group favoured clinical implementation of new technologies.77 A new Middle East Fertility Society first met in 1993, in collaboration with ESHRE.78 In the Nordic region, Denmark, Norway, Sweden, Finland and Iceland had held meetings every eighteen months since 1981, and in 1998 formalised their connections as the Nordic Fertility Society.79 And in 2001, Israel-based Austrian obstetrician and endocrinologist Bruno Lunenfeld, himself a founder of ‘The G Club’, co-founded the Asia Pacific Initiative on Reproduction (ASPIRE) with Singapore-based obstetrician P. C. Wong.80 Cooperation across disciplinary boundaries was the cornerstone of AR practice, and some of the new associations entrenched this new form of collegiality. Indeed, one clinician made a colourful self-mocking comparison of his role to that of scientists, saying, ‘except for minor changes in the stimulation protocols and aspiration of oocytes we [clinicians] did

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“bugger all”’.81 ESHRE enshrined a policy that scientists and clinicians would take turns to chair the group.82 The Fertility Society of Australia went further, ensuring from the start that its members came from across the multiple disciplines involved in the creation of AR births, including nurses and social workers. Even clients became society members in some cases, as they worked with providers to influence policy in the interests of the infertile.83

International Training In the early 1980s, US clinician Richard Marrs was attempting to provide IVF without success, and decided ‘I really needed to go see someone who had had a baby’.84 According to one medical financier, the problem with IVF was that it was difficult to replicate successfully because the ‘procedures happen to be operator sensitive. It is like a famous neurosurgeon who is able to do a procedure that his best students cannot do very well’.85 This view was echoed by a practitioner in a more vernacular vein: ‘The best IVF doctors are like master chefs … Very subtle differences in the recipe can make the difference between success and failure’.86 One recipe for success entailed hands-on training. Early providers responded to requests to teach their colleagues how to perform the complex mix of techniques that might lead to an IVF birth. These collegial traditions were well established in surgery, for example, but in the case of IVF, gaining expertise in the laboratory was equally important.87 Just as the British Empire had played a central role in the early development of IVF, places such as Bourn Hall and Monash University in turn became little scientific ‘empires’, to which aspiring practitioners looked for knowledge.88 Marrs himself spent six weeks in Melbourne working with the two competing teams: ‘I learned how to stimulate, how to time ovulation. I watched the PhDs in the lab—how they handled the eggs and the sperm, what the conditions were, the incubator settings’.89 Paul Devroey, founder of an influential Belgian AR program recalled: ‘We went to America and Australia to different centres, to get an idea about the technology’.90 Masakuni Suzuki, the obstetrician who facilitated the first IVF birth in Japan, established an extensive program of international

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scholars to visit his unit in Sendai over thirteen years.91 International collegiality was at times strained: Edwards wrote of rival clinics attempting to poach Bourn Hall employees and referred to some providers as being ‘outspokenly mercenary’, having accepted ‘free advice as they planned chains of clinics like Woolworths across a country or continent’.92 Expansion, however, has been fundamental to the global commercial success of AR. Bourn Hall now gives its name to part of a multinational medical conglomerate, TVM Capital Healthcare, currently with two centres in the United Arab Emirates.93 The Dubai unit specifically invokes its European origins: ‘Visiting Bourn Hall Centre Fertility in Dubai gives you access to the best of our British heritage with the best minds in fertility treatment and the latest assisted reproductive technology—and you’ll receive treatment in one of the most beautiful cities in the world, Dubai!’94 In Mali, the founder of the country’s first AR clinic trained in Ukraine and his biologist offsider trained in Bulgaria, possibly reflecting Mali’s early links with the Eastern bloc.95 A newly founded regional society on the African continent, Groupe inter Africain d’étude, de recherche et d’application sur la fertilité (GIERAF), uses French as its principal language of communication, reflecting French and Belgian colonial histories.96 Limitations on funding and expertise, in particular, have always affected the uptake of AR. In some countries, the more recent establishment of AR has recapitulated the stories of inventiveness of the early providers. The first practitioners in Mali purchased second-hand instruments from France; clinician Zhang Lizhu in the People’s Republic of China asked colleagues visiting from abroad to bring in supplies, and kept her multi-use surgical instruments sharp by taking them to a watch repairer.97 A sole clinic opened in Zimbabwe in 1987 but closed in the early 2000s, due to lack of expertise, reopening again in 2017.98 Indeed, a globally uneven distribution of expertise has continued to entail the presence at different treatment sites of ‘IVF troubadours’, travelling clinical or scientific experts.99 Beyond global medical networks, money and the news media have been indispensable to the development and uptake of AR.

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Money In some countries, fertility providers who were already established as clinicians contributed money to set up clinics. In 1983, Ian Johnston referred to himself and a clinician colleague paying the salaries of team members at the Royal Women’s Hospital in Melbourne, saying: ‘a very big slab of the reproductive team is paid for by myself and R’.100 Robert Winston in London also provided personal funds to his program.101 In Mali at the start of the twenty-first century, the same pattern continued. There, the principal clinician, Dr Mba, used his own money to obtain training overseas, then borrowed to set up the fertility clinic in his practice.102 Funding by individual benefactors and patient support groups also played a crucial role for the Oldham/Cambridge team, for key Australian units, and for the Norfolk program. Just as the UK team received funds from Lillian Lincoln Howell, the Royal Women’s Hospital in Melbourne received funding from a ‘multi-millionaire’ in Western Australia, and a former patient’s family foundation provided start-up funds for Jones and Seegar Jones.103 Patients donated funds to Carl Wood’s Monash unit for salaries, and the parents of Australia’s first IVF child, Candice Reed, donated a significant sum to the Royal Women’s Hospital Program, from a payment they received for an exclusive news story.104 Activism on the part of AR patients and clients became an international movement that continues in different forms today. In New Zealand, among other places, state support for the introduction of AR as a fertility treatment was a response to lobbying by patients.105 Alliances like the US group Resolve, founded in 1974, the New Zealand groups Resolve and the Auckland Infertility Society, and Australia’s IVF Friends all provided client support, as well as lobbying for liberalisation in government policies and funding for AR.106 Currently there are around thirty-six such groups worldwide.107 Medical insurance policies and the presence or absence of public health service provision and health insurance, such as Australia’s Medicare and the UK’s NHS, have shaped and continue to shape the manner in which AR takes place. Warren Jenkins, an employee of the fertility drugs

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manufacturer Serono, recalled that in Australia in the 1980s, before AR treatment was listed on the national health scheme, ‘it was noted that it was expensive for uninsured patients to pay for IVF, particularly the drugs. There was a need to put pressure on Canberra’—site of the federal government—to obtain reimbursement for IVF, so that the client base could be expanded. To advance the cause Serono set up an in-house office for a pre-existing patient advocacy group to lobby for medical rebates.108 Funding for AR also followed the more traditional pathway for any high-­ end venture: seeking equity from investors.109

Commercial Ties: Drugs and Devices Pursuit of improved rates of success entailed continued development of variations on drug regimens and the investigation of new drugs, as well as the development of surgical instruments and laboratory consumables such as culture media. Manufacturers of fertility drugs from early on provided support to underpin the institutionalisation of AR. Warren Jenkins recalled: From the start, there were two competing drug companies, Serono and Organon, to supply the clinics with gonadotrophins … Basically both the products were the same, so we had to come up with some differentiating factors to encourage medical practitioners to prescribe one drug in preference to another.

These strategies included providing ‘educational support’ to providers.110 For a group like ESHRE, the sale of commercial space meant meetings became not merely a chance to exchange knowledge but, as is often the case in medical industries, caused them to take on something of the character of a trade fair.111 In the 1980s, Serono’s profits from AR rose dramatically in light of the widespread use of ovulation induction for AR.  One report cites profits rising in the United States from US$7.2 million in 1982 to US$35 million in 1986. In 1988 its parent company, Aeres-Serono, was able to purchase Bourn Hall itself.112

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Early medical-scientific teams remained active in the development of the technical components of AR. Jacques Testart and his team in France built a catheter to implant embryos; it was named the Frydman catheter and is still in use today.113 Testart also recalls tinkering with an incubator for premature babies, adding a magnifying glass through a hole in the plexiglass, and later a microscope, and creating a temperature-controlled working space, ‘a small enclosure which was, in the end, the whole laboratory’.114 Economies of scale have led to a transition from home-made to industrial. As Australian-based IVF scientist John Tyler observed, culture media were once ‘prepared in the laboratory, using highly distilled water, and the instruments were made on site and re-used. Now these things can be provided commercially’.115 Since the 1980s, several Nordic programs have contributed design expertise to facilitate AR, early government treatment subsidies having positioned the industry to expand. Several early AR companies developed new surgical instruments, laboratory fittings and culture media.116 One Danish company worked with clinicians towards the introduction of ultrasound in IVF from 1982, devising techniques for oocyte imaging that gradually led to the replacement of the laparoscope as the surgeon’s visual guide for egg retrieval. This technique in turn allowed for the increased use of transvaginal oocyte extraction, thereby reducing the need for a general anaesthetic.117 So profitable is the technical side of the industry today that stock market prospectuses section off the technical component of AR as a stand-alone item, meriting investment in its own right. Online investment advice currently projects that the AR devices market will reach more than US$7 billion in 2025.118 Providers were from the start wary of the need to balance commercialisation with the ethos of patient care. ESHRE was mindful of the risk of over-reliance on industry, and sought to retain independence, to avoid ‘the risk of conflict of interest’.119 Leading US gynaecologist and IVF provider Alan DeCherney, in a 1983 editorial in Fertility and Sterility, meditated on the challenge the commercial prospects of these technologies posed to medicine’s historical self-image of selfless devotion to saving lives. He saw the creation of an IVF industry as ‘threatening to catapult the obstetric-gynecologic community into [the] medical industrial complex’, coining the (pejorative) term ‘technodocs’ to describe doctors who

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acted as purveyors of technical expertise potentially at the cost of patient care.120

News Media and Public Relations An echo of the ‘medical industrial complex’ is the idea of the ‘media/ medicine nexus’, a term that captures the reliance of the medical industry on media to create public awareness of its work, and the reliance in turn of news media on medical storylines.121 News of the many ‘firsts’ of AR has regularly travelled around the globe. Assisted reproduction has supplied media with stories suited to several saleable genres, with front-page tales of national or local pride; human interest and ‘women’s’ issues, suitable for magazines or weekend sections of the daily news; and ‘hardheaded’ ethical, theological and policy discussions for the editorial and features pages.122 Cartoons alongside news items have shown mocking images of AR clinicians as everything from mad scientists to used car salesmen with loud ties. They have portrayed identical jackbooted offspring marching out of freezers or laboratory bottles containing babies, images resonant for generations of readers of Brave New World.123 Syndicated news services such as Associated Press and Reuters from the beginning have delivered AR stories to a wide readership. As early as the 1940s, it was news stories, as much as direct contact with treatment providers, which seem to have suggested there were new medical solutions to people’s fertility problems. The work of John Rock and Miriam Menkin, long believed to have been responsible for assembling the first in vitro embryos, gained wide reportage in the United States thanks largely to Associated Press.124 Menkin recalled that, along with letters of criticism from religious opponents, one man wrote to her seeking ‘“a respectable woman” of a certain religion’ to provide an egg to his wife.125 The sensitivity of fertility matters to individual families also meant that, as was the case for Kanupriya Agarwal’s birth, not all intending parents were comfortable with publicity.126 Providers were deeply aware of the importance of the media from early on. Carl Wood commented to a Victorian government committee on AR in 1983, ‘babies are always such a good story for the press, aren’t they?’,

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but also reflected on a media leak from his own unit, saying, ‘It’s quite a big problem, the press’.127 Wood referred to conversations with lesbians hoping to use IVF, who he felt he had to turn away because of the risk of bad publicity.128 Australian clinician Ian Johnston even accused his rivals of making statements that gave rise directly to unwanted government interference: ‘Some people … kept making outrageous statements which were terrifying to the general public. This created the need for the government to be seen to be doing something’.129 Wood himself co-wrote a paper-back introduction to IVF, the cover of which promoted it as ‘A guide for couples, doctors and the community to the revolutionary breakthrough in treating infertility including the ethical, legal and social issues’.130 Public relations units created to offset the fear factor and bring good news have been a staple of AR clinics for many years. The Fertility Society of Australia (FSA) had a designated media spokesperson whose task was to ‘accurately deal with any new events’, particularly in light of negative press about higher-order (more than two) multiple births.131 When in 1990 ESHRE learned that a World Health Organization (WHO) paediatrician, Marsden Wagner, was publicly criticising IVF as unacceptably experimental, they set up a debate between him and leading practitioner Jean Cohen.132 Ric Porter of Westmead Hospital in Sydney recalled a Christmas party at the hospital in the mid-1980s with ‘all the parents and babies in attendance’, so that a ‘pre-Christmas good news story’ could appear on television throughout Australia to help people accept ‘that IVF had arrived’.133 IVF units worldwide have conducted celebrations of anniversaries of the successful technology, effectively on the birthday of Louise Brown, who cheerfully remarked in her autobiography, ‘the media get interested whenever my birthday has a 5 or a 0 at the end!’134 As Vicki Baldwin, founder of the US-based IVF Australia (later IVF America), observed in 1987, ‘we invest heavily in public relations’.135 To celebrate its first two years in the United States, the company held a picnic in Central Park for all its US-conceived babies. As the New York Times reported it:

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Yesterday was a fine day for baby-sightings in Central Park. They arrived in carriages, strollers and backpacks, in cars, taxicabs and stretch limousines, 54 state-of-the-art babies going to brunch at Tavern on the Green.136

Upbeat celebrations have also occasioned reflection. In 1998, one journalist began an article on the twentieth anniversary of IVF full of moral outrage, writing: Britain has become a fertility freak show. From lesbians buying sperm over the Internet to … the 61-year-old farmer who’s just had a baby and wants another—the world has come a long way from the innocent excitement of Louise Brown’s birth.

Robert Edwards, interviewed for the same article, reflected on what he saw as a problematic development in relation to fertility drugs: ‘Since in-­ vitro fertilisation spread worldwide, it’s turned into pharmaceutical nonsense … What do we want with 50 eggs? I want four or five excellent eggs and embryos. This has got to do’.137 His comments, twenty years after the first IVF birth, convey a sense that AR had attained a truly industrial production profile beyond the wishes of even as visionary a scientist as Edwards. His words point to a tension that has always been there: between what AR might achieve medically, and the uses to which it could be put economically or culturally. The mobilisation or control of assisted reproduction in ‘the national interest’ has been a significant part of this story.

Nations, Natalism and Assisted Reproduction Nations and subnational jurisdictions have responded in culturally distinct ways to the advent of AR, with the technology ‘perceived and used within different geopolitical regions in locally distinct manners’.138 In many places, the introduction of AR staked a claim for the nation’s position in the technology-driven modern world. Press reports of Israel’s successful use of IVF in 1982 maintained that the country’s capacity in the field was superior to the work of the leading overseas teams; Thailand’s first IVF birth in 1987 was associated with ‘nationalist pride in Thai

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scientific progress’; in Sri Lanka in 2002, the first IVF birth resulting from the work of an all-Sri Lankan team was celebrated as a sign of the nation’s technological self-sufficiency.139 In the People’s Republic of China the first IVF provider, Zhang Lizhu, introduced AR by framing her surgical technique as a distinctively Chinese response to a common cause of women’s infertility in that country, pelvic scarring caused by tuberculosis.140 A writer on India’s now vast IVF industry has seen it as symbolic of the country’s push into the new ‘bio-economy’, with practices such as community-based ova selling allowing the nation effectively to bypass the industrial age.141

Population and Procreation One of the basic constitutive elements of the modern idea of nation is that ‘population’ is a natural and meaningful category with which to describe human collectivity.142 Just as reproduction is significant to the identity of individuals, families and communities, equally, official attitudes to population growth have at times reflected views on demographic trends affecting the economy or, more problematically, issues of religion or of ethnicity. Seeing AR in the light of various national population strategies goes to the heart of its significance beyond the immediate interests of individuals or families. Indeed, population growth and control cannot be separated from the ideology of nationhood: it is nations that count people, and political and bureaucratic views of population pertain to what nations expect of citizens, what they are prepared to provide to citizens, and what makes a suitable citizen. Jurisdictions implicate individuals and couples in a communal or national script, at times trying to elevate procreation of some groups above others.143 The word ‘natalism’, along with its derivatives ‘pro-natalism’ and ‘antinatalism’, relates to policies or belief systems that refer to procreation. Natalism is an important theme when we consider the history of AR, because nations as well as influential religious or cultural groups historically have often sought to ‘reproduce themselves’ through the procreative labours of individuals.144 The implications of this aim can range from the general promotion of reproduction to more problematic uses of

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AR for ethnically based social engineering. In the French Pacific, for example, attitudes towards AR show a natalist colonial imprint, as policies that encourage childbearing have made their way from France to its former colonies. In New Caledonia, the cost of four IVF cycles is 90% covered, as are flights from the islands for treatment, the latter particularly important for women living far from the capital, Noumea.145 The costs of AR to patients are very low and mostly reimbursed.146 New Caledonians can also choose to travel to France for their AR, because as French citizens they can also receive it there cost-free. Thus, historical links to France have given New Caledonia, and those with fertility issues who live there, opportunities to access services unavailable to people who live in other parts of the Pacific. Contrastingly, Turkey’s pro-natalist policies have, according to Zeynep Gürtin, reflected a neo-conservative family values agenda, proposed as a response to government fears about an ageing population, alongside a rise in religiously driven anti-abortion sentiment.147 Assisted reproduction has held out the possibility of shaping the population profile both numerically and in relation to the health status of people who might be born. Carl Wood, as early as 1983, expressed a view that the genetic testing of embryos might be of benefit to governments wanting to reduce the cost of ill-health to nations: Not only in the community, but the Government might see advantages in extending these sorts of things that we’re setting up … if [the outcomes for newborns] are slightly better, it could end up as an example in the community for the rest to say, well, perhaps people might think about what they’re doing and see the doctor before.148

This same argument provided Zhang Lizhu with an opening for her IVF experiments to be accepted in China. She invoked the discourse of yousheng, which refers to population ‘quality’ strategies, which pre-existed the introduction of IVF there. With overtones of what is sometimes called ‘positive’ or ‘liberal’ eugenics’, Zhang made the case for IVF as an arm of yousheng population health, rather than as a response to infertility.149 By doing so, she found a way through China’s longstanding policies of limiting population growth, notably the one-child policy (1979–2015), which might seem to have been antithetical to the introduction of AR.

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Eugenic Thinking and Assisted Reproduction Population scholars and public policy makers at times show an interest in the idea of population ‘replacement rates’ for a range of reasons, including concerns about who will support an ageing community if the ‘population pyramid’ becomes top-heavy with the elderly. Even clinicians, who generally have an individual focus, have linked the use of AR to national population trends. In a recent interview promoting the practice of egg freezing for younger women, AR clinician Pasquale Patrizio argued in relation to the United States that ‘soon there will be a problem that there are not enough children being born and something has to give’.150 Population ‘replacement’, however, not only references the problems such as a nation’s dwindling tax base; it can be bound up with discriminatory population politics, a statistical description masking an ideological view. In some countries there is a growing promotion of ethnically oriented eugenic agendas, which can implicate the use of AR. For Singapore, government interest in AR in the mid-1980s was associated with a swing in policy away from discouragement of procreation for labour-force growth purposes to a new natalism bound up with local ethnic ‘replacement rate’ agendas.151 For Romania, Michal Nahman suggests that liberal attitudes to AR are a possible reflection of government views on the ethnic composition of the country. She cites President Traian Basescu’s call to a group of business women: ‘How on earth can Roma women have five or six children and [ethnic] Romanian women cannot?’152 Hungary’s government under President Viktor Orbán is quite explicit, rejecting migration because ‘we want Hungarian children’, and offering free treatment cycles in new, nationalised IVF clinics.153 In Sri Lanka, in an ethnically and religiously complex political climate, AR has been inflected with a reproductive nationalism that anthropologist Bob Simpson sees as characteristic of the Sinhala Buddhist majority.154

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In Mexico, the first fertility clinics were opening at the same time as the government was concerned primarily about perceived overpopulation.155 But although the birth rate has reduced from 7.3 children per woman in 1960 to 2.2 per woman in 2010, one government official has made clear that limiting reproduction is aimed at changing a distribution of fertility, the ‘rural, indigenous, and poor’ being positioned as less desired sources of the nation’s population.156 Israel, one of the earliest adopters of AR and which had its first IVF birth in 1982, has policies that serve the idea of increasing the population of Jews. Israel’s Ministry of Health (MOH) has long entitled ‘every Israeli woman aged 18 to 45, irrespective of her family status or sexual orientation, to unlimited, funded treatment up to the birth of two live children with her current partner’.157 While this financial support applies to all and is therefore nominally inclusive, some commentators have linked the uptake of IVF to specific cultural attitudes to reproduction within Judaism.158 A capacity for AR to play a small part in population increase has led some commentators to represent developing countries with large populations as unsuitable sites for its use, echoing the historic rhetoric of population control. A Times reporter commenting on the opening of the first IVF clinic in Zimbabwe in 1987, for example, judged that such a development ‘seems strange in a country with a population growth rate put at 3.2 percent per  annum’.159 Australian newspaper headlines such as ‘Fertility Clinics in Demand as India’s Population Soars’ and ‘Fertile India’s IVF Program’ have similarly hinted at some of the same discriminatory assumptions about eligibility to reproduce that underpinned aspects of the population control movement.160 One IVF provider who works with countries on the African continent has argued that such a ‘narrow approach contradicts human rights in general and reproductive rights in particular’.161 Potential tensions that traverse the relationship of reproduction to individual, familial, community and national goals have provided much of the fuel for ongoing public debate. As AR has become naturalised as an avenue to parenthood, fissures have arisen when its commercial and client elements of AR have collided with religious and government ideologies. These issues, accompanied by continued concern among non-AR medical professionals about the safety of techniques and the risks of

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commercialism, have staked out the global reproscape since the industry made its mark on fertility awareness in the early 1980s, questions to be discussed in the following chapter.162

Conclusions By 1990, at least fifty countries had seen their first IVF births.163 This chapter has shown early providers joining forces to optimise the results of their work through the widespread use of fertility drugs and the expansion of possible AR client groups. Scientists and clinicians practising AR created a distinctive global footprint for the new technologies. Professional meetings, including many more at Bourn Hall, the work of new or revamped national fertility societies, the establishment of supranational groupings and the publication of new journals and collections all gave momentum to the new industry, increasingly distinguishing the provision of fertility treatment using IVF from treatment of the physical causes of infertility, notably in supplanting the use of tubal surgery for women.164 Would-be providers sought out those who had met with success to obtain hands-on training. Commercial sponsorships to develop laboratory and clinical materials were crucial, as were both formal and informal knowledge-sharing on the part of leading practitioners. Financing from diverse sources alongside the work of news media provided the field with both impetus and direction. Bourn Hall’s early funding woes showed the importance of obtaining money to facilitate the practice of AR, while scientific and mainstream press provided exposure to innovation, alongside a platform for expressions of public concern. Without significant funding the new assisted reproductive technologies might have ended as appealing to the imagination but ultimately unable to secure significant long-term results, clinically or commercially. The fact that it was a news organisation that first invested and then withdrew funding from the Bourn Hall project highlights the importance to the ongoing expansion of AR of positive news stories about births, growing success rates and new treatments. Active public relations efforts on the part of providers and

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public relations experts helped to shape favourable perceptions of the technologies. Change in AR has reflected the reproductive goals of providers and clients, the commercial goals of medical manufacturers, the geopolitical histories of nations initiating IVF and the goals of the media, for whom stories of reproductive science covered a range of genres. This extensive range of activities cemented in place the basic features of a global medical industry. Rather than there having been the natural ‘spread’ of a perfected system, then, most countries have had, to some extent, to reset the AR historical clock according to their interests and capacities.165 The beginnings of AR in any place relied to some extent on the same kinds of conditions—who had the expertise? where was the money to come from?—as those that had affected earliest practitioners. Local developments have been mediated and facilitated in culturally specific ways, reflecting diverse understandings of the importance of procreation. The significance of reproduction through IVF extended beyond the personal wishes of individuals or couples, with its introduction being relevant in different ways for and within nations.

Notes 1. Jean Cohen, Alan Trounson, Karen Dawson, Howard Jones, Johan Hazekamp, Karl-Gösta Nygren, and Lars Hamberger, ‘The Early Days of IVF outside the UK’, Human Reproduction Update 11, no. 5 (2005): 439–59, 440. 2. ‘Birth of the Blues’, Guardian Diary, Guardian (UK), 25 March, 1980. 3. Robert G. Edwards, ‘An Introduction to Bourn Hall: The Biomedical Background of Bourn Hall Clinic’, in Textbook of In Vitro Fertilization and Assisted Reproduction: The Bourn Hall Guide to Clinical and Laboratory Practice, 3rd ed., ed. Peter R. Brinsden (Abingdon: Taylor & Francis, 2005), 1–8, 6. 4. ‘Birth of the Blues’. 5. Edwards, ‘An Introduction to Bourn Hall’, 6. 6. ‘Test Tube Baby’, Guardian (UK), 24 June, 1980. 7. ‘Test Tube Clinic Opens’, Guardian (UK), 2 October, 1980. 8. Yulian Zhao, Paul Brezina, Chao-Chin Hsu, Jairo Garcia, Peter R. Brinsden, and Edward Wallach, ‘In Vitro Fertilization: Four Decades

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of Reflections and Promises’, Biochimica et Biophysica Acta 1810, no. 9 (2011): 843–52, 845. 9. Cohen et al., ‘Early Days of IVF outside the UK’, 450. 10. Christine Doyle, ‘Big Rush for “Test Tube” Babies’, Observer, 13 July, 1980. 11. Peter R. Brinsden, ‘Thirty Years of IVF: The Legacy of Patrick Steptoe and Robert Edwards’, Human Fertility 12, no. 3 (September 2009): 137–43, 139. 12. ‘Birth of the Blues’; Robert Edwards, ‘A Matter of Life 1. The Scientist’, Observer, 16 March, 1980; Patrick Steptoe, ‘Now, the Clinical Reality: A Matter of Life 2. The Doctor’, Observer, 23 March, 1980; Patrick Steptoe, ‘A Matter of Life 3. The Baby’, Observer, 30 March, 1980. 13. Philip McIntosh, ‘Scientist to Preach the Test Tube Baby Method’, Age (Melbourne), 11 March, 1981. 14. R.  G. Edwards, ‘Test-Tube Babies, 1981’, Nature 293, no. 5830, 24 September (1981): 253–56, 253. 15. Ian Johnston, Alex Lopata, Andrew Speirs, Ian Hoult, Geoff Kellow, and Yvonne du Plessis, ‘In Vitro Fertilization: The Challenge of the Eighties’, Fertility and Sterility 36, no. 6 (1981): 699–706, 704. 16. Victorian Assisted Reproductive Treatment Authority (VARTA), ‘Minutes of the Inaugural Meeting to Examine In Vitro Fertilization’. Meeting 5 pm 25 May 1982, in ‘Folder of Minutes of the Inaugural Meeting (25 May 1982) to the Minutes of the 47th Meeting (9 August 1984) of the Committee to Examine In Vitro Fertilisation’. VARTA Collection, Melbourne, Folder 22, 5. Wood and John Leeton had themselves created an artificial fallopian tube in the early 1970s. Alan Trounson and Carl Wood, ‘Extracorporeal Fertilization and Embryo Transfer’, Clinics in Obstetrics and Gynaecology 8, no. 3, 1981: 681–713, 687. 17. José Van Dyck, Manufacturing Babies and Public Consent: Debating the New Reproductive Technologies (Houndmills: Macmillan, 1995), 72–73. 18. Andrew Veitch, ‘Adoption Plan by Test Tube Baby Doctors’, Guardian (UK), 30 January, 1982; Trounson and Wood, ‘Extracorporeal Fertilization and Embryo Transfer’, 682. 19. The team of Ian Johnston had published in Fertility and Sterility a full four months before the birth of Candice Reed and even provided an exclusive to a popular women’s magazine at the same time, identifying Linda Reed. Alexander Lopata, Ian W.  H. Johnston, Ian J.  Hoult,

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Andrew I. Speirs, ‘Pregnancy Following Intrauterine Implantation of an Embryo Obtained by In Vitro Fertilization of a Preovulatory Egg’, Fertility and Sterility 33, no. 2, 1980, 117–20; ‘How the Medical Team Succeeded’, Australian Women’s Weekly, 20 February, 1980, 4–5. There had been a miscarriage in the unit at 20 weeks which was reported in April of 1980. ‘Test-Tube Mother Miscarries’, Sydney Morning Herald, 30 April, 1980. 20. McIntosh, ‘Scientist to Preach the Test Tube Baby Method’. 21. McIntosh, ‘Scientist to Preach the Test Tube Baby Method’. 22. Simon Brown, ESHRE: The First 21 Years (Oxford: Oxford University Publishing, 2005), 13. 23. Alan O.  Trounson, John F.  Leeton, Carl Wood, Beresford Buttery, Janice Webb, Jillian Wood, David Jessup, J.  Mc. Talbot, and Gabor Kovacs, ‘A Programme of Successful In Vitro Fertilization and Embryo Transfer in the Controlled Ovulatory Cycle’, in Human Reproduction: Proceedings of III World Congress, Berlin, March 22–26, 1981, ed. Kurt Semm and Liselotte Mettler (Amsterdam; Princeton: Excerpta Medica; New York: Sole distributors for the USA and Canada, Elsevier North-­ Holland, 1981), 173–80. See also Trounson and Wood, ‘Extracorporeal Fertilization and Embryo Transfer’. 24. Wood and colleagues reported 103 patients treated between March and October 1980. Carl Wood, Alan Trounson, John Leeton, J. McKenzie Talbot, Beresford Buttery, Janice Webb, Jillian Wood, and David Jessup, ‘A Clinical Assessment of Nine Pregnancies Obtained by In Vitro Fertilization and Embryo Transfer’, Fertility and Sterility 35, no. 5 (1981): 502–08, 502; Edwards reported in Nature on 122 patients (between October 1980 and mid-1981). ‘Test-Tube Babies, 1981’, 254; Johnston et al. reported in Fertility and Sterility on 402 treatment cycles carried out in 1979 and 1980 involving >177 patients. Johnston et al., ‘In Vitro Fertilization: The Challenge of the Eighties’, 701–702. As the Johnston and Wood teams split in June 1980, potentially there is a slight overlap in the numbers for each team’s studies from March to June. 25. Cohen et al., ‘Early Days of IVF outside the UK’, 451. Cohen’s personal notes from the Bourn Hall meeting do not provide numbers for the Scandinavian teams, but they were already active. 26. Ovarian hyperstimulation syndrome (OHSS) was a known risk of ovulation induction in non-IVF fertility treatments, but was rarely men-

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tioned. M. Mozes, H. Bogokowsky, E. Antebi, B. Lunenfeld, E. Rabau, D. M. Serr, A. David, and M. Salomy, ‘Thromboembolic Phenomena after Ovarian Stimulation with Human Gonadotrophins’, Lancet 286, no. 7424 (1965): 1213–15. The low number of eggs produced in the early 1980s suggests that dosages of some drugs might have been lower, and some of the drugs used have also changed over time. 27. Edwards, ‘Test-Tube Babies, 1981’, 253. 28. Johnston et al., ‘In Vitro Fertilization: The Challenge of the Eighties’, 699; Trounson and Wood, ‘Extracorporeal Fertilization and Embryo Transfer’, 682; Edwards, ‘Test-Tube Babies, 1981’, 254. 29. Wood et  al., ‘A Clinical Assessment of Nine Pregnancies’, 502, 503; McIntosh, ‘Scientist to Preach the Test Tube Baby Method’. 30. Trounson and Wood, ‘Extracorporeal Fertilization and Embryo Transfer’, 684; Alan Trounson and Angelo Conti, ‘Research in Human In-Vitro Fertilisation and Embryo Transfer’, British Medical Journal (Clinical research ed.) 285, no. 6337 (1982): 244–48, 246. 31. Edwards, ‘Test-Tube Babies, 1981’, 256. Edwards placed ‘spare embryos’ in inverted commas. 32. Trounson and Wood, ‘Extracorporeal Fertilization and Embryo Transfer’, 710; https://monashivf.com/about-us/history 33. Johnston et al., ‘In Vitro Fertilization: The Challenge of the Eighties’, 704; 700. Van Dyck also drew attention to this claim. Manufacturing Babies, 72. 34. Trounson and Wood, ‘Extracorporeal Fertilization and Embryo Transfer’, 710–11. 35. ‘Discussion on the Ethics of Fertilization In Vitro’, in Human Conception In Vitro: Proceedings of the First Bourn Hall Meeting, ed. R. G. Edwards and Jean M. Purdy (London: Academic Press, 1982), 359. 36. Veitch, ‘Adoption Plan by Test Tube Baby Doctors’; Andrew Veitch, ‘First Test Tube Baby on NHS Is Only “A Matter of Time”’, Guardian (UK), 30 September, 1981. 37. David Hencke, ‘Doctors Warned on Test Tube Technology’, Guardian (UK), 3 July, 1981. 38. Martin H.  Johnson, Sarah B.  Franklin, Matthew Cottingham, and Nick Hopwood, ‘Why the Medical Research Council Refused Robert Edwards and Patrick Steptoe Support for Research on Human

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Conception in 1971’, Human Reproduction 25, no. 9 (2010): 2157–74, 2157. 39. Nicholas Timmins, ‘Doctor Explains Danger of Test Tube Baby Techniques’, Times (London), 3 July, 1981. 40. Veitch, ‘Adoption Plan by Test Tube Baby Doctors’; Andrew Veitch, ‘Thatcher May Hold Test Tube Babies Inquiry’, Guardian (UK), 11 February 1982, 1, 26. 41. ‘Test Tube Baby Plans’, Guardian (UK), 15 August, 1980; Angela Singer, ‘Test-Tube Twins Raise Questions on Method and Hopes for the Childless’, Guardian (UK), 15 December, 1981 (for Robert Winston quote); Douglas M. Saunders, Fertility Society of Australia: A History (Cremorne, NSW: Douglas M. Saunders, 2013), 66. Winston has remained in many ways an ‘IVF sceptic’. See also G. David Adamson and Anthony J.  Rutherford, ‘The Commercialization of In-Vitro Fertilization’, in In-Vitro Fertilization: The Pioneers’ History, ed. Gabor Kovacs, Peter Brinsden, and Alan DeCherney (Cambridge, UK: Cambridge University Press, 2018), 240–48. 42. Sarah Franklin, Biological Relatives: IVF, Stem Cells, and the Future of Kinship (Durham, NC: Duke University Press, 2013), 45. 43. Carl Wood, ‘Minutes of the Inaugural Meeting to Examine In Vitro Fertilisation. Meeting 5 pm 25 May 1982’, in ‘Folder of Minutes of the Inaugural Meeting (25 May 1982) to the Minutes of the 47th Meeting (9 August 1984) of the Committee to Examine In Vitro Fertilisation’. VARTA Collection, Melbourne, Folder 22, 9. 44. Edwards, ‘An Introduction to Bourn Hall’, 6. 45. Robert Edwards, Life Before Birth: Reflections on the Embryo Debate (London: Century Hutchinson, 1989), 17. 46. David Hencke, ‘Doctors Warned on Test Tube Technology’, quoting Michael Thomas. 47. Duncan Wilson, The Making of British Bioethics (Manchester: Manchester University Press, 2014), 154–55. 48. Trounson and Wood, ‘Extracorporeal Fertilization and Embryo Transfer’, 706. 49. Cohen et al., ‘Early Days of IVF outside the UK’, 448. 50. T. C. Anand Kumar, ‘In Vitro Fertilization in India’, Current Science 86, no. 2 (2004): 254–56, 254. 51. The figures provided at the meeting do not include the Wood Monash team’s births. Cohen et al., ‘Early Days of IVF outside the UK’, 451.

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52. Trounson et al., ‘A Programme of Successful In Vitro Fertilization and Embryo Transfer’. 173–80; See also H. J. Kannegiesser, Conception in the Test Tube: The IVF Story: How Australia Leads the World (South Melbourne: Macmillan, 1988). 53. Geraldine Brooks, ‘Professor Wood Goes to Market for His Test Tube Babies’, The Good Weekend, Sydney Morning Herald, 5 September, 1981. Bourn Hall issued a press release in the first week of October, to the effect that five babies had been born after treatment there in the previous year. Alan Rusbridger, ‘5 Born at Test Tube Clinic’, Guardian (UK), 6 October, 1981. 54. Cohen et al., ‘Early Days of IVF outside the UK’, 448. 55. Cohen et al., ‘Early Days of IVF outside the UK’, 450; René Frydman, interview with Nicola Marks, 13 April, 2016; University of Wollongong Human Research Ethics Committee (HREC), 10 February, 2016 (approval HE/16028). 56. Edwards, Life Before Birth, 16. 57. Brown, ESHRE: The First 21 Years, 13. 58. Brooks, ‘Professor Wood Goes to Market’; Veitch, ‘First Test Tube Baby on NHS Is Only “A Matter of Time”’; Angela Singer, ‘Test-Tube Twins Raise Questions’. Steptoe’s practice in Oldham, however, had been part of the NHS and, as Sarah Franklin notes, Edwards was a ‘lifelong socialist’. Sarah Franklin, ‘A Tale of Two Halves? IVF in the UK in the 1970s and 1980s’, in The Reproductive Industry: Intimate Experiences and Global Processes, ed. Vera Mackie, Nicola J.  Marks, and Sarah Ferber (Lanham, MD: Lexington, 2019), 15–30, 17. The Monash team’s private fees were nonetheless well below those of Bourn Hall, providing the likely basis for Wood’s comments. 59. Bruno Lunenfeld, ‘Historical Perspectives in Gonadotrophin Therapy’, Human Reproduction Update 10, no. 6 (2004): 453–67, 456; John McBain, ‘Children of a Fertile Revolution: IVF’, Australian, 19 June, 2010, https://www.theaustralian.com.au 60. Cohen et al., ‘Early Days of IVF outside the UK’, 451. 61. Cohen et al., ‘Early Days of IVF outside the UK’, 451; Brown, ESHRE: The First 21 Years, 12. 62. H.  W. Jones, Jr., ‘The Ethics of In Vitro Fertilization—1981’, in Edwards and Purdy, Human Conception, 351–57, 356. 63. Brown, ESHRE: The First 21 Years, 14. 64. ‘Test Tube Babies—Whatever Next?’, Lancet 318, no, 8258 (1981), 1265–66, 1265. 65. ‘Test Tube Babies’, 1265–6.

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66. Nicholas Timmins, ‘Wide Scope for Test Tube Baby Method’, Times (London), 9 December, 1981. 67. Timmins, ‘Wide Scope’. 68. Timmins, ‘Wide Scope’. 69. Veitch, ‘Thatcher May Hold Test Tube Babies Inquiry’; Martin H.  Johnson, ‘Robert Edwards: The Path to IVF’, Reproductive BioMedicine Online 23, no. 2 (2011): 245–62. On prior use of the initials PGD, see the current AR glossary: Fernando Zegers-Hochschild, G.  David Adamson, Silke Dyer, Catherine Racowsky, Jacques de Mouzon, Rebecca Sokol, Laura Rienzi, Arne Sunde, Lone Schmidt, Ian D.  Cooke, Joe Leigh Simpson, and Sheryl van der Poel, ‘The International Glossary on Infertility and Fertility Care, 2017’, Human Reproduction 32, no.9 (2017): 1786–1801, 1798. 70. Veitch, ‘Thatcher May Hold Test Tube Babies Inquiry’. 71. Brown, ESHRE: The First 21 Years, ix–x. 72. Brown, ESHRE: The First 21 Years, x. 73. Brown, ESHRE: The First 21 Years, 110. 74. Brown, ESHRE: The First 21 Years, 120. 75. Ian Johnston, Warren Jones, and Douglas Saunders, ‘The Embryo Comes of Age: The First Decade of the Fertility Society of Australia’, Australian and New Zealand Journal of Obstetrics and Gynaecology 31, no. 1 (1991): 55–57. 76. Jane Adams, ‘Fertility Factors: Infertility, Medicine and the Law in New Zealand, 1950–2004’ (PhD diss., University of Otago, 2016), 180; Sally Wilde, ‘History of the Society’, Urological Society of Australia and New Zealand, https://www.usanz.org.au/history 77. Masakuni Suzuki, ‘In Vitro Fertilization in Japan: Early Days of In Vitro Fertilization and Embryo Transfer and Future Prospects for Assisted Reproductive Technology’, Proceedings of the Japan Academy. Series B, Physical and Biological Sciences 90, no. 5 (2014): 184–201, 188; H. Yui, ‘Clinical Application of In Vitro Fertilization and the Establishment of the Japan Society of Fertilization and Implantation’, Kagakushi kenkyu, 55, no. 278 (2016): 118–32, 132. For the several associations involved in Mexican AR, see Sandra P. González-Santos, ‘From Esterilología to Reproductive Biology: The Story of the Mexican Assisted Reproduction Business’, Reproductive BioMedicine & Society Online 2 (2016): 116–27. 78. Brown, ESHRE: The First 21 Years, 125. 79. Cohen et al., ‘Early days of IVF outside the UK’, 454.

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80. ASPIRE, http://www.aspire-reproduction.org/about-us; Roberto Romero, ‘A Profile of Bruno Lunenfeld, MD, FRCOG, FACOG (hon)’, American Journal of Obstetrics & Gynecology 219, no. 3 (2018): 225–34. 81. Saunders, Fertility Society of Australia, 66. 82. Brown, ESHRE: The First 21 Years, 10. 83. Saunders, Fertility Society of Australia, 61–62; Johnston, Jones and Saunders, ‘The Embryo Comes of Age’, 56–57. 84. Jennie Smith, ‘IVF Pioneers: Field Marked by Competition, Innovation’, Ob. Gyn. News 51, no. 9 (1 September, 2016). 85. Sandra Blakeslee, ‘Trying to Make Money Making “Test-Tube” Babies’, New York Times, 17 May 1987. 86. Blakeslee, ‘Trying to Make Money Making “Test-Tube” Babies’. 87. Sally Wilde, ‘The English Patient in Post-Colonial Perspective, or Practising Surgery on the Poms’, Social History of Medicine 18, no. 1 (2005): 107–21; Sally Wilde, ‘See One, Do One, Modify One: Prostate Surgery in the 1930s’, Medical History 48, no. 3 (2004): 351–66. 88. Robert Edwards’ first Cambridge mentor, ‘Bunny’ Austin, was an Australian; both Subhas Mukerji (India) and Robert Edwards (the UK) had obtained their PhDs at Edinburgh, one of the world’s major centres of science and medicine, and Alan Trounson, an Australian, had a Cambridge doctorate. 89. Smith, ‘IVF Pioneers’. 90. Alan Hope, ‘30 Years of IVF in Flanders’, Flanders Today, 16 October, 2013, http://www.flanderstoday.eu 91. Suzuki, ‘In Vitro Fertilization in Japan’, 192–93. 92. Edwards, Life Before Birth, 17. 93. At one point, there were clinics at three cities in India, but these are in the process of liquidation. TVM Capital Healthcare, ‘Bourn Hall International’, https://www.tvmcapitalhealthcare.com/portfolio/ bourn-hall-international, accessed 1 December, 2017 and 19 March, 2020. 94. Bourn Hall Fertility Centre, ‘International Patients’, http://www. bournhall-clinic.ae/international-patients, accessed 16 August, 2019. See also Marcia C.  Inhorn, ‘The “Local” Confronts the “Global”: Infertile Bodies and New Reproductive Technologies in Egypt’, in Infertility around the Globe: New Thinking on Childlessness, Gender, and

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Reproductive Technologies, ed. Marcia Inhorn and Frank van Balen (Berkeley: University of California Press, 2002), 263–82, 263. 95. Viola Hörbst, ‘“You Cannot Do IVF in Africa as in Europe”: The Making of IVF in Mali and Uganda’, Reproductive BioMedicine & Society Online 2 (2016): 108–15, 110. Dr Mba’s full name is difficult to confirm with certainty and Hörbst elsewhere appears to refer to him only as Dr M. 96. ‘Inter-African group for study, research and application in relation to fertility’, the current ‘antenna’ countries for which include Benin, Cameroon, Ivory Coast, Mali, Congo Brazzaville, DR Congo, Senegal, Togo, Niger and Gabon. GIERAF, https://www.gieraf.org. See also Willem Ombelet, ‘The Development of In-Vitro Fertilization in Africa’, in Kovacs, Brinsden and DeCherney, In-Vitro Fertilization, 158–71. 97. Hörbst, ‘“You Cannot Do IVF in Africa as in Europe”’, 110; Lijing Jiang, ‘IVF the Chinese Way: Zhang Lizhu and Post-Mao Human In Vitro Fertilization Research’, East Asian Science, Technology and Society: An International Journal 9, no. 1 (2015): 23–45, 37. 98. Thanks are due to Dr Megan Brayshaw for finding this history. 99. Bob Simpson, ‘IVF in Sri Lanka: A Concise History of Regulatory Impasse’, Reproductive BioMedicine & Society Online, 2 (2016): 8–15, 10. On the work of one travelling embryologist in Ghana, see Trudie Gerrits, ‘Assisted Reproductive Technologies in Ghana: Transnational Undertakings, Local Practices and “More Affordable” IVF’, Reproductive BioMedicine & Society Online 2 (2016): 32–38, 34. 100. Ian Johnston, Interview with Waller Committee, 15 June 1983, in ‘Folder of Minutes of the Inaugural Meeting (25 May 1982) to the Minutes of the 47th Meeting (9 August 1984) of the Committee to Examine In Vitro Fertilisation’, VARTA Collection, Melbourne, Folder 22, 15. 101. Veitch, ‘First Test Tube Baby on NHS Is Only “A Matter of Time”’. 102. Hörbst, ‘“You Cannot Do IVF in Africa as in Europe”’, 110. 103. Johnston, Interview, 15 June 1983, 16.; Cohen et al., ‘Early Days of IVF outside the UK’, 447. 104. Barbara Burton, infertility activist. Interview between Members of the IVF Committee and Representatives of the IVF Programme, 6 July 1983, in ‘Folder of Minutes of the Inaugural Meeting (25 May 1982) to the Minutes of the 47th Meeting (9 August 1984) of the Committee to Examine In Vitro Fertilisation’, VARTA Collection, Melbourne,

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Folder 22, 5; ‘Parents Make Big Gift to Test-Tube Project’, Sydney Morning Herald, 4 July, 1980. 105. Adams, ‘Fertility Factors’, 120. 106. IVF Friends was established in 1991. 107. AccessAustralia, http://access.org.au/?p=54 108. Saunders, Fertility Society of Australia, 84. 109. ‘Here’s Why Private Equity Companies Are Buying Fertility Clinics’, MarketWatch, 6 April 2018, https://www.marketwatch.com 110. Saunders, Fertility Society of Australia, 85–86; Brown, ESHRE: The First 21 Years, 109–10. 111. Brown, ESHRE: The First 21 Years, 49, 125. 112. Blakeslee, ‘Trying to Make Money Making “Test-Tube” Babies’; Edwards, Life Before Birth, 181. 113. Olivier Lamour, Duels: Frydman/Testart, le divorce des pères, Duels series 2, episode 6, Morgane Production, screened France 5 Télévision, 26 February, 2015. 114. Jacques Testart, interview with Nicola J. Marks, 14 April, 2016. 115. Saunders, Fertility Society of Australia, 71. 116. Cohen et al., ‘Early Days of IVF outside the UK’, 455–56. 117. Cohen et  al., ‘Early Days of IVF outside the UK’, 455. Key Nordic companies and products are: Bruel and Kjaer, Denmark (sonography, vaginal transducers); SweMed Lab (puncture needles, needle guides, equipment); K-Systems (laboratory equipment); MediCult (culture media); Vitrolife (culture media). Cohen et al., ‘Early Days of IVF outside the UK’, 456. 118. ‘IVF Devices and Consumables Market Outlook–2026’, https://www. alliedmarketresearch.com/in-vitro-fertilization-devices-and-consumables-market 119. Brown, ESHRE: The First 21 Years, 109. 120. Alan H. DeCherney, ‘Doctored Babies’, Fertility & Sterility 40, no. 6 (1983): 724–27, 725; Arnold S. Relman, ‘The New Medical-Industrial Complex’, New England Journal of Medicine 303, no. 17 (1980): 963–70. 121. Aditya Bharadwaj, ‘The Indian IVF Saga: A Contested History’, Reproductive BioMedicine & Society Online 2 (2016): 54–61, 55. 122. Rebecca M. Albury, ‘“Babies Kept on Ice”: Aspects of the Australian Press Coverage on IVF’, Australian Feminist Studies 2, no. 4 (1987): 43–71.

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123. Edwards, Life Before Birth, 21, 63; Brooks, ‘Professor Wood Goes to Market’. 124. The Associated Press was the first news syndicate to have a specialist science reporter, Howard Blakeslee. One of the most penetrating pieces of investigative writing on IVF from the 1980s is the work of his journalist granddaughter, Sandra Blakeslee. ‘Trying to Make Money Making “Test-­Tube” Babies’. 125. ‘Biologist Miriam Menkin Recalls Pioneer Efforts’, Morning Call (Allentown, PA), 30 July, 1978. 126. See Chap. 2. 127. Carl Wood, Interview with Waller Committee 15 June 1983, in ‘Folder of Minutes of the Inaugural Meeting (25 May 1982) to the Minutes of the 47th Meeting (9 August 1984) of the Committee to Examine In Vitro Fertilisation’, VARTA Collection, Melbourne, Folder 22, 18. 128. Wood, Interview with Waller Committee 15 June 1983, 10. 129. Quoted in Helen Szoke, ‘Social Regulation, Reproductive Technology and the Public Interest: Policy and Process in Pioneering Jurisdictions’ (PhD diss., University of Melbourne, 2004), 279. 130. Carl Wood and Ann Westmore, Test-tube Conception (Melbourne: Hill of Content, 1983). 131. Saunders, Fertility Society of Australia, 82–83. 132. Brown, ESHRE: The First 21 Years, 117–19. 133. Saunders, Fertility Society of Australia, 83. 134. Louise Brown and Martin Powell, Louise Brown: My Life as the World’s First Test-Tube Baby (Bristol: Bristol Books CIC, 2015), 120. 135. Blakeslee, ‘Trying to Make Money Making “Test-Tube” Babies’. 136. Georgia Dullea, ‘Happy Parents Toast In-Vitro Births’, New York Times, 24 March, 1988. 137. Matthew Pinkney, ‘The Trouble with IVF’, Herald Sun (Melbourne), 25 July, 1998. 138. Jiang, ‘IVF the Chinese Way’, 26. 139. Daphna Birenbaum-Carmeli, ‘Pioneering Procreation: Israel’s First Test-Tube Baby’, Science as Culture 6, no. 4 (1997): 525–40, 528–29; Andrea Whittaker, ‘From “Mung Ming” to “Baby Gammy”: A Local History of Assisted Reproduction in Thailand’, Reproductive BioMedicine & Society Online 2 (2016): 71–78, 71; Simpson, ‘IVF in Sri Lanka’, 9. On Turkey’s ‘repro-nationalism’, see Zeynep B.  Gürtin, ‘Patriarchal

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Pronatalism: Islam, Secularism and the Conjugal Confines of Turkey’s IVF Boom’, Reproductive BioMedicine & Society Online 2 (2016): 39–46. 140. Jiang, ‘IVF the Chinese Way’, 27, 36. 141. Sumit K.  Majumdar, India’s Late, Late Industrial Revolution: Democratizing Entrepreneurship (Cambridge, UK: Cambridge University Press, 2012), 2–3. 142. Richard Togman, ‘The Third Modulation: Foucault, Security and Population’, Foucault Studies 25, no. 2 (2018): 228–50, 231. 143. These developments can be understood within Foucauldian frame of ‘biopolitics’. See Michel Foucault, The History of Sexuality, Vol. 1: An Introduction, trans. R.  Hurley (New York: Vintage, 1990); Michel Foucault, Society Must be Defended: Lectures at the Collège de France, 1975–1976, trans. D. Macey (New York: Picador, 2003); Vera Mackie, ‘Japan’s Biopolitical Crisis’, International Feminist Journal of Politics 16, no. 2 (2014): 278–96. 144. The question of the multiple cultural entities that AR ‘reproduces’ is a central theme in Franklin, Biological Relatives. 145. Transfers with frozen embryos do not count within the limit of four, and the counter is re-set after each pregnancy; so, in practice many more than four inseminations can be covered. The reimbursements include medical costs, embryo transfer, embryo freezing and so on. Nicola Jane Marks, ‘Population, Reproduction and IVF in New Caledonia: Exploring Sociocultural and Caring Dimensions of Sustainable Development’, PORTAL Journal of Multidisciplinary International Studies 14, no. 2 (2017), https://doi.org/10.5130/portal. v14i2.5410 146. Costs are covered either directly by the New Caledonia social security system, or by the CAFAT, Caisse de compensation des prestations familiales, des accidents du travail et de prévoyance des travailleurs salariés de Nouvelle Calédonie (compulsory health insurance for people in employment). 147. Gürtin, ‘Patriarchal Pronatalism’, 41. 148. Wood, Interview with Waller Committee 15 June 1983, 3. 149. Yousheng is derived from the English neologism ‘eugenics’, with its now-inevitable resonances of the destructive eugenics of the mid-­ twentieth century. Scholars argue that in China the term has taken on different nuances after several decades of use in its local context. Juliette Chung Yuehtsen, ‘Better Science and Better Race? Social Darwinism

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and Chinese Eugenics’, Isis 105, no. 4 (2014): 793–802; Jiang, ‘IVF the Chinese Way’, 32–35. See also Sarah Ferber, Bioethics in Historical Perspective (Houndmills: Palgrave, 2013), 191. 150. ‘Here’s Why Private Equity Companies Are Buying Fertility Clinics’, MarketWatch, 6 April 2018, https://www.marketwatch.com, accessed 14 March, 2019. 151. John DiMoia, ‘Blastocysts and Family Planning: IVF and Tracking a Developmental Context for Biomedical Research in Singapore (1966–1994)’, Science Technology & Society 18, no. 3 (2013): 275–89, 275–79; Saw Swee-Hock, Population Policies and Programmes in Singapore, 2nd ed. (Singapore: ISEAS-Yusof Ishak Institute, 2016), 276–83. 152. Michal Rachel Nahman, ‘Romanian IVF: A Brief History through the “Lens” of Labour, Migration and Global Egg Donation Markets’, Reproductive BioMedicine & Society Online 2 (2016): 79–87, 85. Nahman’s insertion of square brackets for the word ‘ethnic’ is crucial, as it highlights Basescu’s endorsement of the discriminatory view that someone can legally be a citizen and yet not truly of a country. 153. Shaun Walker, ‘“Baby Machines”: Eastern Europe’s Answer to Depopulation’, Guardian, 4 March, 2020, https://www.theguardian.com 154. Simpson, ‘IVF in Sri Lanka’, 9. 155. Sandra P.  González-Santos, ‘The Sociocultural Aspects of Assisted Reproduction in Mexico’(PhD diss., University of Sussex, 2010), 45. 156. Lara Braff, ‘Somos Muchos (We Are So Many): Population Politics and “Reproductive Othering” in Mexican Fertility Clinics’, Medical Anthropology Quarterly 27, no. 1 (2013): 121–38, 125–26. 157. Daphna Birenbaum-Carmeli, ‘Thirty-Five Years of Assisted Reproductive Technologies in Israel’, Reproductive BioMedicine & Society Online 2 (2016): 16–23, 17. 158. Birenbaum-Carmeli, ‘Thirty-Five Years of Assisted Reproductive Technologies in Israel’, 22; Daphna Birenbaum-Carmeli, ‘The Politics of “The Natural Family” in Israel: State Policy and Kinship Ideologies’, Social Science & Medicine 69, no. 7 (2009): 1018–24, 1020. Susan Martha Kahn, Reproducing Jews: A Cultural Account of Assisted Conception in Israel (Durham, NC: Duke University Press, 2000). 159. Jan Raath, ‘First Test-Tube Pregnancy Under Way in Black Africa’, Times (London), 23 October, 1987.

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160. Michael Fitzgerald, ‘Fertile India’s IVF Program’, Herald (Melbourne), 25 April, 1989; John Zubrzycki, ‘Fertility Clinics in Demand as India’s Population Soars’, Australian, 25 November, 1996. 161. Ombelet, ‘The Development of In-Vitro Fertilization in Africa’, 165. 162. Marcia C.  Inhorn and Pankaj Shrivastav, ‘Globalization and Reproductive Tourism in the United Arab Emirates’, supplement, Asia-­ Pacific Journal of Public Health 22, no. 3 (2010): 68S–74S. 163. Data compiled by Dr Megan Brayshaw in 2019, based on the available literature. 164. Angela Singer, ‘Test-Tube Twins Raise Questions’. 165. Warwick Anderson challenges what he refers to as the ‘hydraulic’ view of global health history, trying to de-naturalise narratives of change that assume the actual outcome of a new development was always destined to be. Warwick Anderson, ‘Making Global Health History: The Postcolonial Worldliness of Biomedicine’, Social History of Medicine 27, no. 2 (2014): 372–84.

4 Regulation and Risk

Assisted reproduction (AR) is a story of many stakeholders, each asking very different questions of AR. For a client, the question might be: how can I become a parent? Or, how can I avoid passing on a deleterious genetic condition? For the gamete or surrogacy provider: how can I obtain the money I need to improve my quality of life, and help others? For the scientist or clinician: how can I use my professional judgment and skills to help patients, and build a career? For a corporation, shareholder, equity provider or fertility agent: will this business earn sufficient profit? For the religious leader: how can I enforce the will of the deity or deities in response to this innovation? Each community, each interest group, sees different opportunities and risks in relation to AR. For governments, the challenge has been to mediate these often-competing goals while serving the state’s economic agendas and fulfilling its basic role in determining citizenship and legal parentage. Whether to regulate, what to regulate and how to do it have preoccupied governments and other stakeholders since the advent of IVF as a fertility treatment. The current global legislative map is complex, diverse and volatile: each jurisdiction tells a different story, and those stories keep changing.1 Assisted reproduction has over many years been the subject of © The Author(s) 2020 S. Ferber et al., IVF and Assisted Reproduction, https://doi.org/10.1007/978-981-15-7895-3_4

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public inquiries, statutes, religious decrees and legal cases, often arising amid passionate public debate. Some governments have performed legislative about-faces when the political climate or global opinion have persuaded them to change tack.2 As the International Federation of Fertility Societies (IFFS) observes: ‘The position adopted for various issues is dependent on different social, cultural, and political norms’.3 The statutes that have come into being have been variously intended to facilitate the practice of AR, to limit it, or possibly to do both at once. Even the absence of laws or regulation can be significant in reflecting political indecision or tacit acceptance of laissez-faire. And when rules change, the ripples go beyond national borders. Assisted reproduction has provided ways to separate the creation of children from heterosexual intercourse, and enabled families to come into being who potentially have no genetic ties. In response, states and religions have worked to alleviate the moral-societal risks they have seen as inherent in AR.4 Governments mediate disputed claims to parentage or inheritance, declare what constitutes legal marriage and who can be a citizen. Specific policies on such matters reflect a particular government’s moral stance. Many religions, meanwhile, stand as arbiters of believers’ morality and set out their own determinants of familial identity. Does the provision of donor sperm constitute adultery, for example? (For many, it does.) The emphasis in public discussion of new laws or regulations has in several cases reflected theological views on the status of the human embryo and on the composition of the family, positioned against proponents of medical autonomy and patient choice. In the wake of Robert Edwards’ team’s 1969 creation of a human embryo in vitro, religious groups’ anxieties about human embryos began to occupy public conversation in the UK, the United States and Australia.5 Soon after the first IVF births, and in response to the anti-abortion lobby in particular, authorities in these key emerging markets began to contemplate control of the new medical-scientific techniques. There has always been a politics to determining what aspects of AR might better be covered by pre-existing laws or require new laws specific to the new techniques. Globally, attention to the question of embryo experimentation and to restricting access to IVF as a means of family creation has predominated in many public conversations, particularly early in the history of IVF.

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IVF as a fertility treatment did not necessarily require that new laws come into being. Some critics argued, for example, that a ‘public interest’ case for IVF-specific laws has doubtful merit, as existing statutes on medical practice and family formation would in general be enough to cover IVF.6 When governments and other authorities began to contemplate AR laws, the questions they asked were dependent on whose views they were listening to. For the United States, the UK and the state of Victoria (Australia), the moral status of the embryo was foremost in debate, an agenda driven primarily by Catholic and other Christian lobbyists in the wake of recently liberalised abortion laws in each jurisdiction.7 Other, weaker, undercurrents of early public discussion referenced fears about the possible uses of AR to create ‘super-humans’; fears about birth defects, informed by the recent history of the thalidomide disaster; and feminist concerns about the health and social effects of AR on women. A consequence of AR politics has been that several important medical and social aspects of AR did not receive significant public attention in the world’s major IVF centres. Clinical risk associated with multiple births was known before 1978, and there were increasing numbers of multiple births following AR, but IVF embryo insertion rates were rarely subject to regulation by government or the fertility profession.8 The possibility that children conceived with genetic material from those who were not their social parents might want to know the identity of donors was often sidelined by governments prioritising protection of donor anonymity and the rights of AR parents to maintain confidentiality. Success rates have been an ongoing issue, with unclear definitions and a lack of accurate data being problems for industry and consumers alike. The emotional and financial risk to healthcare consumers of receiving misleading information about AR success rates has arguably taken a back seat in public discussions of the ethics of AR. This chapter provides an overview of the different kinds of AR regulation as they have developed since the late 1970s. It first outlines laws and regulations developed between 1979 and 1990, in a time when new statute laws, rather than reliance on the court system, were being considered for issues arising from the many potentialities of IVF. For the United States, Victoria, Egypt, France and the UK, it shows the importance of fears about protection of the embryo and concerns about family and

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lineage. It then describes some key drivers of AR activism: the work of religious activists, the fertility industry’s quest for self-regulation and the role of feminist critique. A case study of a controversial Italian law from 2004 shows the ways in which religion has continued to influence laws, in the face of advocacy by clinicians and patients. Finally, the chapter points to the growing importance of ‘soft regulation’, such as the use of funding strategies and data-keeping, to encourage best practice. In particular, it addresses increasing attention to the risk of multiple births, donor anonymity and the vexed question of AR success rates.

Early Regulatory Moves Before the first IVF births in 1978, scientists had identified the in vitro embryo as a potential source both of babies and of knowledge about fertility. As Robert Edwards established in 1965, a wide spectrum of possible uses in reproductive and regenerative medicine for IVF-created embryos could be clearly anticipated.9 For this reason, as Sarah Franklin observes, debate about the human embryo has been ‘less about clinical IVF than experimental embryology’.10 It is not so much that a focus on the embryo hijacked debate about regulation: in more than one case, it was the reason that the debate occurred in the first place. Beginning in 1979, state authorities in the UK, the United States, Victoria and France, as well as religious authorities in Egypt, undertook inquiries into a rollcall of AR-related issues, such as gamete donation, surrogacy, reproductive cloning and embryo experimentation for reproductive and non-reproductive uses. An initial question for all these jurisdictions, hardly imaginable now, was whether IVF should be permitted at all. All concluded that it should be.11 In the United States, Victoria and the UK, the moral status of the embryo came to be of central importance. Secular France positioned its response to embryo research and IVF as an assertion of the authority of the government in the context of claims for independent action sought by scientists. It established the Comité Consultatif National d’Éthique (national ethics consultative committee) in 1983 that came into being as a legal authority in 1994. President

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François Mitterrand asserted: ‘It is not for the State to respond to these matters and to make edicts to which researchers must submit, but nor is it for researchers alone to decide, just as society cannot be relieved of its own responsibility’.12 In early 1979, within months of the world’s first IVF births, the US federal Department of Health, Education, and Welfare (HEW) undertook a wide-ranging inquiry.13 It solicited written submissions and held a travelling forum to gauge public sentiment. For the previous three years, no federal funding for embryo experimentation had been provided. The recent births of IVF babies provided a basis for reopening debate about the value of studying embryos to assist the creation of children through IVF.14 Federal funding for research on IVF embryos not intended for implantation was at the nub of the inquiry.15 A Democrat member of the House of Representatives, Aaron Jaffe, pointed, however, to the more prosaic family law implications of AR, saying, ‘Our hope is to come up with something reasonable and logical, dealing with laws of inheritance, adultery, parent liability, medical malpractice and birth legitimacy’.16 This was a minimalist, and essentially secularist, aspiration. In the event, no such federal law came into being, leaving states in the United States to take carriage of AR for family creation, a path recommended by the HEW panel.17 The panel’s final report endorsed the use of public funding for early embryo research under certain conditions, but regulatory impediments led to its de facto prohibition.18 Government-funded research required Ethics Advisory Board approval, but, as one news report noted, ‘since 1980 no Secretary of Health and Human Services has appointed the board’.19 Providers of IVF in the United States continued to argue that creating embryos for research was essential for the development of IVF as a treatment response to infertility, and that denial of federal funds meant the ‘clinical practice of in  vitro fertilization and embryo transfer (IVFET) was in danger of outstripping its scientific foundations’.20 Over time in the United States ‘a mixture of restriction and laissez faire’ has reflected the lack of public funds for embryo experimentation, in the context of numerous localised options for fertility treatment itself.21

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In Egypt in 1980, an equally prompt, though more family-focused, response to AR came into being for the country’s majority Sunni Muslims. The Grand Shaykh of Al-Azhar University issued a fatwa that ‘permitted treatment for Muslims, but disallowed any form of third-party reproductive assistance, including surrogacy’.22 The policy focused on familial questions from a moral standpoint, aligning third-party donation with adultery and pointing to the risk of ‘incest among the half-siblings of anonymous donors’, as well as risks to lineage affecting ‘kinship, inheritance, family life and the psychological state of the donor child’.23 Egypt’s Coptic Christians have since adopted the same policy.24 In Australia and the UK, as in the United States, the primary focus was embryo experimentation. What constituted an embryo experiment? Indeed, as so few children had been born following the use of IVF, was not the treatment itself an experiment? Or did the liberalisation of abortion laws make it legally easier to terminate an adversely affected foetus? If non-reproductive medical research relied on the use of human embryos, were so-called ‘spare embryos’ from women who had undergone superovulation for IVF the only ones that could be donated for non-treatment research? Or could women be asked to provide oocytes for experimental embryos? For how long might the embryos be developed in vitro before they should no longer be used for testing? Was the testing of embryos to ascertain the presence of a genetic risk an experiment if the embryo could be biopsied and then safely implanted? Such questions preoccupied the inquiries, and, later, the regulatory authorities they brought into being. In 1982 the UK and the state of Victoria were home to the world’s leading IVF clinics, and each jurisdiction embarked at that time on public inquiries into assisted reproduction—albeit several years after the United States had acted to inquire into similar issues.25 Two significant figures—philosopher Mary Warnock in the UK and legal scholar Louis Waller in Victoria—chaired inquiries that led to the introduction of new statutes and the creation of regulatory authorities. The respective chairs combined broadly secular sensibilities with religious identifications: Warnock was known as an ‘atheist Anglican’, while Waller was an active member of the Jewish community.26 Put pragmatically, each inquiry faced the implicit task of finding a legislative path that would facilitate the practice of IVF and some embryo experimentation, while limiting

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the industry’s exposure to religious lobbying. For each jurisdiction, the process was lengthy and highly conflictual. In the UK, Warnock argued that new statutes were preferable to reliance on the court system. According to historian Duncan Wilson, she believed new laws would safeguard public and political trust by ensuring ‘that no nameless horrors were going on, hidden away in laboratories’, and that this would allow scientists ‘to get on with their work, without the fear of private prosecutions, or disruption by those who object to what they are doing’.27

Louis Waller believed similarly that statute law represented a better version of democracy than the inevitably ad hoc use of case law.28 Scientists had been wary of possible new laws but were aware that public conversations provided a platform for making their case: they were, for example, able to invoke substantial public support for IVF for the infertile.29 In 1984, Victoria brought in the Infertility (Medical Procedures) Act and created a statutory committee, the Standing Review and Advisory Committee on Infertility (SRACI), also chaired by Waller, to oversee industry practice. The act created ‘a system for the licensing, monitoring, and regular reviews of IVF providers’; set limits on embryo experimentation, surrogacy and gamete donation; and banned reproductive cloning. It also provided for a register of which gamete donations had resulted in births although this did not come into operation until four years later, creating a gap in donor records.30 The Warnock Committee reported in 1984, but the Human Fertilisation and Embryology Act, which also created a statutory authority—the Human Fertilisation and Embryology Authority (HFEA)—to oversee AR clinical practice and the use of ‘gametes and embryos for human clinical and research application’—was not passed until 1990.31 This act also set out the means to ‘ensure quality and safety standards, record and give information to patients and clinicians, offer counseling, and take into account the welfare of children who are born following fertility treatment’.32 For both Australia and the UK, a shift of focus from the abortion debates of the 1960s and mid-1970s opened up a cultural space for the

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anti-abortion lobby to assert that an embryo was fully human from the time of conception. In Australia, Carl Wood complained in 1986 that the ‘difficulty in holding accurate debate can be best demonstrated by those changing the meaning of terms, for example, calling a multi-cell, microscopic embryo an unborn baby’.33 Indeed, such semantic jousting has had material policy consequences. Scientists in Victoria proposed that the point of ‘syngamy’ (fusion of egg and sperm at around twenty-two hours after contact) was a suitable cut-off point to make the new technique of sperm microinjection acceptable to church leaders, arguing that the term ‘embryo’ at that stage was inaccurate.34 Use of the term ‘pre-­ embryo’ in the UK played a similarly political role during a lengthy process that resulted in permission to use human embryos up to fourteen days in other research.35 Occasional use of the term ‘fertilised egg’ rather than embryo in mainstream and medical literature might have also served as a mild subterfuge against the sceptical eye of the anti-abortion lobby. Both the UK and Victorian acts, and the bodies appointed to administer them, became lightning rods for ongoing debate amidst the development of new IVF techniques.36 Research towards the application of preimplantation genetic diagnosis (PGD; now one element of preimplantation genetic testing, or PGT) was progressing rapidly. The technique involves removing a cell or cells from an early embryo and testing for specific genetic diseases, with only embryos free of the defective gene(s) to be implanted into the woman.37 It does not involve an intervention in the embryo’s genetic make-up and so does not introduce genetic changes that can be passed on to future generations. But it was an experimental use of embryos because it was not yet proven clinically and, like IVF, could not be proven ultimately without healthy human births. The Warnock Committee had concluded in 1984 that use of genetic testing of embryos was unlikely in the near future, but by 1989 a team at Hammersmith Hospital in London reported having biopsied embryos to detect their sex and hence to identify the risk of carrying a sex-linked condition.38 Thus the UK’s 1990 act provided for its clinical use.39 Contrastingly, when the Monash University fertility program had wanted to use this form of ‘non-destructive embryo experimentation’ in 1989, the Victorian state health minister stepped in to impose a moratorium, overriding the statutory committee appointed to determine the

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permissibility of new forms of embryo research.40 The apparent reason for the minister’s action was party politics, at the time of a key by-election.41 After a lengthy process of negotiation, which had sought balance between the religious and medical lobbies, debate in Victoria became incendiary, with the result that prominent embryologist Leeanda Wilton left to work in the UK.42 In general, in Australia and the UK, liberalisation has characterised changes and modifications to the laws, permitting an increased number of research practices and types of user in both places. In Australia, a 2002 federal law created a centralised Embryo Research Licensing Committee to deal with embryo experimentation, lifting control of the most politically controversial issue out of the hands of state governments, and created national regulations on gamete provision.43 In the UK, the HFEA continues to decide, often on a case-by-case basis, which experiments and treatments are permissible.44 One notable exception to the trend towards permissiveness is that Victoria passed a law in 2008 subjecting all prospective AR clients to police checks. The law was seen as targeting lesbians seeking access to AR, which had been secured in a legal challenge in 2001, along with the same rights for single women.45 According to one account, the ‘Attorney-General admitted to two directors of the patient association ACCESS that this was a ruse to capture lesbian women, who some members of the Cabinet considered likely to abuse children. To single them out would have been in breach of the Commonwealth Sex Discrimination Act, so they applied it to everyone’. A later government reversed the decision, in 2020.46 Expert opinions vary as to the suitability for clinical practice and medical research of the original acts and their later versions.47 Helen Szoke, policy scholar and former head of the statutory Victorian Infertility Treatment Authority (the second of three statutory AR bodies), argues that the Waller Committee and SRACI—each tasked with public consultation and brokering relations between the twin pillars of the religious and medical lobbies—faced political pressure, as well as pushback from within the government, which limited the chances of ascertaining how the public interest might be best served.48 Over the decades, possibly the greatest contribution of the HFEA and, on a smaller scale, Victoria’s current VARTA (Victorian Assisted Reproduction Treatment Authority) and

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its predecessors, is their operation, especially for clients of AR, as clearinghouses for the up-to-date information on complex treatments. Public education is a key role, increasingly facilitated by the internet.49 Since the early legislative and regulatory ventures in the United States, Egypt, France, the UK and Australia, other jurisdictions have displayed the same diversity in approach and outcome. A 2018 survey showed that more than 80% of countries with AR facilities have some kind of relevant ‘legislation, guidelines or both’, but around one third of those countries had no AR-specific laws. Penalties for breaches of different forms of regulation include ‘financial penalties, loss of license, and the possibility of criminal prosecution’.50 Federations and nations with multiple regional levels of lawmaking highlight the variation in the legal status of AR: Australia, Canada, China, Mexico and the United States, for example, all show differences at law along state or provincial lines.51 In Canada, an attempt to create a federal law foundered on legal challenges, with the result that sub-national jurisdictions now rely on case law to resolve issues arising out of AR.52 Hunan Province in the People’s Republic of China brought in policies in 1989 that effectively curtailed both an IVF and a sperm donation project, because of concerns they went against the country’s population-limiting policies.53 Elsewhere in China, however, AR expanded until the early twenty-first century, when the government brought in national regulations, effectively normalising the use of IVF. These laws require, among other things, adherence to national population ‘quality’ measures, while limiting the use of AR to married heterosexual couples.54

Regulatory Activism: The Role of Religion Religion in reproductive politics is one of the most powerful forces in AR regulatory history, with activism having helped to redirect the practice of AR as much as have the industry’s own clinical and laboratory work.55 Assisted reproduction has highlighted and complicated the roles of the secular state and of religious authorities. Several of the world’s major religions have shown a continued interest and investment in the use of AR, and their influence on even nominally secular government policies has

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been profound, with governments yielding to pressure based on religious tenets to enshrine their views in law.56 Because a great many societies are pluralist, the chance to seize control of reproductive politics has also been a way to forward the goals of specific religious groups for society more broadly. The so-called religions of the book—Judaism, Christianity and Islam— rely on the theological interpretation of a body of sacred texts to determine responses to AR. In Israel, the government encourages procreation, in part along the lines of religious precepts.57 Anxieties about possible ‘genetic incest’ have led some believers to recruit non-Jewish donors of sperm and oocytes; others have prioritised Jewish donors, reflecting some rabbis’ views of the Jewish religion as itself in some sense genetic.58 In New York City, one clinic welcomes the presence of an Orthodox rabbi throughout the laboratory processes, to ensure surveillance according to Jewish law, and to avoid questions arising about a child’s ‘lineage’.59 Within Islam, Shi’ite Islam permits the acceptance of gamete donation whereas it is prohibited for Sunnis.60 Thus Sunni Muslim couples affected by male-factor fertility issues now generally choose intra-cytoplasmic sperm injection (ICSI) because it enables a genetic link between father and child. There is a wide spectrum of Christian belief on AR; among the churches, the greatest concern is expressed as the risk to the embryo.61 The Catholic Church has been the most consistently active. The Vatican set down its position in two key statements: the first in the 1987 Donum Vitae (The Gift of Life), followed by a more detailed document in 2008, Dignitas Personae (The Dignity of the Person).62 The statements underlined perceived moral risks, the first being the physical risk to the human embryo, which is accorded the moral status of a human person. As the Vatican puts it, ‘The fundamental values connected with the techniques of artificial human procreation are two: the life of the human being called into existence and the special nature of the transmission of human life in marriage’.63 China—possibly now the largest AR user worldwide—as the world’s largest communist country is officially secular. However, the country’s history of Confucianism, while not strictly a religion, is believed to form the social basis for the interpretation of AR.64 Some Chinese bioethicists

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want to rework Confucian ideas of the importance of family lineage to assimilate the use of donor sperm—which breaches the perceived centrality of biological kinship—to wider ideals of family as an affective bond.65 There have been sperm banks in China for many years, including sperm banks of ‘eminent donors’; with young people more accepting of sperm donation, commentators argue that such an approach could reduce hostility to the practice.66 Restrictive attitudes to lesbians’ and single women’s access to sperm donors, even in the context of the possible impact of a declining birth rate on the ability of the country to sustain future older generations, reflect social conventions; again, these debates are by no means unique to China.67 India’s recent lawmaking has reflected conventional politics on gender relations, although Hinduism, the majority religion, has been relatively unrestrictive in relation to AR.68 Hindu teachings are also embodied in sacred texts but Hindus are relatively less encumbered by direct theological instruction on what adherents might or might not do, in relation to modern medical practice.

Religion and Compliance While many religious activists seek to enshrine their views in law, the primary goal in relation to AR is to affect the reproductive decision-­ making of individuals and families. In Judaism there has been substantial buy-in on the part of believers.69 For Egypt, likewise, believers among clinicians and patients have voluntarily followed local fatwas.70 Marcia Inhorn has found that Egyptian IVF patients, as well as their IVF doctors, attempt to scrupulously uphold these religious injunctions forbidding third-party donation practices, thereby revealing a level of conjunction between moral discourse and medical practice that is not found in most other regions of the world.71

As Inhorn implies, pronouncements and compliance can vary: in Lebanon, for example, Sunnis come from Syria to access treatment.72 Many Catholics have ignored the church, or indeed perceived in AR itself a form of God’s work. In Ecuador, as well as in many other

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majority-­ Catholic communities, adherents—including the clinicians themselves—find ways to accommodate their reproductive priorities with their faith.73 Elizabeth Roberts has found that some Catholic communities’ kinship priorities have led them to hold views of the human embryo quite opposed to those of the church.74 They would prefer an unused embryo be discarded, rather than seeing it donated to families beyond their own kin network. Her informants made clear that a strong kinship ethics, rather than the theology of their church, affected their decision-making on this point.75 Similarly, in majority-Catholic Poland, while the Catholic Church ‘categorically opposes’ assisted reproduction, the public ‘overwhelmingly supports’ its use.76 Spain, which is predominantly Catholic, has some of the most liberal laws on AR, said to be a consequence of the ongoing reaction to a long history of ‘interference of the dictator Francisco Franco into the private life of citizens’ that left people with a greater inclination to reject government intervention in matters seen as personal. Its 2006 laws considered AR ‘a matter for the individual’.77 For those Catholics who do prioritise compliance, a technique known as GIFT (gamete intra-fallopian transfer), which entails placing egg and sperm in a woman’s fallopian tubes rather than creating an embryo in the laboratory, came to be favoured as a treatment choice.78 The United States Conference of Catholic Bishops maintains, ‘Catholic couples are free to choose it or reject [GIFT] depending on the guidance of their own conscience’.79

Religion, AR and ‘Left’ Versus ‘Right’ Conventional divides between ‘left’ and ‘right’ politics have fragmented as a result of government action on AR, particularly in the face of religious views. The Australian state of Victoria’s 1980s social democratic government, as one example, brought in one of the earliest and very restrictive laws on AR, in response to pressure from the  Catholic and Anglican churches. For Latin America, Morgan and Roberts observe that some socialist governments have been staunch in their defence of official Catholic views on abortion and AR, leading feminist women there to see access to AR as one among many reproductive rights for which they are

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struggling.80 In the UK, by contrast, a government led by Margaret Thatcher brokered a regulatory regime that would permit embryo experimentation of the kind envisioned by Robert Edwards, in the face of a vocal Christian lobby. In that case, the ‘religious right’ lost their battle, notwithstanding the presence of a Conservative government. Indeed, AR has itself exposed the religious seams holding together ostensibly secular jurisdictions. In Turkey, where there is a growing tendency for Islam to challenge the officially secular government, some rulings on AR have reflected theology, with goals of ‘protecting inheritance, preventing incest, prohibiting adulterous relations and preserving lineage’ characterised at law as ‘“bioethical” and “moral” rather than religious’.81 In Sri Lanka, legislative deliberations have, in the view of anthropologist Bob Simpson, reflected a tacit interest in retaining the power of the Buddhist majority, while the country’s formal ‘religious pluralism’ has been ‘safely accommodated within an apparently secular process of ethical deliberation’.82 Further complicating the picture, one study of Orthodox Serbia refers to a kind of ‘crypto-Christianity’, finding that even in individuals there can be an elective aspect to adherence to the rules and values of religion, depending on the intervention in question.83 Religion is central to the history of many public debates about AR, yet the cultural logic underlying some policies on AR is decipherable only at close range. In Germany, sperm provision is legal, but ovum provision is not. Anthropologist Sven Bergmann observes that this is not for the protection of donor women or for any clear religious reason, but to avoid so-called fragmented motherhood, in violation of a principle of Roman law: ‘mater semper certa est’ (who the mother is, is always certain).84 Swedish and Norwegian views of sperm donation are based on the sensibility that the practice is ‘manipulation of nature beyond an acceptable level’.85 At a certain point, it can become difficult to separate out a jurisdiction’s dominant religious traditions from its secular identity: many states, for example, have explicitly limited access to AR to married heterosexual couples regardless of direct religious influence. Local differences ultimately affect conditions for many prospective clients who then might cross national borders to obtain the treatment they want, a phenomenon discussed in the next chapter, particularly in relation to surrogacy.86

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Regulatory Activism: Peer Regulation The work of religious activism in several major IVF centres has led the industry to reinforce a stance in favour of peer regulation, often working in concert with infertility support groups.87 Fertility treatment providers have been reluctant to welcome government involvement in decisions they see as best made on the basis of expert views of patient care, particularly where criminal sanctions are at stake. Typically, they envisage a ‘light’ form of regulation as the best means to avoid intrusion on sacrosanct areas such as professional autonomy and patient privacy.88 Several governments have elected to rely on peer groups such as medical associations and fertility societies to provide standards for clinics and laboratories, and to carry out surveillance. In Japan, for example, the government has left it to the Japan Society of Obstetrics and Gynecology (JSOG) to regulate assisted reproduction.89 In Ireland, it was the Medical Council, not the government, which prohibited the creation of embryos for experimentation in 1998.90 Irish fertility providers themselves mobilised to establish a new multidisciplinary Irish Fertility Society in 2005, at a time when the government began discussing possible new AR-specific laws.91 Proponents of peer regulation maintain that their own internal processes are preferable to those of government, which they point to as sluggish by comparison. They refer in particular to matters such as laboratory conditions, health checks of donor gametes, and evaluation of clinical efficacy. Catherine Rongieres, a France-based AR provider, says of France’s 1994 bioethics law—another that was nearly a decade in the making— that it controls clinical practice too closely, diminishing potential treatment time. She points to France’s delayed introduction of vitrification, a freezing technique that had been ‘demonstrated in numerous scientific articles and … adopted by our international counterparts’, but could not be used until approved by the French bioethics committee.92 ‘As soon as we were able to use it’, she explained, ‘our results very clearly improved’.93 New Zealand AR provider John Peek argues that government regulation is inflexible and inefficient, citing in particular the UK’s HFEA.94 He argues that peer-governed risk-management strategies in relation to the AR laboratory’s physical environment can do a better job reducing levels

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of contamination on surfaces and in the air, to enhance treatment outcomes.95 One legal scholar has argued that for Canada, by contrast, the federal government has potentially compromised basic AR safety by conceding the management of donor gamete testing to AR providers, who follow a voluntary code.96 Within the medical professions, however, colleagues generally will not try to dictate what members should do: ‘clinical best practice’ guidelines, for example, set standards but are not strictly binding. Nevertheless, if a member of a particular peer association fails to adhere to guidelines, sanctions such as suspension of a licence, or denial of access to discounted equipment or drugs, can result. In one Japanese case in 1998, JSOG revoked the membership of a clinician who carried out a prohibited gamete donation procedure, albeit permitting him to continue to practise.97 In terms of establishing effective safeguards for patients, licence revocation also has the significant disadvantage that it can occur only retrospectively. The case for peer regulation is thus probably best supported when the industry prioritises its collective autonomy in the face of government above the individual autonomy generally accorded to clinicians. As AR takes place in a competitive environment, developing and maintaining such a unified stance can pose a challenge. In a field with exceptional commercial potential, many of the foremost AR providers have sought diplomatically to differentiate themselves from potentially overzealous colleagues, in the interests of clients and, implicitly, the credibility of AR as a whole.98 Likewise, their colleagues in cognate specialisms, such as paediatrics and obstetrics, have sought, over many decades, to draw attention to the clinical problems associated with AR.99 These clinicians, along with some members of the fertility industry itself, have called repeatedly for better science to underpin AR practice.100 In Australia, for example, influential medical researcher Fiona Stanley has argued for more research into the prevention of infertility, while drawing attention to the risks associated with IVF, including those of multiple birth.101

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Regulatory Activism: Feminist Interventions Just as abortion law debates provided a basis for the emerging politics of IVF, numerous feminist activists and scholars focused on the implications of IVF for women, rather than embryos.102 Catholic philosopher Max Charlesworth claimed in 1989 that feminists had had ‘a very powerful effect in the State of Victoria’.103 In relation to actual policy outcomes, evidence for this claim is limited. As political scientist Rebecca Albury observed at the time, even in the mainstream media, where feminist concerns about IVF featured most strongly, coverage of ‘women’s’ issues was often localised to women’s magazines and newspaper lifestyle segments, a phenomenon that seems to have been common across the Anglophone world.104 A 1987 article by social psychologist Robyn Rowland entitled ‘Where Do Embryos Come From?’, for example, which sought to reorient debate by alerting readers to the use of superovulation to create ‘spare’ embryos from IVF treatments, appeared in the Melbourne Age’s lifestyle section, ‘Accent’.105 In Australia, access to mainstream media was at times compromised by the perceived need to promote drama over discussion, something evident even to opponents.106 A key spokesperson for the Catholic perspective, Nicholas Tonti-Filippini, observed that a calculated representation of feminists on television as intrusive and ‘shrill’ served the goals of media over those of reasoned debate.107 Amidst the focus on embryo research, hyperbolic public conversations, featuring headlines such as ‘The Maverick Senator Who Had to Decide the Meaning of Life’, arguably affected the capacity not only of feminist critics, but also of concerned medical providers and public health advocates, to play a useful role in raising public awareness of some key aspects of AR.108 Perhaps the most enduring influence of feminist discussion has been the growth of an extensive academic literature that takes feminist questions—that is, questions that consider AR in the light of its impact on women—for granted. Early members of the group FINRRAGE (Feminist International Network of Resistance to Reproductive and Genetic Engineering) were predominantly working from within an academic framework, across multiple disciplines, as were

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the many other feminist scholars considering the development of IVF.109 Holding a diverse range of views on the meaning and value of AR for women and gender relations, these writers have in turn influenced a new generation of scholars to ask broadly feminist questions.110 Unlike lobbyists, scholars work from the view that one must be open to new or unexpected research findings that will change one’s understanding. Of course, all scholarly questions are necessarily informed by a sensibility that is, to a greater or lesser degree, inherently political. Research can be ‘feminist’ in the sense that it asks questions about women and gender, whilst retaining the broader scholarly goal of a search for new knowledge and increased understanding. As in the feminist movement more widely, scholarly conversations about AR continue to be characterised by diversity, while scholarly, peer-reviewed data can orient the focus of regulators and inform policy directions. In Italy, initiatives arising as a consequence of religiously-based views elicited reactions from the medical profession and patient groups, as well as feminist criticism, in a process, still ongoing at the time of writing, which has altered the legal landscape for AR in that jurisdiction.

Case Study: Italy’s Law 40/2004 The story of a recent AR law in Italy highlights the kind of political and legal dynamics that have accompanied the history of AR since the 1970s. In 2004, the Italian government passed its only piece of legislation on AR since the first IVF birth there in 1984.111 The law endorsed religious views over those of providers, patients and other activists, all of whom have since fought it through multiple court systems in Italy and farther afield. The law reflected, above all, the Catholic Church’s view that the welfare of the human embryo should take precedence over other possible concerns. Referred to as Law 40/2004, it banned embryo experimentation and preimplantation genetic testing of embryos, as well as embryo freezing in all but exceptional cases. It prohibited surrogacy, the use of provider gametes and the provision of AR to same-sex couples, single people, older women and spouses surviving after the death of their partner.112 It limited the number of embryos created in an IVF treatment to

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three, but, quite remarkably, required that clinicians implant all embryos created in a treatment cycle in a woman’s body.113 Nothing could underscore more strongly the prioritising of concern for the embryo over the welfare of female patients and potential children than this requirement. At a time when clinicians worldwide were increasingly drawing attention to the dangers to mother and child posed by multiple births following IVF, the Italian law mandated protocols that increased the risk of such births.114 From the outset, clinicians and patients, alongside legal and feminist commentators, were concerned about the impact of the new law.115 One woman quoted on an Italian advocacy website explained why, when the law was due to come in, she chose to risk a high-order multiple birth rather than be denied the chance of using frozen embryos. She said: Having obtained five embryos I thought I could have some frozen, but already in 2003 the clinic where I was could not freeze embryos because there was already knowledge of Law 40 coming into being. Therefore, in February of that year I had all five embryos implanted, but it was a failure.116

She then had five embryos implanted twice more after that. Another woman drew attention to the impact of such a law on her treatment choices, asserting that those who are infertile [should] be allowed to decide with their doctor on the most appropriate therapies and techniques for them, without being thwarted by laws that result in one having to repeatedly seek risky hormone therapies or expensive treatments abroad.117

From being a regulatory vacuum that commentators referred to as the ‘wild west’ of reproductive technology, in a step, Italy became one of the most restrictive AR regimes in the world.118 In 2005, opponents of the law sponsored a set of four national referenda. They did not obtain the necessary quorum to reverse some of its key aspects—a campaign by the Catholic Church urging citizens to abstain from voting appears to have led to a high rate of no-shows.119 Arguably, any society with or without strong religious views might struggle to agree on all the elements of the

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Italian law, as few IVF laws are universally popular. However, most of those who did vote supported reversals of the law. Now, the wide-ranging Italian law is one of many examples of a pattern of AR regulatory history: long-pondered initiatives followed by ad hoc reversals. Amidst continued and widespread concern about its discriminatory implications, as well as their effect on medical autonomy, and on patient and child welfare, plaintiffs have taken several cases to a range of Italian and European courts.120 Clinicians were able successfully to establish that the laws were inimical to the welfare of female patients.121 Through a gradual and piecemeal process of challenging the constitutionality of the statute, inter alia, the law has come closer to respecting the rights of doctors to practise with regard to patient welfare and intentions, as well as the right of women to undergo AR without amplified risk to their health or the health of future children. Other challenges led to permission for the use of embryo freezing and preimplantation genetic testing of embryos for at-risk couples.122 Slowly, the law has been pared back, softening some of its most restrictive features, but as notable scholar of AR regulation Jennifer Gunning has observed, ‘Laws are easier to make than to repeal’.123 At the present time (2020) same-sex couples, single people and older women are still excluded from access to AR in any form, while prohibitions against surrogacy and the posthumous use of gametes or embryos remain in place. While Mary Warnock and Louis Waller extolled the value of statute law over case law, the Italian experience displays the interaction of the two different kinds. Law 40/2004 was created to limit the use of human embryos so as to minimise the risk of their destruction, and to prevent people using AR in ways that might offend others’ ideas of proper familial structures. The workings of case law made it possible to test the legitimacy of different elements of the legislation, in courts ranging from local to constitutional, up to the European Court of Human Rights. The question remains as to whether drafting and passing a statute provided the best way to reflect highly diverse social attitudes. Moves towards soft regulation have tended to advocate persuasion over prohibition, and to pay greater heed to the medical and emotional safety issues that have been obscured by a widespread legal focus on the embryo  and public morality.

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 oft Regulation, Risk Management S and Compliance Strategies In general, the global AR regulatory environment can be characterised by some relatively consistent features. The medical profession, for example, seeks to regulate itself, opposing in principle the involvement of the state in the practice of medicine, while accommodating state requirements or assisting states through provision of expert regulatory guidelines. State action or inaction generally reflects the views of dominant lobby groups, with factors such as economic benefit and social conservatism sometimes existing in tension. Legal change has often taken place in the political fast lane, whereas religious advocates and medical-scientific groups proceed in a more deliberate fashion, each playing what might be called ‘the long game’ in an ongoing struggle to control the industry. With greater cooperation between government and industry, a general trend away from wide-ranging criminal laws has been in evidence. Forms of ‘soft regulation’, intended to channel and persuade rather than prohibit, operate in matters such as record keeping, health insurance policy, site inspection regimes and testing donor gametes for infection. Medical peer regulation can play an important part, supplanting possibly more stringent government interventions, or aligning with government regulatory goals. Many such policies have been brought into being since the 1980s; those considered here relate to the clinical risk of multiple birth, the medical and emotional implications of donor anonymity, and the question of how to measure AR success rates.

Clinical Risk: The Example of Multiple Births Studies have identified several clinical risks of AR. These concern oocyte providers, pregnant and parturient women (women who have recently given birth), and perinatal and long-term risks to children.124 The most common clinical risks for women are ovarian hyperstimulation syndrome (OHSS) from fertility drugs, and for women and children, multiple birth. The 2019 International Federation of Fertility Societies (IFFS) report is blunt, stating that multiple births have ‘plagued ART for three

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decades, and have resulted in unacceptably high rates of fetal and maternal complications’.125 One 2009 report states that the latter occur at a global rate of around 50% of all IVF births, although rates do vary between countries, and are declining in many.126 In the light of these figures, ‘The birth of a healthy singleton baby’, one industry overview notes, ‘is increasingly becoming the most important outcome parameter following assisted reproductive treatment’ rather than ‘crude pregnancy rates’.127 Early on, however, consideration of the risks of multiple births was not a priority for the fertility industry; on the contrary, such births were often celebrated. In 1989, a Perth (Australia) clinic delivered a set of quins and a set of quads on the same day, leading one news report to headline their story ‘IVF Rates Boosted’.128 Now, the ‘good news’ of IVF multiple births has given way to a more realistic assessment of whether inserting more than one embryo is a good idea for either mother or children. As one report spells out: The medical risks to the offspring include death, low birth weight, deformational plagiocephaly, and other physical and mental disabilities. Risks to the women include premature labor, premature delivery, pregnancy-­ induced hypertension, toxemia, gestational diabetes, and vaginal-uterine hemorrhage. Children born in multiples face difficulty socializing, developmental delays, and behavioral problems, whereas their parents risk exhaustion, depression, and anxiety.129

Concerned providers, heeding urgent calls from founding figures such as Robert Edwards and René Frydman, have increasingly called on colleagues to take seriously  the incidence of multiple AR births.130 This stance is widely expressed in the medical literature, where multiple birth is seen as a ‘very hot issue’ and ‘a major complication and concern of ART practitioners for many years’, as new efforts ‘are being made in many countries to reduce [its] incidence’.131 In recent years, some clinical groups and governments, as well as public and private insurance programs, have shown increasing willingness to adopt strategies to limit multiple births without reducing the chance of a singleton birth. Ethicists and clinical commentators have urged the US

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federal and state governments, for example, to use pragmatic funding options to help reduce multiple births.132 They suggest: expanding insurance coverage for IVF, to reduce the incentive for clients to want more embryos implanted in one treatment; avoidance of IUI (intrauterine insemination) by direct uptake of IVF, especially as some insurance companies require the use of the more dangerous IUI before funding IVF; and redefining the meaning of the term ‘cycle’ for IVF treatments, so that insurance coverage would expand to cover more realistic expectations in relation to the number of treatments required for a live birth.133 They point to jurisdictions such as Belgium, Sweden and Quebec, in which ‘regulations or financial incentives’ have been used to increase or to require the use of elective single embryo transfer (eSET), and where good singleton live birth rates have been achieved.134 In several of the countries surveyed by the IFFS, an increased chance of funding for treatment can function as a form of soft regulation to encourage the transfer of fewer embryos. In the UK, the HFEA collaborated with ‘professional bodies, patients and clinics’ to limit the number of multiple births. The American Society of Reproductive Medicine (ASRM) guidelines encourage eSET, but industry compliance is patchy.135 Among AR clinical providers generally, there has historically been and remains considerable diversity in approach. In Taiwan, for example, a 2007 regulation capped the permitted number of embryo transfers, but still allowed for four embryos to be transferred at once, a number that poses serious risks to mother and child. In the words of sociologist Chia-­ Ling Wu, the policy amounted to ‘rhetoric only’.136 Overall, the most recent IFFS report notes with concern that ‘no significant changes have occurred in the proportion of countries that tie reimbursement to number of embryos transferred’.137

Multiple Births and Patients’ Perspectives The implantation of multiple embryos can arithmetically increase the chance of a pregnancy, but considerations of cost can also affect patient decisions. According to one report, ‘the number of embryos transferred has been shown to be associated with the cost that patients pay for ART

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treatment, with less affordable treatment creating a financial incentive to transfer more embryos in the hope of achieving a pregnancy in a limited number of costly ART cycles’.138 Moreover, while selective foetal reduction is an ‘established method to reduce the number of fetuses, improve the live-birth rate, and reduce risks to the surviving fetuses’, for some prospective parents, the procedure might be morally or emotionally unacceptable.139 Information and advice can give clients a basis to make choices, but among those is the choice to ignore advice, especially in relation to the relatively lesser risk of twins. As one HFEA official observed of this kind of decision-making, the risk of twins ‘to the individual woman … is as nothing compared to the risk of not having a baby’.140 Given the emotional loading in such decisions, one group of clinicians have advised their colleagues that the transfer of only one embryo requires ‘careful patient counselling’.141 Others have commented that some clinics can compromise their patients’ informed decisions by presenting inadequate information about probability.142 While a seeming majority in the fertility industry lay responsibility at the feet of colleagues to avoid the creation of multiple pregnancies in the first place, the IFFS believes ‘the problem remains significant, and offers considerable room for improvement’.143 In many cases, both providers and clients want to ensure that each cycle optimises the chance of a pregnancy and, in a highly competitive fertility marketplace, multiple births can increase a clinic’s published success rates.

Donor Anonymity Many people born through gamete provision are now well into adulthood, and donor-conceived people (DCP) activism is a growing international phenomenon. The 2019 IFFS report identifies as increasingly prominent ‘ethical controversies regarding the appropriateness of preserving anonymity for gamete donation’.144 Within the industry, and among bioethics commentators, there is debate about the extent to which anonymity should be preserved, and the conditions in which DCPs might access donor data.145 The case for anonymity, a practice intended in the early years of IVF to encourage donation and to reassure social

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parents, is also under challenge as a result of the spread of DNA matching. Donor-conceived activists urge understanding of their experience of both medical and emotional risk, in the absence of knowledge about the providers of gametes to their social parents. In 2017, Victoria (Australia) again became the site of a new regulation when it passed ‘Narelle’s law’, named for a young woman who died of heritable bowel cancer.146 The law provided for access to donors’ identities, subject to safeguards intended to protect donors or DCPs from unwanted contact.147 Humane arguments for anonymity remain, in relation to the protection of donors and social parents, but the global trend favours giving DCPs knowledge of their conception by donor, as well as the identity of the donor(s).148 A recent article in Human Reproduction gave a stark warning that, with the increased use of DNA ancestry websites, ‘All parties concerned must be aware that … donor anonymity does not exist’.149 Some jurisdictions still permit total anonymity, nonetheless, and many donor or surrogacy providers’ identities are likely to be permanently inaccessible, regardless of incoming laws or donor registries. In jurisdictions where minimally regulated gamete donation and surrogacy are or have been widespread, the children who were born are unlikely to be able to find out about the providers, nor the providers about them. Even with DNA matching, in the absence of international policy harmonisation either within the industry or between governments, donor anonymity will remain another area in which the fertility trade poses a challenge to the range of options available to DCPs. A legal commentary on the international Donor Sibling Registry website voices cynicism about the value of peer regulation, questioning the ASRM’s ‘recommendations’ for ‘no more than 25 pregnancies per donor per population of 800,000’, extrapolating the (perhaps rhetorical) point that each male donor could remain within the society’s guidelines, equivalent to one birth per 32,000 people, and still provide sperm to create 213,766 children.150

Success Rates From the 1980s to the present day, prominent members of the fertility profession have voiced concern about clinics misleading current and

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prospective patients in regard to success rates in AR. In the United States, for example, in 1987, of around 150 clinics in operation—more than half the clinics in the world at that time—the majority were yet to register a live birth; many of the births were taking place in a handful of clinics.151 Major industry figures, such as Alan DeCherney and Benjamin Younger, argued that IVF was mistakenly perceived as a first or only option for infertility, rather than a last resort.152 Other providers’ statements illustrate the difficulties facing consumers to reconcile image and reality: while one had the view that each ‘facility must create a brandname for itself ’, another warned potential patients against ‘storefront’ programs, saying, ‘You must make sure you get into the right place’.153 In 1987, Fertility and Sterility published an article that asked: ‘Are we exploiting the infertile couple?’ It identified ‘(1) inappropriate use of credentials, (2) misuse of new reproductive technologies, and (3) truth in advertising’, as all being ‘highly susceptible to potential exploitation’.154 The journal’s response to its analysis was a collegial call for restraint. Political and consumer pressure mounted and in 1989, following a congressional hearing, the Society for Assisted Reproductive Technology (SART), part of the American Fertility Society, undertook to publish its statistics.155 A key figure in this process was a Democrat member of the House of Representatives, Ron Wyden, who observed: What you’ve got here is a very combustible mix, essentially no regulation, large sums of money, constantly changing and improving technology, and vulnerable couples who want to have a baby more than anything else on earth.156

In 1992, Wyden sought the cooperation of the fertility industry to garner support for the bill to create the Fertility Clinic Success Rate and Certification Act of 1992, ‘implemented to ensure the quality of ART services and to furnish consumers with reliable information on pregnancy success rates of individual ART clinics’.157 Clinicians who supported the act explained to regulation-shy colleagues that such cooperation with government was a defensive strategy to shore up the credibility of the industry against continued bad press. An

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article in Fertility and Sterility pointed to the value to the profession of, in effect, playing along with regulation: What has the discipline gained by involvement in the legislative process and what are the implications? The implications are threefold: [1] to further enhance the respect and credibility of the profession, [2] to improve the chances for insurance reimbursement for ART procedures, and [3] to use our support for the Wyden bill as a bargaining chip in restoring federal funding for IVF research. Participation in the process garnered positive publicity for the profession as acknowledged by Representative Wyden during House debate on the bill.158

The compilation and distribution of accurate and well-defined treatment outcome data go to the question of industry accountability and transparency. According to Charis Thompson, for the United States, data ‘might not seem like a conventional form of governance’, but it has ‘emerged as a major policy tool, helping the sector to make the case to and with professionals, patients/consumers and the government that the industry could adequately self-regulate’.159 Because the fertility industry in the United States is so loosely regulated, in terms of what treatments are available, its paradoxical history of willingness to provide extensive data to the federal government provides an important case study of soft regulation. The Centers for Disease Control and Prevention continue to gather some of the most comprehensive data on AR techniques and outcomes.160 Other national and international industry-based record-­ keeping projects emerged in the late 1980s.161 Still today, a perceived need to provide encouraging, but potentially misleading, figures arises from the fact that, as one major British provider expressed it in 2008, ‘The success rates [of AR] remain stubbornly low’. She added, ‘the high rate of multiple births is unacceptable, and the lack of active research in many treatment centres smacks of a production line or profit culture’.162 Another recent commentary was even more pointed, saying, ‘lack of will to question the perceived success of IVF is preventing progress’, and concluding that ‘it is time to reconnect the drive to “regulate practice” with a drive to generate knowledge on best practice and long term safety’.163 Where regulators do exist, they continue to assert

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that the industry is not always transparent in its use of statistics. For example, in November 2016 the Australian Competition and Consumer Commission (ACCC) urged the IVF industry to tackle the use of ‘potentially false or misleading’ representations of success rates, although misleading advertisements were still being published a year later.164 The Reproductive Technology Accreditation Committee (RTAC), a peer group that accredits Australian clinics on behalf of government, has acted to curb the advertising of AR success rates in clinics’ publicity.165 In the UK, the HFEA, some fertility specialists and the media are raising concerns that ‘foreign’ IVF clinics to which British patients travel are claiming inflated success rates.166 Others point to the commercially driven aspects of AR more broadly, especially in relation to perceived unnecessary interventions and some adjuvant treatments.167 At the time of writing in 2020, there is still no internationally agreed definition of AR success: providers’ public statements often refer to ‘clinical pregnancy’, ‘chemical pregnancy’ or just ‘pregnancy’, rather than live birth rate per treatment cycle or embryo transfer (or, colloquially, ‘take home baby rate’). As one US healthcare consultant observed when the 1992 US law was under consideration, obfuscation has personal consequences as ‘people who are infertile don’t give a hoot whether they get pregnant. … They want to be able to take a baby home’.168 More than twenty years later, leading IVF scientist Alan Trounson expressed the same opinion: ‘What you need to know is the probability of having a baby, because you didn’t come in to get pregnant, you came in to have a baby’.169 IVF clinician Rob Norman argues that changing definitions at the clinical level further cloud lay understandings. He notes, for example, that ‘You’ll find some clinics define pregnancy on the basis of an ultrasound, [while] others are included from 12 weeks onwards, so it’s a bit of a mess all over the place’.170 In a major industry initiative, the Cochrane International Review project, which aggregates and discerns trends from studies in a range of medical fields, was working in 2019 with the European Society for Human Reproduction and Embryology (ESHRE) to create a definition of AR success for use in the medical research literature. A Cochrane statistician noted that ‘outcomes such as clinical pregnancy were defined in over 60 different ways or were not defined at all, thus causing

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methodological frailty in the evidence base’.171 The project is working with the industry and consumers to ensure that well-credentialed journals work to a recognised set of criteria for ‘success’ in evaluating submissions on AR-related subjects.

Conclusions Reports on AR routinely refer to the existence of ethical dilemmas, as if the technology itself inherently posed the questions that are asked. Yet, as we have seen, the questions asked originate in the first instance from stakeholders with very specific interests in mind, which might mean that either their questions might not be important for everyone, or that there are other questions that are not asked when other stakeholders install their questions as the ‘natural’ ones to be asked. That is the historical trend that has led to the current ‘reproscape’, in which questions eclipsed long ago are now re-emerging with greater strength. The issue of donor conception, for example, relied on the coming to adulthood of children born through these arrangements. Or, in the case of multiple births, the problem was not completely invisible early on, but became increasingly conspicuous once the debate about embryos had begun to subside, as multiple births became more commonplace, as new drug uses led to the creation of more eggs, and as industry leaders, including Robert Edwards, began to voice their concern. The history of success rates seems to be more of a merry-go-round: anyone following the history of AR reportage will know that new techniques with better chances of success are the staple of AR news, but that these stories are often juxtaposed with views questioning the value of new techniques and the validity of success rate claims, or arguing for greater regulation. Helen Szoke refers to ‘the public interest’ as a founding principle of policy.172 A quest to represent the public interest implies the legitimacy of the very idea of a public sphere, within which policies are determined by elected representatives, and implemented through their agencies, that is, the public or civil service. The questions the Warnock Inquiry posed were based on a view that ‘society’, notwithstanding differences of view, was a point of moral point of reference.173 Yet, as Sarah Franklin has argued, the

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era of Margaret Thatcher, when the most vigorous debate about AR in the UK took place, was also one in which the idea of ‘society’ as a place of collective thought and experience was coming under challenge.174 The British laws on AR represented a compromise with religious views, rather than an outright concession. Modern reproductive technologies have offered a platform for the furtherance of theological and ideological agendas. It could even be said that the ways in which the public sphere—or civil society—is constituted in the early twenty-first century—and indeed the very idea of civil society—are in significant part a consequence of the public reception of AR, with its focus on personhood, reproduction and the family. There are risks accompanying oversight of AR clinics and research, either exclusively by peer regulation or exclusively by government. Effective peer regulation relies on collegial agreement on basic requirements of a medical discipline, as well as consensus on the terms for scrutiny of medical peers who are also in a commercial environment—indeed, often in direct competition with each other. The evidence is strong that AR clinicians and researchers hold a very wide range of views about regulation, and that medical colleagues in other fields are particularly concerned about the risks of AR to patients and children. Moreover, there is scope within the profession for accepting patient-centred arguments even in relation to dangerous medical interventions: if a woman wishes to have more than one embryo reimplanted, for example, some doctors would argue their role is not to dispute this choice. In some jurisdictions, such a libertarian approach, which places the right of the individual above the right even of industry or government to regulate on the basis of alleviating known risks, might hold sway. Changing regulatory regimes have produced a chequerboard of subnational, national and international laws and regulations that have, in the context of increased fertility travel by providers and clients, generated a transnational momentum that regularly switches and redirects the clinical practice of AR.  The extent of reproductive travel highlights both the desirability of reconciling differing attitudes to a wide range of AR interventions, and the unlikelihood that that will occur. This chapter began with the observation that there is a politics to the manner in which governments have seen the need for action on AR. The

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precise politics giving shape to laws, however, shift regularly in an unstable constellation of action, inaction and reaction. Each historical moment recreates anew the ideological grammar that contextualises and legitimates—or constrains—AR.  Forty years ago, it might not have been anticipated that the global community would have had its attention riveted so closely to matters of religion; nor to matters of gender and sexual orientation in relation to parenting; nor to matters touching the very legitimacy of state authority.175 Anthropologist Joanna Mishtal argues that such questions now go to the heart of debates about governance, while science and technology studies scholars Sheila Jasanoff and Ingrid Metzler refer to the significance of AR for ‘overarching notions of political coherence and legitimacy’.176 Indeed, sociologist Laura Briggs has argued that ‘all politics’ has now become ‘reproductive politics’.177

Notes 1. An early comparative study is Jennifer Gunning, Human IVF, Embryo Research, Fetal Tissue for Research and Treatment, and Abortion: International Information (London: HMSO, 1990). For Australia, see Rachel Simpson, Assisted Reproductive Technology (NSW Parliamentary Library Research Service, Background Paper 6/98, 1998). 2. Shaun D. Pattinson, ‘Current Legislation in Europe’, in The Regulation of Assisted Reproductive Technology, ed. Jennifer Gunning and Helen Szoke (Aldershot: Ashgate, 2003), 7–19, 9. 3. International Federation of Fertility Societies (IFFS), ‘International Federation of Fertility Societies’ (IFFS) Surveillance 2019: Global Trends in Reproductive Policy and Practice, 8th Edition’, Global Reproductive Health 4, no, 1 (2019): e29. 9. See also Dmitry M. Kissin, G. David Adamson, Georgina M. Chambers, and Christian De Geyter, eds., Assisted Reproductive Technology Surveillance (Cambridge, UK, Cambridge University Press, 2019). 4. Marilyn Strathern, ‘Displacing Knowledge: Technology and the Consequences for Kinship’, in Conceiving the New World Order: The Global Politics of Reproduction, ed. Faye D. Ginsburg and Rayna Rapp (Berkeley: University of California Press, 1995), 346–63.

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5. See, for example, Robert G. Edwards and Patrick Steptoe, A Matter of Life: The Story of a Medical Breakthrough (New York: William Morrow, 1980), 109–116. 6. Martin H.  Johnson and Kerry Petersen, ‘Public Interest or Public Meddling?: Towards an Objective Framework for the Regulation of Assisted Reproduction Technologies’, Human Reproduction 23, no. 3 (2008): 716–28, 722. 7. Carol Kleiman, ‘Do Test Tube Babies Have a Future in the U.S.?’, Chicago Tribune, 2 January, 1979; Louis Waller and Sandra Dill, ‘The Regulation and Legislation of In-Vitro Fertilization’, in In-Vitro Fertilization: The Pioneers’ History, ed. Gabor Kovacs, Peter Brinsden, and Alan DeCherney (Cambridge, UK: Cambridge University Press, 2018), 224–31, 224; Helen Szoke, ‘Social Regulation, Reproductive Technology and the Public Interest: Policy and Process in Pioneering Jurisdictions’ (PhD diss., University of Melbourne, 2004), 370; Johnson and Petersen, ‘Public Interest or Public Meddling?’, 722. 8. Johnson and Petersen, ‘Public Interest or Public Meddling?’, 720; 722. 9. Martin H. Johnson, ‘Robert Edwards: The Path to IVF’. Reproductive BioMedicine Online 23, no. 2 (2011): 245–62, 253. For other uses than those proposed by Edwards, see United States Department of Health, Education, and Welfare. Ethics Advisory Board, HEW Support of Research Involving Human In Vitro Fertilization and Embryo Transfer: Report and Conclusions (Washington: Advisory Board, Department of Health, Education and Welfare, 1979), 22 and ‘Victoria Lifts Its Ban on Test-tube Baby Programs’, Sydney Morning Herald, 14 December, 1983. 10. Sarah Franklin, Biological Relatives: IVF, Stem Cells, and the Future of Kinship (Durham, NC: Duke University Press, 2013), 57. 11. Waller and Dill, ‘The Regulation and Legislation of In-Vitro Fertilization’, 224; Marcia Inhorn, ‘Gender, Religion and In Vitro Fertilization’, ISIM Newsletter 11, no. 2 (2002): 23; Marcia C. Inhorn, Pasquale Patrizio, and Gamal I.  Serour, ‘Third-Party Reproductive Assistance around the Mediterranean: Comparing Sunni Egypt, Catholic Italy and Multisectarian Lebanon’, Reproductive BioMedicine Online 21, no. 7 (2010): 848–53, 850; Mary Warnock, A Question of Life: The Warnock Report on Human Fertilisation and Embryology (Oxford: Basil Blackwell, 1984), 32. 12. Sébastien Sakkas, ‘L’expertise éthique face à la régulation publique des biotechnologies de la reproduction: une comparaison France-Belgique

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de l’influence des comités nationaux d’éthique sur le contenu des politiques publiques’ (Thèse de doctorat, Université catholique de Louvain, 2014), 201. Text is authors’ translation (NM). 13. United States Department of Health, Education, and Welfare. Ethics Advisory Board, HEW Support of Research Involving Human In Vitro Fertilization and Embryo Transfer; Carol Kleiman, ‘Do Test Tube Babies Have a Future in the U.S.?’; John D.  Biggers, ‘IVF and Embryo Transfer: Historical Origin and Development’, Reproductive BioMedicine Online 25, no. 2 (2012): 118–27, 125. 14. Kleiman, ‘Do Test Tube Babies Have a Future in the U.S.?’ 15. United States Department of Health, Education, and Welfare. Ethics Advisory Board, HEW Support of Research Involving Human In Vitro Fertilization and Embryo Transfer, 101–04. 16. Kleiman, ‘Do Test Tube Babies Have a Future in the U.S.?’ 17. United States Department of Health, Education, and Welfare. Ethics Advisory Board, HEW Support of Research Involving Human In Vitro Fertilization and Embryo Transfer, 102. 18. United States Department of Health, Education, and Welfare. Ethics Advisory Board. HEW Support of Research Involving Human In Vitro Fertilization and Embryo Transfer, 102–04. 19. Christopher Sullivan, ‘10  Years after First “Test-Tube Baby”, Many Questions Remain’, Associated Press, 23 July, 1988. 20. Committee on the Basic Science Foundations of Medically Assisted Conception & NAS-NRC Assessment Panel (U.S.) & Institute of Medicine (U.S.). Division of Health Sciences Policy & National Research Council (U.S.). Board on Agriculture, Medically Assisted Conception: An Agenda for Research: Report of a Study (Washington, DC: National Academy Press, 1989), vii. 21. Jennifer Gunning, ‘Regulating ART in the USA: A Mixed Approach’, in The Regulation of Assisted Reproductive Technology, ed. Jennifer Gunning and Helen Szoke (Aldershot: Ashgate, 2003), 55–66, 55. 22. Inhorn, Patrizio, and Serour, ‘Third-Party Reproductive Assistance around the Mediterranean’, 50. 23. Inhorn, Patrizio, and Serour, ‘Third-Party Reproductive Assistance around the Mediterranean’, 50. See also Marcia C.  Inhorn, ‘Making Muslim Babies: IVF and Gamete Donation in Sunni versus Shi’a Islam’, Culture, Medicine and Psychiatry 30, no. 4 (2006): 427–50, 432–33, and G. I. Serour, ‘Islamic Perspectives in Human Reproduction’, Reproductive BioMedicine Online 17, Supp. 3 (2008): 34–38.

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24. Inhorn, ‘Gender, Religion and In Vitro Fertilization’, 23. 25. Waller and Dill, ‘The Regulation and Legislation of In-Vitro Fertilization’, 224–31; Warnock, A Question of Life. 26. ‘Obituary: Mary Warnock: Seeing Things Clear’, Economist, 30 March, 2019; ‘Vale Emeritus Professor (Peter) Louis Waller AO’, Monash University Website, 10 October, 2019, https://www.monash.edu 27. Duncan Wilson, The Making of British Bioethics (Manchester, UK: Manchester University Press, 2014), 159. 28. Waller and Dill, ‘The Regulation and Legislation of In-Vitro Fertilization’, 228. 29. Joan McGregor and Frédérique Dreifuss-Netter, ‘France and the United States: The Legal and Ethical Differences in Assisted Reproductive Technology (ART)’, Medicine and Law 26 (2007): 117–35, 119; Jean Cohen, Alan Trounson, Karen Dawson, Howard W.  Jones, Johan Hazekamp, Karl-Gösta Nygren, and Lars Hamberger, ‘The Early Days of IVF outside the UK’, Human Reproduction Update 11, no. 5 (2005): 439–60, 444. 30. Waller and Dill, ‘The Regulation and Legislation of In-Vitro Fertilization’, 225. 31. Rina Agrawal, Elizabeth Burt, and Roy Homburg, ‘Time-Line in HFEA Developments and Regulatory Challenges: 20  Years of Overseeing Fertility Practices and Research in the UK’, Journal of Obstetrics and Gynecology of India 63, no. 6 (2013): 363–69, 364. 32. Agrawal, Burt, and Homburg, ‘Time-Line in HFEA Developments and Regulatory Challenges’, 364; https://hfea.gov.uk/about-us 33. Victoria,  Standing Review and Advisory Committee on Infertility (SRACI), ‘Public Seminar: In Vitro Fertilization and Related Issues’, 17 September, 1986. VARTA Collection, Melbourne, Folder 23, 7. 34. Szoke, ‘Social Regulation’, 299. 35. Christine Crowe, ‘Whose Mind over Whose Matter? Women, In Vitro Fertilisation and the Development of Scientific Knowledge’, in The New Reproductive Technologies, ed. Maureen McNeil, Ian Varcoe, and Steven Yearley (London: Palgrave Macmillan, 1990), 27–57; Michael Mulkay, The Embryo Research Debate: Science and the Politics of Reproduction (Cambridge: Cambridge University Press, 1997). 36. Waller and Dill, ‘The Regulation and Legislation of In-Vitro Fertilization’; Victorian Assisted Reproductive Treatment Authority (VARTA), ‘History of Victorian ART Regulation’, https://www.varta.org.au/regu-

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lation/history-victorian-art-regulation; Agrawal, Burt, and Homburg, ‘Time-Line in HFEA Developments and Regulatory Challenges’; Human Fertilisation and Embryology Authority, ‘Celebrating 40 Years of IVF’, https://www.hfea.gov.uk/celebrating-40-years-of-ivf 37. PGT is a coverall term now increasingly used to describe two principal kinds of tests: genetic tests on embryos (formerly PGD, embryo testing for a heritable disorder) and embryo screening for chromosomal abnormalities (formerly PGS, more often now preimplantation genetic testing for aneuploidy, PGT-A). Victorian Assisted Reproductive Treatment Authority (VARTA), ‘Preimplantation Genetic Testing’, https://www.varta.org.au/resources/publications/ preimplantation-genetic-testing-pgt 38. Warnock, A Question of Life, 73; A. H. Handyside, R. J. A. Penketh, R.  M. L. Winston, J.  K. Pattinson, J.  D. A.  Delhanty, and E. G. D. Tuddenham, ‘Biopsy of Human Preimplantation Embryos and Sexing by DNA Amplification’, Lancet 333, no. 8634 (1989): 347–49. 39. United Kingdom, ‘Human Fertilisation and Embryology Act 1990, Chapter 37’, document generated 20 April, 2019: Schedule 2, Section 3(2)a, http://www.legislation.gov.uk/ukpga/1990/37/enacted/data.pdf 40. Michael Pirrie, ‘Embryo Tests Halted by Cain’, Age (Melbourne), 18 March, 1989; Michael Pirrie, ‘IVF Committee Backs Hogg on Moratorium Decision’, Age (Melbourne), 1 April, 1989. 41. Pirrie, ‘Embryo Tests Halted by Cain’. 42. ‘Embryo Experimentation and the Role of Government: Clarifying the Issues, Yvonne Bowden Auditorium, Royal Women’s Hospital, Melbourne, 9 May 1989’, VARTA collection, Item 2, 7; 9. The date of the meeting was Thursday, 11 May 1989, and it was sponsored by the Monash Bioethics Centre. 43. Waller and Dill, ‘The Regulation and Legislation of In-Vitro Fertilization’, 225; National Health and Medical Research Council (Australia), ‘Embryo Research Licensing Committee’, https://www. nhmrc.gov.au 44. Agrawal, Burt, and Homburg, ‘Time-Line in HFEA Developments and Regulatory Challenges’. 45. Katrine Del Villar, ‘McBain v State of Victoria: Access to IVF for All Women’. Research note, 15 August, 2000.  Parliament of Australia, https://parlinfo.aph.gov.au 46. Waller and Dill, ‘The Regulation and Legislation of In-Vitro Fertilization’, 230; State of Victoria, Minister for Health, ‘Removing

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Police Checks to Make IVF Fairer and Easier’, media release. 19 February, 2020, https://www.premier.vic.gov.au/removing-policechecks-to-make-ivf-fairer-and-easier 47. Waller and Dill, ‘The Regulation and Legislation of In-Vitro Fertilization’; Johnson and Petersen, ‘Public Interest or Public Meddling?’; Sonia Marie Allan, ‘The Regulation of Research Involving Human Embryos and Cloning in the United Kingdom and Australia’ (PhD diss., University of Melbourne, 2009). 48. Szoke, ‘Social Regulation’. 49. Human Fertilisation and Embryology Authority (HFEA), https:// www.hfea.gov.uk; Victorian Assisted Reproductive Treatment Authority (VARTA), https://www.varta.org.au 50. IFFS, ‘International Federation of Fertility Societies’ Surveillance (IFFS) 2019’, 12. 51. Karin Hammarberg, Louise Johnson, and Tracey Petrillo, ‘Gamete and Embryo Donation and Surrogacy in Australia: The Social Context and Regulatory Framework’, International Journal of Fertility and Sterility 4, no. 4 (2011): 176–83; Yulian Zhao, Paul Brezina, Chao-Chin Hsu, Jairo Garcia, Peter R.  Brinsden, and Edward Wallach, ‘In Vitro Fertilization: Four Decades of Reflections and Promises’, Biochimica et Biophysica Acta (BBA)-General Subjects 1810, no. 9 (2011): 843–52, 848. 52. Pamela White, ‘“A Less than Perfect Law”: The Unfulfilled Promise of Canada’s Assisted Human Reproduction Act’, in Revisiting the Regulation of Human Fertilisation and Embryology, ed. Kirsty Horsey (London: Routledge, 2015), 170–84, 174. 53. Ayo Wahlberg, Good Quality: The Routinization of Sperm Banking in China (Oakland: University of California Press, 2018), 49. 54. Wahlberg, Good Quality, 17; Ayo Wahlberg, ‘The Birth and Routinization of IVF in China’, Reproductive BioMedicine & Society Online 2 (2016): 97–107, 104–05; Jie Qiao and Huai L. Feng, ‘Assisted Reproductive Technology in China: Compliance and NonCompliance’, Translational Pediatrics 3, no. 2 (2014): 91–97, 93. 55. See Guiseppe Benagiano, ed., ‘Symposium: Religion in Assisted Reproduction’, special issue, Reproductive BioMedicine Online 17, Supp. 3 (2008): 6–67. 56. Wendy Chavkin, ‘The Old Meets the New: Religion and Assisted Reproductive Technologies’, Development 49, no. 4 (2006): 78–83; Charis Thompson, ‘God Is in the Details: Comparative Perspectives on

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the Intertwining of Religion and Assisted Reproductive Technologies’, Culture, Medicine and Psychiatry 30 (2006): 557–61; Ariana Eunjung Cha, ‘How Religion Is Coming to Terms with Modern Fertility Methods’, Washington Post, 27 April, 2018, https://www.washingtonpost.com 57. Susan Martha Kahn, Reproducing Jews: A Cultural Account of Assisted Conception in Israel (Durham, NC: Duke University Press, 2000). 58. Daphna Birenbaum-Carmeli, ‘Thirty-Five Years of Assisted Reproductive Technologies in Israel’, Reproductive BioMedicine & Society Online 2 (2016): 16–23, 18–19. 59. Cha, ‘How Religion Is Coming to Terms with Modern Fertility Methods’. 60. Inhorn, Patrizio, and Serour, ‘Third-Party Reproductive Assistance around the Mediterranean’, 851. 61. D. Gareth Jones, ‘Christian Responses to Challenging Developments in Biomedical Science: The Case of In Vitro Fertilisation (IVF)’, Science & Christian Belief 26, no. 2 (2014): 143–64; H.  N. Sallam and N.  H. Sallam, ‘Religious Aspects of Assisted Reproduction’, Facts, Views and Vision in Obstetrics and Gynaecology 8, no. 1 (2016): 33–48, 35–40; a  brief but useful summary for student use can be found at ‘Fertility Issues’, BBC Bitesize, https://www.bbc.co.uk/bitesize/guides/ z2jmyrd/revision/4 62. John Hooper, ‘Vatican Condemns IVF in Bio-Ethics Review’, Guardian (UK), 13 December, 2008. 63. Congregation for The Doctrine of The Faith, Instruction on Respect for Human Life in Its Origin and on The Dignity of Procreation: Replies to Certain Questions of the Day, 1987, http://www.vatican.va/roman_curia/ congregations/cfaith/documents/rc_con_cfaith_doc_19870222_ respect-for-human-life_en.html; Congregation for The Doctrine of The Faith, Instruction Dignitas Personae On Certain Bioethical Questions, http://www.vatican.va/roman_curia/congregations/cfaith/documents/ rc_con_cfaith_doc_20081208_dignitas-personae_en.html 64. Juhong Liao, Bart Dessein, and Guido Pennings, ‘The Ethical Debate on Donor Insemination in China’, Reproductive BioMedicine Online 20 (2010): 895–902. 65. Liao, Dessein, and Pennings, ‘The Ethical Debate on Donor Insemination in China’, 896.

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66. Liao, Dessein, and Pennings, ‘The Ethical Debate on Donor Insemination in China’, 899. 67. Liao, Dessein, and Pennings, ‘The Ethical Debate on Donor Insemination in China’, 899–900; Cecily Huang, ‘For Single Mothers and Lesbians in China, Accessing Fertility Treatment Is a Nightmare’, ABC News, 16 March, 2019, https://www.abc.net.au/news; ‘Chinese Birth Rate Falls to Lowest in Seven Decades’, BBC News, 17 January, 2020, https://www.bbc.com 68. Sallam and Sallam, ‘Religious Aspects of Assisted Reproduction’, 44. 69. Kahn, Reproducing Jews. 70. Inhorn, Patrizio, and Serour, ‘Third-Party Reproductive Assistance around the Mediterranean’, 851. 71. Inhorn, ‘Gender, Religion and In Vitro Fertilization’. 72. Inhorn, Patrizio, and Serour, ‘Third-Party Reproductive Assistance around the Mediterranean’, 849. See also Inhorn, ‘Making Muslim Babies’; Marcia C.  Inhorn, Daphna Birenbaum-Carmeli, Soraya Tremayne, and Zeynep B. Gürtin, ‘Assisted Reproduction and Middle East Kinship: A Regional and Religious Comparison’, Reproductive BioMedicine & Society Online 4 (2017): 41–51. 73. Elizabeth F. S. Roberts, God’s Laboratory: Assisted Reproduction in the Andes (Berkeley: University of California Press, 2012). 74. Elizabeth F. S. Roberts, ‘Extra Embryos: The Ethics of Cryopreservation in Ecuador and Elsewhere’, American Ethnologist 34, no. 1 (February 2007): 181–99. 75. Roberts, ‘Extra Embryos’, 182. 76. Joanna Mishtal, ‘Reproductive Governance and the (Re) Definition of Human Rights in Poland’, Medical Anthropology 38, no. 2 (2019): 182–94. 77. Catherine Rongieres, ‘We Need Progress in French ART Law’, BioNews, no. 938, 19 February, 2018, https://www.bionews.org.uk 78. Cohen et al., ‘The Early Days of IVF outside the UK’. 79. John M. Haas, ‘Begotten Not Made: A Catholic View of Reproductive Technology’, United States Conference of Catholic Bishops (USCCB), http://www.usccb.org 80. Lynn M. Morgan and Elizabeth F. S. Roberts, ‘Reproductive Governance in Latin America’, Anthropology & Medicine 19, no. 2 (2012): 241–54, 247.

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81. Zeynep B. Gürtin, ‘Patriarchal Pronatalism: Islam, Secularism and the Conjugal Confines of Turkey’s IVF Boom’, Reproductive BioMedicine & Society Online 2 (2016): 39–46, 44. 82. Bob Simpson, ‘IVF in Sri Lanka: A Concise History of Regulatory Impasse’, Reproductive BioMedicine & Society Online, 2 (2016): 8–15, 12. 83. Veselin Mitrović, ‘Parents’ Religious and Secular Perspectives on IVF Planning in Serbia’, Journal for the Study of Religions and Ideologies 15, no. 43 (2016): 48–81, 73. 84. Sven Bergmann, ‘Reproductive Agency and Projects: Germans Searching for Egg Donation in Spain and the Czech Republic’, Reproductive BioMedicine Online 23 (2011): 600–08, 601. 85. Cohen et al., ‘The Early Days of IVF outside the UK’, 454. 86. Aaron D. Levine, ‘The Oversight and Practice of Oocyte Donation in the United States, United Kingdom and Canada’, HEC Forum 23, no. 1 (2011): 15–30. 87. Waller and Dill, ‘The Regulation and Legislation of In-Vitro Fertilization’, 229. 88. Johnson and Petersen, ‘Public Interest or Public Meddling?’. 89. Hidekazu Saito, Seung Chik Jwa, Akira Kuwahara, Kazuki Saito, Tomonori Ishikawa, Osamu Ishihara, Koji Kugu, Rintaro Sawa, Kouji Banno, and Minoru Irahara, ‘Assisted Reproductive Technology in Japan: A Summary Report for 2015 by The Ethics Committee of the Japan Society of Obstetrics and Gynecology’, Reproductive Medicine and Biology 17 (2018): 20–28. 90. Pattinson, ‘Current Legislation in Europe’, 9 and 16, n. 13, n. 14. 91. Irish Fertility Society, http://www.irishfertilitysociety.com; David J. Walsh, Mary L. Ma, and Eric Scott Sills, ‘The Evolution of Health Policy Guidelines for Assisted Reproduction in the Republic of Ireland, 2004–2009’, Health Research Policy and Systems 9, no. 1 (2011): 28. 92. Rongieres, ‘We Need Progress in French ART Law’; McGregor and Dreifuss-Netter, ‘France and the United States’, 119. 93. Rongieres, ‘We Need Progress in French ART Law’. 94. John Peek, ‘Risk and Regulation: The Role of Regulation in Managing an IVF Unit’, in Organization and Management of IVF Units, ed. S. Fleming and A. Varghese (Cham: Springer, 2016), 51–67, 55. 95. Sandro C. Esteves and Fabiola C. Bento, ‘Implementation of Cleanroom Technology in Reproductive Laboratories: The Question Is Not Why

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but How’, Reproductive BioMedicine Online 32 (2016): 9–11; Sharon T. Mortimer and David Mortimer, Quality and Risk Management in the IVF Laboratory, 2nd ed. (Cambridge, UK: Cambridge University Press, 2015); D.  Mortimer, J.  Cohen, S.  T. Mortimer, M.  Fawzy, D.  H. McCulloh, D.  E. Morbeck, X.  Pollet-Villard, R.  T. Mansour, D. R. Brison, A. Doshi, J. C. Harper, J. E. Swain, and A. V. Gilligan, ‘Cairo Consensus on the IVF Laboratory Environment and Air Quality: Report of an Expert Meeting’, Reproductive BioMedicine Online 36, no. 6 (2018): 658–74. 96. White, ‘“A Less than Perfect Law”’, 178–80. 97. Jennifer Gunning, ‘Regulation of Assisted Reproductive Technology: A Case Study of Japan’, Medicine & Law 22, no. 4 (2003): 751–61, 756. 98. For example, Richard E. Blackwell, Bruce R. Carr, R. Jeffrey Chang, Alan H.  DeCherney, Arthur F.  Haney, William R.  Keye Jr., Robert W.  Rebar, John A.  Rock, Zev Rosenwaks, Machelle M.  Seibel, and Michael R. Soules, ‘Are We Exploiting the Infertile Couple?’, Fertility and Sterility 48, no. 5 (1987): 735–39; The International Society of Natural Cycle Assisted Reproduction (ISNAR), The First World Congress on Natural Cycle/Minimal Stimulation IVF, London, December 15th and 16th 2006, at the Royal College of Obstetricians and Gynaecologists, London, UK, Final Programme and Abstract Book, http://ismaar.org/wpcontent/uploads/ISNAR-Congress-Programme.pdf; G.  M. Warnes and R. J. Norman, ‘Quality Management Systems in ART: Are They Really Needed? An Australian Clinic’s Experience’, Best Practice & Research Clinical Obstetrics & Gynaecology 21, no. 1 (2007): 41–55; Y.  Abramov, U.  Elchalal, and J.  G. Schenker, ‘Severe OHSS: An “Epidemic” of Severe OHSS: A Price We Have to Pay?’, Human Reproduction 14, no. 9 (1999): 2181–83. 99. These include Fiona Stanley in Australia, and Cindy Farquhar and Susan Bewley in the UK.  See, for example, Susan Bewley, ‘Shock! Horror! Or Business as Usual?’, BioNews, no. 854, 6 June, 2016, https://www.bionews.org.uk 100. Geraldine Hartshorne, ‘Thirty Years of IVF’, Human Fertility 11, no. 2 (2008): 77–83, 82; Bewley, ‘Shock! Horror! Or Business as Usual?’ 101. Mark Ragg, ‘Australia: IVF Under Fire’, Lancet 340, no. 8815 (1992): 362; Fiona Stanley, ‘Barriers to Conception’, Australian, 10 May, 2005. 102. Lisa Woll, ‘The Effect of Feminist Opposition to Reproductive Technology: A Case Study in Victoria, Australia’, Reproductive and

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Genetic Engineering: Journal of International Feminist Analysis 5, no. 1 (1992): 21–38. Stevienna De Saille, Knowledge as Resistance: The Feminist International Network of Resistance to Reproductive and Genetic Engineering (London: Palgrave Macmillan, 2017). 103. ‘Transcript of public meeting held at the Yvonne Bowden Auditorium, Royal Women’s Hospital, Melbourne, on Thursday 9 May, 1989 at 7.30 pm’, VARTA Collection, Item 2, 24. The date of the meeting was Thursday 11 May, 1989, and it was sponsored by the Monash Bioethics Centre. 104. Rebecca M. Albury, ‘“Babies Kept on Ice”: Aspects of the Australian Press Coverage on IVF’, Australian Feminist Studies 2, no. 4 (1987): 43–71. 105. Robyn Rowland, ‘Where Do Embryos Come From?’ Age (Melbourne), 30 January, 1987. See also Robyn Rowland, Living Laboratories: Women and Reproductive Technologies (Melbourne: Spinifex Press, 1992). Rowland and Renate Klein were based at the same university as Max Charlesworth (Deakin). They articulated feminist perspectives in the media as well as researching the experience of infertility. See n110. 106. The best overview of the history of feminist activism on AR is Sarah Franklin, ‘Transbiology: A Feminist Cultural Account of Being after IVF’, The Scholar and Feminist Online 9, nos. 1–2 (2010–2011), http:// sfonline.barnard.edu/reprotech/franklin_01.htm 107. Woll, ‘The Effect of Feminist Opposition to Reproductive Technology’, 28. 108. Michael Pirrie, ‘The Maverick Senator Who Had to Decide the Meaning of Life’, Age (Melbourne), 11 October, 1986. Albury, ‘“Babies Kept on Ice”’, 64; Franklin, ‘Transbiology’. 109. Rebecca M. Albury, The Politics of Reproduction: Beyond the Slogans (St Leonards, NSW: Allen & Unwin, 1999). Sarah Ferber was a member of FINRRAGE in the late 1980s and early 1990s. 110. An early and influential collection is Rita Arditti, Renate Duelli Klein, and Shelley Minden, eds., Test Tube Women: What Future for Motherhood? (Boston, MA: Pandora Press, 1984). 111. Guido Ragni, Adolfo Allegra, Paola Anserini, Franco Causio, Anna P.  Ferraretti, Ermanno Greco, Roberto Palermo, and Edgardo Somigliana, ‘The 2004 Italian Legislation Regulating Assisted Reproduction Technology: A Multicentre Survey on the Results of IVF Cycles’, Human Reproduction 20, no. 8 (2005): 2224–28; Giuseppe

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Benagiano, Valentina Filippi, Serena Sgargi, and Luca Gianaroli, ‘Italian Constitutional Court Removes the Prohibition on Gamete Donation in Italy’, Reproductive BioMedicine Online 29, no. 6 (2014): 662–64; A. Malvasi, F. Signore, S. Napoletano, V. Bruti, C. Sestili, and N.  M. di Luca, ‘2014–2017. How Medically Assisted Reproduction Changed in Italy: A Short Comparative Synthesis with European Countries’, La Clinica Terapeutica 168, no. 4 (2017): e248–52; Inhorn, Patrizio, and Serour, ‘Third-Party Reproductive Assistance around the Mediterranean’. 112. Giuseppe Benagiano and Luca Gianaroli, ‘The New Italian IVF Legislation’, Reproductive BioMedicine Online 9, no. 2 (2004): 117–25; Andrea Boggio, ‘The Legalisation of Gamete Donation in Italy’, European Journal of Health Law 24, no. 1 (March 2016): 85–104. 113. Malvasi et  al., ‘2014–2017. How Medically Assisted Reproduction Changed in Italy’. 114. Rachel Anne Fenton, ‘Catholic Doctrine Versus Women’s Rights: The New Italian Law on Assisted Reproduction’, Medical Law Review 14, no. 1 (2006): 73–107, 73. 115. Fenton, ‘Catholic Doctrine Versus Women’s Rights’. 116. ‘The Law 40/2004. Five Years of Hindrance of Assisted Reproduction in Italy’, World Congress for Freedom of Scientific Research, 6 April, 2010, https://www.freedomofresearch.org/the-law-40-2004 117. ‘The Law 40/2004’. 118. Rory Carroll, ‘Why Italy Is the Wild West of Infertility Treatment’, Guardian, 9 August, 2001, https://www.theguardian.com; Mark V.  Sauer, ‘Italian Law 40/2004: A View from the “Wild West”’, Reproductive BioMedicine Online 12, no. 1 (2006): 8–10. See also Inhorn, Patrizio, and Serour, ‘Third-Party Reproductive Assistance around the Mediterranean’, 849–52. 119. Giuseppe Benagiano, ‘The Four Referendums Attempting to Modify the Restrictive Italian IVF Legislation Failed to Reach the Required Quorum’, Reproductive BioMedicine Online 11, no. 3 (2005): 279–81. 120. Giuseppe Benagiano and Luca Gianaroli, ‘The Italian Constitutional Court Modifies Italian Legislation on Assisted Reproduction Technology’, Reproductive BioMedicine Online 20, no. 3 (2010): 398–402; Benagiano et al., ‘Italian Constitutional Court Removes the Prohibition on Gamete Donation in Italy’.

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121. Malvasi et  al. ‘2014–2017. How Medically Assisted Reproduction Changed in Italy’, e248. 122. Irene Riezzo, Margherita Neri, Stefania Bello, Cristoforo Pomara, and Emanuela Turillazzi. ‘Italian Law on Medically Assisted Reproduction: Do Women’s Autonomy and Health Matter?’ BMC Women’s Health 16, no. 44 (2016): 1–7, 3. doi: https://doi.org/10.1186/s12905-016-0324-4 123. Jennifer Gunning, ‘Oocyte Donation: The Legislative Framework in Western Europe’, Human Reproduction 12, suppl_2 (1998): 98–102, 102. 124. Jiabi Qin, Xiaoying Liu, Xiaoqi Sheng, Hua Wang, and Shiyou Gao, ‘Assisted Reproductive Technology and the Risk of Pregnancy-Related Complications and Adverse Pregnancy Outcomes in Singleton Pregnancies: A Meta-Analysis of Cohort Studies’, Fertility and Sterility 105, no. 1 (2016): 73–85. 125. IFFS, ‘International Federation of Fertility Societies’ Surveillance (IFFS) 2019’, 46. 126. Peter R. Brinsden, ‘Thirty Years of IVF: The Legacy of Patrick Steptoe and Robert Edwards’, Human Fertility 12, no. 3 (2009): 137–43,141–42; ESHRE, ART Fact Sheet, 2020, https://www.eshre.eu/Press-Room/ Resources. On OHSS, see Selma Mourad, Julie Brown, and Cindy Farquhar, ‘Interventions for the Prevention of OHSS in ART Cycles: An Overview of Cochrane Reviews’, Cochrane Database of Systematic Reviews 1 (2017): CD012103. 127. Lulu Al-Nuaim and Julian Jenkins, ‘A Brief Historical Overview of Assisted Reproduction’, South African Journal of Obstetrics and Gynaecology 13, no. 2 (2007): 38–41, 41. 128. ‘IVF Rates Boosted’, Age (Melbourne), 20 January 1989. 129. Nanette Elster, ‘Less Is More: The Risks of Multiple Births’, Fertility and Sterility 74, no. 4 (2000): 617–23, 617. 130. The International Society of Natural Cycle Assisted Reproduction (ISNAR), The First World Congress on Natural Cycle/Minimal Stimulation IVF. 131. Al-Nuaim and Jenkins, ‘A Brief Historical Overview’, 40; Brinsden, ‘Thirty Years of IVF’, 142. 132. Josephine  Johnston, Michael K.  Gusmano, and Pasquale  Patrizio, ‘Preterm Births, Multiples, and Fertility Treatment: Recommendations for Changes to Policy and Clinical Practices’, Fertility and Sterility 102, no. 1 (2014): 36–39.

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133. Johnston, Gusmano, and Patrizio, ‘Preterm Births, Multiples, and Fertility Treatment’. Without the control provided by selective reimplantation, if a woman has intrauterine insemination (IUI) following the use of fertility drugs, fertilisation of a large number of oocytes can lead to very-high-order multiple births. 134. Johnston, Gusmano, and Patrizio, ‘Preterm Births, Multiples, and Fertility Treatment’, 37. 135. IFFS, ‘International Federation of Fertility Societies’ Surveillance (IFFS) 2019’, 50; Agrawal, Burt, and Homburg, ‘Time-Line in HFEA Developments and Regulatory Challenges’, 365. 136. Chia-Ling Wu, ‘IVF Policy and Global/Local Politics: The Making of Multiple-Embryo Transfer Regulation in Taiwan’, Social Science & Medicine 75, no. 4 (2012): 725–32, 725. 137. IFFS, ‘International Federation of Fertility Societies’ Surveillance (IFFS) 2019’, 27. See, for example, Christian De Geyter, Peter Fehr, Rebecca Moffat, Isabel Marieluise Gruber, and Michael von Wolff, ‘Twenty Years’ Experience with the Swiss Data Registry for Assisted Reproductive Medicine: Outcomes, Key Trends and Recommendations for Improved Practice’, Swiss Medical Weekly 145, no. w14087 (2015). 138. S. Dyer, G. M. Chambers, J. De Mouzon, K. G. Nygren, F. Zegers-­ Hochschild, R. Mansour, O. Ishihara, M. Banker, and G. D. Adamson, ‘International Committee for Monitoring Assisted Reproductive Technologies. World Report on Assisted Reproductive Technologies: 2008, 2009 and 2010’, Human Reproduction 31, no. 7 (May 2016): 1588–1609, 1608. 139. IFFS, ‘International Federation of Fertility Societies’ Surveillance (IFFS) 2019’, 103. 140. Hartshorne, ‘Thirty Years of IVF’, 81. 141. Al-Nuaim and Jenkins, ‘A Brief Historical Overview’, 40. 142. Johnston, Gusmano, and Patrizio, ‘Preterm Births, Multiples, and Fertility Treatment’, 38. 143. IFFS, ‘International Federation of Fertility Societies’ Surveillance (IFFS) 2019’, 27. 144. IFFS, ‘International Federation of Fertility Societies’ Surveillance (IFFS) 2019’, 9. See Susanna Graham, Sebastian Mohr, and Kate Bourne, ‘Regulating the “Good Donor”: The Expectations and Experiences of Sperm Donors in Denmark and Victoria, Australia’, in Regulating Reproductive Donation, ed. Susan Golombok, Rosamund

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Scott, John B.  Appleby, Martin Richards, and Stephen Wilkinson (Cambridge, UK: Cambridge University Press, 2016), 207–31. 145. See Susan Golombok, Rosamund Scott, John B.  Appleby, Martin Richards, and Stephen Wilkinson, eds., Regulating Reproductive Donation (Cambridge, UK: Cambridge University Press, 2016); Tabitha Freeman, Susanna Graham, Fatemeh Ebtehaj, and Martin Richards, eds., Relatedness in Assisted Reproduction: Families, Origins and Identities (Cambridge, UK: Cambridge University Press, 2014). 146. Sonia Allan, ‘Donor Identification: Victorian Legislation Gives Rights to All Donor-Conceived People’, Family Matters 98 (2016): 43–55; Fiona Kelly, ‘Is It Time to Tell: Abolishing Donor Anonymity in Canada’, Canadian Journal of Family Law 30 (2017): 173–226. 147. Allan, ‘Donor Identification’, 47. See also James Purtill, ‘A Daughter’s Search for Anonymous Sperm Donor RMRi084’. Triple J Hack, 26 February, 2016, http://www.abc.net.au/triplej/programs/hack 148. Jessica Longbottom, ‘Sperm Donor Laws: Man Tracked Down by Dying Daughter Backs Changes to Anonymity Rules’, ABC News, 27 November, 2015. https://www.abc.net.au/news; Allan, ‘Donor Identification’, 43. 149. Kevin O’Sullivan, ‘“Remote” IVF Allows Use of Anonymous Donor Eggs without Travel’, Irish Times, 3 July, 2018; Joyce C. Harper, Debbie Kennett, and Dan Reisel, ‘The End of Donor Anonymity: How Genetic Testing Is Likely to Drive Anonymous Gamete Donation out of Business’, Human Reproduction 31, no. 6 (2016): 1135–40, 1135. 150. Marilyn Huff, ‘What’s the Limit of Offspring per Donor? A Commentary on the ASRM’s Guidelines for the Number of Offspring per Donor’, The Donor Sibling Registry, https://www.donorsiblingregistry.com/ sites/default/files/files/ASRM_Limit_of_offspring_per_donor.pdf. The current wording in the ASRM practice guidelines is: ‘It has been suggested that in a population of 800,000, limiting a single donor to no more than 25 births would avoid any significant increased risk of inadvertent consanguineous conception’. ‘Recommendations for Gamete and Embryo Donation: A Committee Opinion’, Fertility and Sterility 99, no. 1 (2013): 47–63, 53. See also Wendy Kramer, ‘Donor Siblings: Our “Spreadsheet Moment”’, 25 July, 2018, The Donor Sibling Registry, https://www.donorsiblingregistry.com/blog/ donor-siblings-our-spreadsheet-moment

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151. Sandra Blakeslee, ‘Trying to Make Money Making “Test-Tube” Babies’, New York Times, 17 May, 1987; Susan Eggering, ‘These Babies Have Come a Long Way’, Anniston Star (Alabama), 15 December, 1986. See also Ann Pappert, ‘The Business of Making Babies: Technique For Fertilization Called Experimental, Risky and Often Disappointing: In Vitro in Trouble, Critics Warn’, Globe and Mail (Toronto) 6 February 1988. 152. Eggering, ‘These Babies Have Come a Long Way’; Saralie Faivelson, ‘Making Babies: In-Vitro Centers Multiply but Success Limited’, Daily News (NY), 3 February, 1987. 153. Blakeslee, ‘Trying to Make Money’; Faivelson, ‘Making Babies’. 154. Blackwell et al., ‘Are We Exploiting the Infertile Couple?’, 735–36. 155. Richard Saltus, ‘Fertility Clinics Plan to Disclose Results Acknowledging Some Centers Made Inflated Claims, They Promise to Give Their Patients “Straight Answers”’, Boston Globe, 20 November, 1989. 156. Alison Leigh Cowan, ‘Market Place: Can a Baby-Making Venture Deliver?’, New York Times, 1 June, 1992. 157. Centers for Disease Control and Prevention, ‘HHS Releases Quality Standards for State Certification of Laboratories Used in Fertility Clinics’, media release, 21 July, 1999, https://www.cdc.gov/media/ pressrel/r990721.htm; Centers for Disease Control and Prevention, ‘The Fertility Clinic Success Rate and Certification Act’, https://www. cdc.gov/art/nass/policy.html 158. Lynne D. Lawrence and Zev Rosenwaks, ‘Implications of the Fertility Clinic Success Rate and Certification Act of 1992’, Fertility and Sterility 59, no. 2 (1993): 288–90, 289. 159. Charis Thompson, ‘IVF Global Histories, USA: Between Rock and a Marketplace’, Reproductive BioMedicine & Society Online 2 (2016): 128–35, 131–32. 160. Centers for Disease Control and Prevention, ‘ART Success Rates’, https://www.cdc.gov/art/artdata/index.html 161. J. Testart, M. Plachot, J. Mandelbaum, J. Salat-Baroux, R. Frydman, and J. Cohen, ‘World Collaborative Report on IVF—ET and GIFT: 1989 Results’, Human Reproduction 7, no. 3 (1992): 362–69; Lynne S.  Wilcox, Herbert B.  Peterson, Florence P.  Haseltine, and Mary C. Martin, ‘Defining and Interpreting Pregnancy Success Rates for In Vitro Fertilization’, Fertility and Sterility 60, no. 1 (1993): 18–25. 162. Hartshorne, ‘Thirty Years of IVF’, 82.

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163. Esme I. Kamphuis, S. Bhattacharya, F. Van Der Veen, B. W. J. Mol, and A. Templeton, ‘Are We Overusing IVF?’, BMJ 348 (2014): g252. 164. Australian Competition and Consumer Commission, ‘IVF “Success Rate” Claims under the Microscope’, 14 November, 2016, https:// www.accc.gov.au; Karin Hammarberg, Tess Prentice, Isabelle Purcell, and Louise Johnson, ‘Quality of Information about Success Rates Provided on Assisted Reproductive Technology Clinic Websites in Australia and New Zealand’, Australian and New Zealand Journal of Obstetrics and Gynaecology 58, no. 3 (2018): 330–34; Lara Pearce, ‘IVF Clinics Are Still Misleading Would-Be Parents Over Their Success Rates a Year after ACCC Review—Here’s How to Sort the Facts from the Hype’, Huffington Post, 13 November, 2017, https://www.huffingtonpost.com.au 165. Fertility Society of Australia, Reproductive Technology Accreditation Committee, Public Information, Communication and Advertising Australian Clinics, April 2017, Technical Bulletin 7, https://www.fertilitysociety.com.au/rtac/technical-bulletins 166. Victoria Allen, ‘Foreign Clinics Target Vulnerable with 97% IVF Success Rate Claim … But Only a Quarter of Women Become Pregnant with a Child after One Cycle’, Daily Mail (UK), 23 April, 2018, http:// www.dailymail.co.uk 167. Fay Schopen, ‘How IVF Became a Licence to Print Money’, Guardian, 18 June, 2018, https://www.theguardian.com; Brette Blakely, Jane Williams, Christopher Mayes, Ian Kerridge, and Wendy Lipworth, ‘Conflicts of Interest in Australia’s IVF Industry: An Empirical Analysis and Call for Action’, Human Fertility 22, no. 4 (2017): 230–37; Wendy Lipworth, Brette Blakely, and Ian Kerridge, ‘Financial Motives Drive Some Doctors’ Decisions to Offer IVF’, The Conversation, 2 November, 2017, https://theconversation.com; AAP, ‘Commercial IVF Clinics under Spotlight’, SBS News, 2 November, 2017, https://www.sbs. com.au/news 168. Cowan, ‘Market Place’. 169. Quoted in Sarah Dingle, ‘IVF Doctors Misleading Women about Success Rates, Industry Experts Say’, ABC News, 30 May, 2016, https://www.abc.net.au 170. Dingle, ‘IVF Doctors’. 171. ESHRE, Vienna Annual Meeting, ‘“Core Outcome Measures” for Improving the Reliability of Fertility Trials’, Focus on Reproduction, 4

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July, 2019, https://www.focusonreproduction.eu/article/ESHREMeetings-RCT-19. See also Cindy Farquhar, ‘The Prospect of Consistent Outcome Measures in Fertility Studies’, video presentation, 26 June, 2019, https://www.focusonreproduction.eu/article/ ESHRE-Meetings-Farquhar19 172. Szoke, ‘Social Regulation’. 173. Warnock, A Question of Life, 2–3. 174. Sarah Franklin, ‘A Tale of Two Halves?: IVF in the UK in the 1970s and 1980s’, in The Reproductive Industry: Intimate Experiences and Global Processes, ed. Vera Mackie, Nicola J. Marks, and Sarah Ferber (Lanham, MD: Lexington, 2019), 15–30, 25. 175. Giuseppe Benagiano, ‘Editorial: Human Reproduction: Are Religions Defending the Core of Human Nature, or the Survival of Traditional Cultural Schemes?’, Reproductive BioMedicine Online 17 Supp. 3 (2008), 6–8. 176. Mishtal, ‘Reproductive Governance’; Sheila Jasanoff and Ingrid Metzler, ‘Borderlands of Life: IVF Embryos and the Law in the United States, United Kingdom, and Germany’, Science, Technology, & Human Values 20, no. 10 (2018): 1–37, 28. 177. Laura Briggs, How All Politics Became Reproductive Politics: From Welfare Reform to Foreclosure to Trump, Reproductive Justice: A New Vision for the 21st Century 2 (Oakland: University of California Press, 2018).

5 Oocytes, Surrogacy and Cross-Border Reproduction

In 2007, a Japanese husband and wife travelled to India to engage in a surrogacy arrangement facilitated by the Akanksha Hospital and Research Institute in Anand, Gujarat. An Indian woman, who received payment, gave birth to a baby girl conceived with the Japanese man’s sperm and the oocytes of a paid Indian provider. The Japan Society of Obstetrics and Gynecology (JSOG) has a policy of opposition to surrogacy, whereas international surrogacy was legal in India and the industry was at that time expanding.1 One month before the baby, who came to be known as ‘Manji’, was born, the Japanese couple divorced. The divorce left Manji without citizenship rights because Japanese law designates the birth mother as the legal mother, although Indian law held that the child had been legally relinquished. Her biological father, as a now-single male, was not permitted to adopt her. After months of disputation, during which Manji’s paternal grandmother cared for her, Indian authorities allowed Manji, on humanitarian grounds, to be taken to Japan with her father.2 The fertility market that permitted this scenario to unfold is global: for any person pursuing fertility treatment who has the available funds, assisted reproduction (AR) can be fully transactional. Gamete providers, birth mothers and social parents can come from anywhere on earth. The © The Author(s) 2020 S. Ferber et al., IVF and Assisted Reproduction, https://doi.org/10.1007/978-981-15-7895-3_5

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commercial, geographical and scientific aspects of Manji’s birth, while they garnered media coverage, are in many ways ‘the new normal’ for AR in the twenty-first century.3 Her case touches on some key features of contemporary AR: the widespread use of donor oocytes or sperm and surrogacy, collectively referred to as third-party IVF or 3IVF, burgeoning cross-border reproductive travel (CBRT), and the human impact of disparate and changing regulatory environments.4 A key question is how best to protect those who are vulnerable, particularly the children born via surrogacy and the women who provide oocytes or children through surrogacy, while respecting the wishes, rights and autonomy of those engaging in AR as clients.5 Stories such as that of Baby Manji are evidence of systemic and at times seemingly irreconcilable priorities. This chapter begins with an overview of oocyte donation and sale, from the early practice of egg sharing in clinics to the creation of an international market for oocytes. It shows the appeal of specific features in oocyte providers, as well as noting cases of excessive clinical stimulation in pursuit of high numbers of oocytes for sale. An overview of CBRT, with a special focus on surrogacy, examines the effects of legal diversity, complications for children born through surrogacy and their social parents, and exploitation and abuse. The proposals of industry, human rights and feminist commentators are canvassed in relation to the protection not only of children born as a result of AR, but of women providers, and prospective parents.

Donation and Selling of Oocytes Egg Donation The provision of oocytes for fertility treatments, through donation, barter and sale, has become an established part of AR. In the 1980s, clinicians began to seek the donation of oocytes from women who were undergoing AR with a stimulated cycle, to be able to provide them to other women with impaired or absent ovulation.6 The first live birth from a donor egg took place through the Monash University program in

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November 1983.7 Prior to the birth, however, the state government had banned the process because its outcomes could not be predicted. Patient advocates succeeded in overturning the ban in December 1983.8 Fertility clinics initially used two means to carry out the procedure, the more common of which entailed fertilising the donor oocytes in vitro prior to insertion in the uterus of the woman hoping to give birth.9 Before the regular use of embryo freezing and, more recently, oocyte freezing, hormonal regulation was required for both the donor and the recipient woman, to ensure their cycles coincided so that fresh embryos could be used.10 A more controversial technique, called uterine lavage or embryo flushing, entailed the eggs being fertilised in the donor’s body (in vivo), then flushed for insertion in the recipient.11 In May 1984, the lavage technique became the subject of a high-profile ethical debate in Melbourne, when feminist social psychologist Robyn Rowland argued that the technique, which could lead to unwanted pregnancy in the donor, was morally unacceptable.12 In protest against its potential use by the Monash IVF team, Rowland resigned from her role as chair of a research committee connected to the program. In the event, the Monash team did not attempt the process.13 By the end of the 1980s the practice was declining, in part because of fears about HIV transmission.14 Around that time, research had begun on in vitro maturation (IVM) of eggs using ovarian tissue; it has not been taken up widely, because, notwithstanding a generally higher level of safety, it has a lower success rate.15

Egg Sharing The words ‘donor’ and ‘donation’ were in the mid-1980s still the most accurate to describe the use of provider eggs to establish an AR pregnancy. By the early 1990s a new concept referred to as egg sharing began to blur the distinction between altruism and commerce.16 Clinics brought in egg-sharing programs to encourage women to donate their oocytes by offering, for example, a higher place in the treatment queue for the donor’s own fertility treatment. This was not strictly a gift, because it was a type of trade; nor was it a sale, because money did not change hands. Egg sharing is still in use, in part because it provides an option in

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jurisdictions where egg selling is not permitted.17 One South African egg donor company has offered a form of barter to prospective donors, providing free travel to Australia, where the sale of oocytes is prohibited. The head of the Fertility Society of Australia, Professor Michael Chapman, said in 2016 he believed the practice, including an ‘inducement to donate such as airfares’, bordered on being a commercial—and therefore, in Australia, an illegal—transaction.18

Egg Selling By the early 1990s, in the largely unregulated United States, the majority of egg provision took place on a commercial basis and clinics attracted providers through advertising.19 Today, the selling of oocytes reflects, in particular, the fact that older women are now the principal clients in what Catherine Waldby calls, in her eponymous 2019 book, ‘the oocyte economy’.20 One study has reported that ‘only 1% of the eggs collected in women between the age of forty-one and forty-two result in the production of a live-born baby’, while a Human Fertilisation and Embryology Authority (HFEA) survey showed that a group of women over forty-four having fertility treatment with their own eggs had a live birth rate per treatment of around 3%.21 The rate for women up to thirty-five, by contrast, is above 20%.22 Younger women are more likely to obtain a live birth through AR, and are also the main source of oocytes for donation or sale. The market for oocytes is an area of significant growth in the United States: between 2000 and 2010, cycles using provider eggs nearly doubled in number, increasing from 10,801 to 18,306.23 Female college students are a major source of commercial recruitment, prestigious colleges now providing information sites for students considering the option.24 Stock market advice and the share prospectuses of AR companies also highlight the growing oocyte market.25 The oocyte economy is a major feature of wider trends in the ‘bio-economy’, in which the person’s body provides the industry with ‘raw material’, in the form of oocytes, as well as providing the work of undergoing its medical extraction.26 It is also now possible for women to sell eggs purely to make them available for

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research.27 Even in commercialised gamete markets, however, as well as in the medical literature, the term ‘donor’ is still commonly used. Commentators in the fertility industry have nonetheless recommended abandoning as unrealistic any ‘notion that egg donation is an act of pure altruism’; they state that ‘without compensation, there would be a significant shortage of eggs’.28

Oocyte Provider Profiling The trade in human oocytes led quickly to donor egg ‘profiling’ based on characteristics valued in the provider. Some clinics began to look for particular features in their providers, with reports of offers of US$50,000 per round to suitable donors.29 As Charis Thompson expresses it for the United States, ‘IVF led to the circulation and monetization of eggs and embryos in ways that quickly developed price stratification according to hierarchies based on highly desirable traits in contemporary US culture, such as academic and artistic achievement, height in men, and thinness and attractiveness in women’.30 The internet enhanced the possibilities of this kind of market, showing glamorous donors with impressive curricula vitae. In Eastern Europe, the collapse of the former Soviet Union and widespread economic disruption have led to a situation in which young women, with complexions seen as suitable for matching in places such as Western Europe, have found in egg selling an opportunity to earn money in a largely unregulated market. One Ukrainian website assures clients their clinic is the place where you can find needed egg donor, as about 95% of Ukrainian population is European light-skinned type. Slavic ladies are famous for their beautiful, slim complexion, smartness and you will be able to find your best egg donor in our base. Generally patients prefer to choose a good-looking and intelligent egg donor with strong and healthy family roots to ensure good genes for the future baby.31

Another typical advertisement, in the Yale Daily News, sought ‘a young woman over five feet five, of Jewish heritage, athletic, with a combined SAT score of 1500, and attractive’, while one clinic assured clients ‘When

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we match donors and recipients we take into account many factors including height, weight, hair and eye color, skin complexion, ethnicity and lifestyle’.32 As these advertisements show, heritable, partly heritable and non-heritable characteristics readily become intermingled, conveying the idea that to buy a certain woman’s oocytes in some way guarantees aspects of a child’s future.33 The shadow of eugenics is also present, for example, in the emphasis on ‘healthy family roots’. Eugenics was a movement primarily related to public policy, leading at its worst to mass sterilisation and state killing of supposedly genetically inferior people.34 The idea of ‘liberal’ eugenics reflects ultimately similar values, within an individualised, consumer-oriented process. The American Society for Reproductive Medicine (ASRM) formally rejects the adjustment of payments on the basis of ‘donor’s ethnic or other personal characteristics’ and in 2007 capped its recommended provider fee at $10,000, following continued reports of offers of $50,000 per provision of eggs from certain women.35 In a new twist in the ongoing story of reproductive rights, a group of US oocyte providers launched a legal challenge to the ASRM. This was essentially a modern-day ‘bio-workers’ rights case, in which the women asserted the right to receive higher levels of compensation in the face of what they saw as ‘price fixing and unfair competitive business practice’. The ASRM was obliged to alter the guidelines to allow for a more flexible pay scale.36 Eggs that will contribute to the birth of Caucasian children are usually the most sought-after, although some white women have sought to have children of a darker complexion. Scholar of Indian AR Daisy Deomampo refers to those white prospective social parents who see ‘Indian donors as desirable precisely because of their “otherness” or exotic beauty’.37 Michal Nahman has interviewed Israeli Jewish women who were willing to have the eggs of Romanian women, but ‘would reject ova from Palestinians’, even though the women would likely have a stronger genetic link to the Palestinian women. Nahman sees this preference as less about intensely felt religion-based population politics in Israel, and more ‘about reproducing Westernness and Whiteness’.38 Similarly, single women in China are now obtaining overseas sperm donation, often choosing donors of European descent.39 Such preferences can play out in complex ways: in Australia, there is a limited number of people of colour wishing to

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provide gametes, affecting some intended parents’ sense of cultural continuity. One Australian Indigenous woman expressed disappointment when she learnt that she would be unable to obtain sperm from an Indigenous donor, because, she said, ‘I wanted someone who I felt could match my culture’.40 Cultural values can be enmeshed equally on the other side of the transaction: in some jurisdictions, sperm or egg providers can ask that their donation not go to unmarried people or lesbians.41

Excessive Hormonal Stimulation and Provider Oocytes With oocyte provision at a premium, AR expert Robert Winston has drawn attention to the temptation for clinics to over-stimulate women in the hope of obtaining more eggs.42 As Cooper and Waldby note, while ‘there is no strict one-to-one relationship between the dosage levels of ovarian stimulation hormone and the number of oocytes produced … higher doses tend to produce more oocytes’.43 Multiple uses of the stimulated cycle and high drug doses pose a greater risk of ovarian hyperstimulation syndrome (OHSS), a significant side effect of AR that can include symptoms such as blood clots, shortness of breath, abdominal pain, dehydration and vomiting; it is potentially lethal.44 Leading British fertility clinician Adam Balen has said that doses of fertility drugs that can produce around forty eggs in one cycle are too high; referring to one Ukrainian clinic, he commented that ‘it sounds more like egg farming to me than egg donation’. One woman who had sold eggs to the clinic said she felt like a ‘milking cow’.45 In Israel in the late 1990s, a prominent clinician was found to be excessively dosing patients with fertility drugs and then surgically removing oocytes to provide for sale without the provider’s consent.46 In 2005, two Romanian egg providers suffered severe OHSS and reported having been given insufficient warnings of the risk.47 There have been at least two deaths from OHSS in India, one of them of a seventeen-year-old, who was below the legal age to sell her eggs.48 For the women sellers themselves, the opportunity to undergo repeat treatments might encourage accepting risks greater  than those experienced by a woman undergoing AR to obtain a child.49 One economic commentator writing on Indian AR in 2012, however, depicted

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‘career’ egg selling as a promising sign for the national economy, which he proposed  could be expanded readily via informal social networks of women.50

Anonymous Gamete Provision In CBRT, clients’ desire for anonymity in gamete providers is a motivating factor. The European Society for Human Reproduction and Embryology (ESHRE) reports that 17.9% of clients seeking donors abroad have a ‘wish for anonymous donation’, in particular those coming  from France, the UK and Germany, followed by Sweden and Norway.51 Protection of donor identity for male and female gamete providers, in countries such as Denmark, Spain and Belgium, reduces the chance of subsequent  contact between the  children, when they reach adulthood, and donors.52 As one Romanian egg provider told researcher Michal Nahman, she knows there might be ‘her babies’, ‘little devils’ like her, running around somewhere in the world. Her view, nonetheless, was that she was ‘giving life’ and ‘it’s not a problem to be paid to give life’.53 Elsewhere, notably in the UK and Australia, legal frameworks exist to facilitate potential contact between child and donor once the child is an adult.54 The option of anonymity in surrogacy is also available in some places, notwithstanding that in the UK, as one example, a child at eighteen can access details of his or her birth mother.55 Contrast between legal regimes is now one of the main characteristics of an internationalised fertility industry.

 urrogacy and Cross-Border Reproductive S Treatment (CBRT)56 In the early years of IVF, prospective parents travelled to the few places where IVF might offer a realistic prospect of having children. Now, while pursuit of expertise remains a factor, there are clinics across the world, and each jurisdiction can offer something different, such as receptivity to diverse client groups or guaranteed parental rights in surrogacy

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arrangements. As of 2019, around 5% of the European AR market derives from CBRT, with 11,000 to 14,000 treatments carried out each year.57 Gürtin and Inhorn sum up the reasons people have CBRT as ‘legal and religious prohibitions … resource considerations [cost] … quality and safety concerns … and personal preferences’.58 For prospective clients, the treatments most commonly sought across borders are: IVF and intracytoplasmic sperm injection (ICSI); provision of gametes and embryos that can also be frozen for export; surrogacy; genetic testing of embryos, including for social sex selection; and fertility preservation interventions.59 Since the 1990s, when state and national laws regulating AR became more common, the capacity of legal disparities to affect market direction has become a central  feature  of the industry. The wide range of legal responses to AR has been a catalyst in the creation of an ever-changing international fertility market: Hudson and Culley point to ‘a disjuncture of regulation’ as ‘a prime driver of cross-border care’.60 As the New York Times observed  of the growing US market, fertility treatment ‘traffic highlights a divide between the United States and much of the world over fundamental questions about what constitutes a family, who is considered a legal parent, who is eligible for citizenship and whether paid childbirth is a service or exploitation’.61 This legal diversity literally opened a world of opportunities to people seeking children, fertility treatment providers and providers of biological labour and material. Looking ahead, Debora Spar anticipated that as the number of CBRT cases began to increase, the social inequities implicit in even localised surrogacy would likely be compounded by the inherent ‘imbalance in the market’ across borders between wealthy and poorer nations.62 The legal reasons for undertaking CBRT are usually that a procedure is not permitted in a particular place, or that it is not permitted to a particular kind of person in their home jurisdiction. Commercialisation in the form of paid surrogacy and gamete-selling has been allowed in some places but disallowed in others. Laws restricting the use of AR to heterosexual couples who are legally married or in an established relationship are widespread, with the consequence that some people in same-sex relationships or single people travel to provider-jurisdictions for treatment or to purchase children through surrogacy.63 Not only nations, but states

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within nations, vary in their rules, increasing the chances for ‘loopholing’. Irregularities between countries and across state lines within a country point to potential confusion for prospective clients: in Australia, as an example, three of the eight sub-federal jurisdictions prohibit residents from commissioning the provision of a child through surrogacy abroad.64 Global legal disparities have fed CBRT travel but also exacerbated some of the discriminatory, disruptive and exploitative aspects of the industry.65 The same features of the market that distribute opportunity also redistribute, alter and compound the potential for deleterious outcomes. Stability in laws facilitates some undertakings, with relatively predictable risks; an absence of laws or a failure to implement them holds other risks; active changes of policy, even with humane motives, have on occasion introduced unintended consequences. A dynamics of uncertainty thus forms the backdrop to all international travel for AR, impacting on egg providers, surrogacy workers, children born through surrogacy and prospective social parents. The mixed effect of laws can be intensified by natural disasters, as the market for CBRT relies, perhaps ironically, on the cooperation of nature for its continued momentum. Remoteness of many clinics from wealthy places with sound physical infrastructure—a remoteness that keeps prices down and provides reassurance to some clients—has exposed the industry’s weaknesses. In 2015, during the earthquake in Nepal, the Israeli government evacuated infants recently born to Indian gestational mothers who were housed in Nepal, along with their gay male commissioning parents.66 The Israeli government also agreed to assist with the travel of women who were pregnant to the men.67 In the early months of the COVID-19 pandemic in 2020, as borders closed down, news media reported that more than one hundred newborns were stranded at the BioTex surrogacy service in Ukraine.68

Surrogacy: General Features Surrogacy, formally speaking, is the practice of a woman committing in advance to give birth to a child for another person or persons, with the express goal of making them the child’s legal parent or parents. The

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surrogacy industry was emerging in the United States before the advent of third-party oocyte provision and IVF, in a period when only the birth mother’s oocytes could contribute to the genetic identity of the child.69 Before IVF came into widespread use for surrogacy, there were high-­ profile legal cases in which the birth mother had changed her mind and sought custody of the child she had committed to relinquish.70 IVF presented the potential advantage to would-be parents and fertility treatment providers that, when the prospective social mother is unable to provide her own oocytes, the use of third-party oocytes might limit possible legal claims on the part of the birth mother.71 Either the intending social mother’s oocytes or those of a third woman could contribute to the creation of an embryo in vitro. The term ‘gestational surrogacy’ was coined to highlight the use of provider eggs. In the late 1980s, IVF surrogacy became common, notably in the United States. Other countries with established AR programs, such as France, Australia and the UK, either prohibited commercial surrogacy or, like Japan, relied on the industry’s peak body (there, JSOG), to ensure that such practices were kept to a minimum. Several countries and jurisdictions, notably India, Mexico, Nepal, Cambodia and Thailand, at one point gained reputations as reproduction hubs, only to later tighten their laws. The United States remains a major destination country for surrogacy: around 16% of its multi-billion dollar surrogacy market comes from international visitors.72 Countries such as Ukraine, Russia, Georgia and Kenya have also emerged as players in the international market.73

Surrogacy: Commercial and Altruistic A distinction between commercial surrogacy, where payment is subject to market forces, and altruistic surrogacy, in which any payments to the woman are intended to cover minimal costs only, informs most jurisdictions’ surrogacy policies. A 2018 overview report categorised countries into three groups: those with no surrogacy of any kind permitted; those in which only altruistic surrogacy is permitted and those in which both altruistic and commercial are permitted. The largest single group is the first (around twenty); the second and third groups being roughly similar

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in number (around ten each).74 Several countries have no specific laws, while jurisdictions permitting unpaid surrogacy include Belgium, Greece, the Netherlands, the UK, Australia, some states in the United States and, more recently, India.75 In some jurisdictions, however, there are legal grey areas, which make the difference between legal and illegal, commercial and unpaid, at times difficult to sustain in practice.76 Greece prohibits commercial surrogacy but has nonetheless established an international surrogacy base, with anonymous gamete donation and clinics that have a ‘pool of surrogates to draw from’. Compensation for wages lost while pregnant is also permitted there.77 Indeed, many commentators question the validity of the commercial/ altruistic distinction for a range of reasons, including the implicit denial of the role of altruism in paid surrogacy and the potential for negative effects on the women in altruistic surrogacy arrangements, including but not limited to not being able to derive income.78 One legal scholar sees the commercial/altruistic distinction as little more than a ‘legal fiction’, while a recent overview study argues, contrastingly, that the negative aspects of surrogacy as a whole are less evident where altruistic surrogacy alone is permitted.79 Like the egg-selling industry, surrogacy in general, at domestic and international levels, is growing.80 For the UK, the number of parental orders, which transfer parenthood from the birth mother to the social parents, more than tripled between 2011 and 2018; for the United States, the number of gestational surrogacy cycles rose from 727 to 3432 between 1999 and 2013 and increased more than twofold as a proportion of all AR cycles.81 There are inherent problems even when the laws are stable and further issues have arisen when there have been changes either to the laws themselves, or in attitudes to enforcement.

Surrogacy: Birth Certificates and Stages of Parenthood The birth certificate—in particular, the question of whose names are given as a child’s parents, and at what point this occurs—is central to surrogacy, indeed, the ‘essence of the arrangement’.82 The timing of the transferral of parental rights is one of the points of commercial difference

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in the international market. Some jurisdictions maintain the legal right of the birth mother to be named as the mother, prior to subsequent transfer at some point after the birth.83 Surrogacy contracts in other jurisdictions do not indicate the role of birth mothers: clinics in Ukraine and Georgia, for example, make a selling point of the legal anonymity of the birth mother in a surrogacy arrangement.84 Cross-border surrogacy has in some cases magnified the questions of parental rights that often apply to surrogacy more widely. There can be stringent constraints on birth mothers: non-payment or partial payment according to the stage of pregnancy reached, the number of children birthed, or the requirement of termination at the intended parents’ behest. There are risks for all parties, including the risk of non-relinquishment by the birth mother, on the one hand, and of rejection of the child by the intended social parents.85 One watershed case in Thailand brought several of these issues to the fore: the story of ‘Baby Gammy’ and his twin sister, Pipah, highlighted the complexities of CBRT and the potential human cost.86 In 2012, a Thai gestational mother gave birth to twins, following the use of an Australian commissioning father’s sperm, and donor eggs. One of the twins, the boy Gammy, had Trisomy 21 (Down syndrome). It is believed that the birth mother declined the termination of the pregnancy when his condition become known.87 The commissioning parents took Pipah back to Australia, leaving Gammy behind. The birth mother later sought the return of Pipah to Thailand, arguing that the Australian couple had abandoned Gammy. In April 2016, the Western Australian Family Court found in favour of the commissioning parents, who argued they did not abandon Gammy but had been forced to leave Thailand due to civil unrest and could take only their daughter, as Gammy was still in hospital, and his gestational mother did not want to relinquish him.88 An online campaign raised over AU$200,000 from Australia and around the world, so that Gammy could be looked after in Thailand. The exposure of this and another case in Thailand, in which a wealthy Japanese man paid for sixteen children to be provided to him by nine Thai women, contributed to the Thai government’s decision to ban international commercial surrogacy.89

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Surrogacy: Obstetric Implications A study of surrogacy in the United States and Israel has identified the risk of multiple births as higher than for non-surrogacy births, referring discreetly to the possibility of ‘some overlooking of professional recommendations for elective single-embryo transfer’.90 Figures for surrogacy in the United States suggest this is something of an understatement. The Centers for Disease Control and Prevention (CDC) publishes regular outcomes for AR, and has reported that ‘Elective single embryo transfer was performed in only 15% of gestational carrier cycles. Transferring fewer embryos during ART cycles, including gestational carrier cycles, can reduce the risk for multiple births’.91 In other words, 85% of gestational carrier cycles involve multiple embryo transfers. One industry review has observed the same phenomenon across the board in CBRT surrogacy, with multiple pregnancies common ‘due to the great emotional desire of infertile patients to become pregnant, as well as the great desire of physicians to increase their success rates and satisfy their patients’.92 A documentary on a surrogacy worker in Ukraine echoes this perception: ‘When Kateryna went to BioTexCom to undergo surrogacy, she told the doctor there she should only get one embryo. But the doctor said no. She was healthy and strong enough for two’.93 Contracts can be ‘prorated for effort and risk’, including for multiple births, but the birth mother depends on the birth  of the child for income.94 One doctor, Olga Gayovych, is sceptical, arguing, ‘It’s actually a choice without a choice’.95 The reported routinisation of clinicians inserting more than one embryo in surrogacy treatments poses developmental risks for children, and health risks for the birth mothers.96

CBRT Surrogacy and Citizenship The use of CBRT has had in some cases implications for the citizenship rights of children, arising from the civil status of the intended parents. Cross-border disparities in relation to laws on marriage and legitimacy have created greater vulnerability for children, with denial of citizenship

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impacting on children’s legal identity and affecting the kind of access to state services to which citizens are entitled. The story of Baby Manji, with which this chapter began, ensuing on a changed marital situation, is such a case. The very idea of ‘legitimacy’ of a person at birth, as with the idea of population ‘replacement rate’ discussed in the previous chapter, is revealed through AR practices as being deeply bound up with ideas of nationhood. The legitimacy and citizenship issues for children born via AR are bound up in turn with the perception of legitimacy of the relationship both with and between their social parents. Even when people have obtained a child legally by travelling to other jurisdictions, they can face local restrictions in their own country when they try to establish family life at home. The French government, for example, does not allow any forms of surrogacy, and many would-be parents travel to Belgium to obtain children through surrogacy there. Until 2014, children coming into France following such an arrangement were not automatically recognised as French citizens. In response, the European Court of Human Rights (ECtHR) maintained that France should give citizenship to children born of gestational mothers outside national borders, leading France to change its laws accordingly.97 Citizenship, which is based on either biology, a parent’s citizenship or both, and legitimacy, which derives from the legal recognition of kinds of family, are often bound together. Some states have denied citizenship to children who could not be registered legally as a member of a recognised family, even though the child was biologically the offspring of one of the parents. In Singapore, where AR centres are not permitted to carry out surrogacy, one male couple travelled to the United States to obtain a child through legal surrogacy. On returning, they were unable to have their parenthood recognised, as they were not a married, heterosexual couple, meaning the child had neither legally recognised parentage nor Singaporean citizenship.98 (A 2018 High Court ruling, possibly relating to the same couple, has allowed a child in such a situation formally to be adopted by the biological father.99) In China, a lesbian couple tells a similar story of cultural tension and the risks for children in the face of discriminatory policies. As lesbians in China are not permitted access to sperm donor programs, children

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who are born following overseas donation cannot legally be recognised as citizens. The couple underwent IVF in Thailand with the sperm of a US donor. They then married legally in the United States but were not able to have their twins recognised as citizens in China because the women’s marriage itself and their names as parents on the birth certificate were not recognised.100 For those reasons they are unable to obtain a ‘hukou’, household registration certificate, thereby limiting the children’s access to ‘education, healthcare and social benefits’. Cases such as these demonstrate the vulnerability of families and children in the face of dissonant and often discriminatory laws.101 One Italian case has highlighted further some of the tensions arising in AR, because of uncertainty about the status of a child born through surrogacy, but with no genetic ties to their prospective social parents. A couple attempted to bring back to Italy a child who had been obtained in a surrogacy arrangement but with whom they had no genetic link. Authorities placed the child in foster care, leading the intended parents to challenge the decision in the European Court of Human Rights. They lost the case on the basis of a combination of the Italian state’s ‘exclusive competence to recognise a legal parent-child relationship’ along with the fact that the child had no genetic connection to either intended parent. As a result, it was determined that the child should remain in foster care. The two willing social parents who had been responsible for the child’s creation were thus legally impeded from providing parental care.102 Underlying such cases is a paradox that lies at the heart of AR: on the one hand, having one’s own genetic child has been a major wish on the part of intended parents and something the industry has prioritised; on the other hand, ignoring genetic origins in the interest of family creation is crucial to the gamete donation industry. Arguments for the best interests of the child can at times be lost between these two powerful discourses of family. The ethical issues are complex: if on the one hand some commentators refer to consumerist ‘jurisdiction shopping’ on the part of prospective social parents, cases described here have shown that governments of many kinds have been prepared to let children be at status risk purely in order to uphold discriminatory policies.103

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Shadow Trading and Legal Change Even when laws are in place, a shadow trade often exists. Burcu Mutlu argues for Turkey that a ban on gamete provision has led to the creation of clandestine interactions based on relationships built up over time between laboratories and clinics working between Turkey and Turkish-­ speaking Cyprus.104 She argues that this trade has embedded secrecy at the heart of family creation in Turkey, in a kind of familial compact to protect gender ideals that would be disrupted if it were openly acknowledged that donor conception took place legally.105 There have been reports that in Brazil, where commercial surrogacy is also illegal, it nonetheless takes place, being arranged via social media advertising.106 In China, surrogacy became illegal in 2001, having taken place before that.107 It appears that some authorities, however, turned a blind eye to a significant ongoing industry, which is estimated to have provided tens of thousands of children, whereas others have forced pregnant women to undergo abortions.108 In India, in at least one case, a single Indian man was able to pay for a woman to bear a child for him, after the use of surrogacy by single males had become illegal.109 In Mexico, too, the state of Tabasco was for some years a place where gay or single males could pay for women to have children for them, until the government banned it in 2017.110 The infrastructure remained in place, however, leading prospective parents to continue finding women, through local intermediaries, in defiance of the new laws, then suing the government, case by case, in order to obtain legal custody. Surrogacy for both homosexual and heterosexual international clients thus continues to be practised, within Tabasco, and in places such as Quintana Roo and Mexico City.111 Increased restrictions have often been a response to unwelcome international exposure, human rights concerns and, in many cases, the reassertion of socially conservative views on reproduction.  The observation to be made here is that whether laws have existed, are coming into being or have ceased to exist, the industry and the market have together built up a critical mass of infrastructure and personnel that limits the actual control that can be exercised on the basis of laws.

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Legal changes, even when ostensibly intended to protect the most vulnerable, have often come at a human cost. Countries have changed their laws because of fears about their international reputation, including from the desire to stop the provision of children for people deemed morally unsuitable, notably gay male couples. New legal scenarios for AR practice in one place have at times led to acceleration or expansion elsewhere, creating risk for women providers, children, and clients. These changes in turn have contributed to systemic breakdowns, abuse and exploitation. When legal conditions have shifted, they have exacerbated the intrinsic risks of surrogacy and cross-border treatment, leading treatment providers to take additional risks themselves, and to expose their employees, in order to stay in business. Proximity plays a part: Nepal and Cambodia briefly became surrogacy hubs after laws changed in their respective neighbours India and Thailand; Cambodia was followed for a short time by Laos, before its own legal changes in 2018.112 The availability of better facilities meant some companies sent the  prospective  birth  mothers employed in surrogacy arrangements  from Cambodia and Laos to Thailand to give birth.113 Ostensibly aimed at prevention of harm to women or children, the motives for changing laws have also exposed local cultural self-image to be a factor: India, Mexico and Thailand have each in different ways altered their laws because of attitudes secondary to the welfare of women and children. For much of the early twenty-first century, India was a major provider of international surrogacy arrangements but has increasingly withdrawn from this role. First, the government banned the use of surrogacy services by international gay male clients and singles in 2012, then all international surrogacy in 2015.114 It then banned commercial surrogacy altogether in 2018, including preventing homosexual males, singles and unmarried couples from obtaining children in surrogacy arrangements.115 In response, some clinics in India are now sending pregnant women to Kenya—as with the case of Thailand, brokerage and conception can be separated, geographically, from the site of late pregnancy and birth.116 Cambodia allowed a period of amnesty after it brought in new laws, but women who had nevertheless entered a paid surrogacy arrangement after the practice was outlawed, and whose children were born after the

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amnesty expired, have been obliged either to bring them up as their own, or to face charges of human trafficking.117 One woman reported being hand-cuffed to a bed so that she would give birth but not be able to relinquish the child. The Cambodian Centre for Human Rights (CCHR) has called for prosecution of illegal surrogacy agencies, rather than the women they recruit into ‘precarious and risky’ situations. In the view of Chak Sopheap, the CCHR executive director, ‘By effectively forcing them to raise a child to avoid prison time, the Cambodian authorities are re-victimising an already vulnerable group’.118 Notwithstanding prohibitions, the social imprint of the industry can thus remain after practices have ceased to be legal, with the mobility of the industry facilitated by fertility intermediaries and agencies. 

Fertility Intermediaries Fertility intermediaries have been a familiar part of the AR landscape since they began to work in the ‘traditional’ surrogacy industry in the late 1970s.119 Qualifications as an intermediary are minimal. Indeed, when IVF surrogacy was first making news in Australia in the late 1980s, a real estate agent declared his hand, featuring in a story in a glossy women’s magazine, with the promise to prospective parents of ‘[keeping] tabs on the women’.120 Intermediaries at times incorporate the idea of holiday with fertility travel, glamorising, but also perhaps mitigating, what for most clients is an arduous emotional journey. A South African company, for example, offered an ‘egg safari’, with a chance to spend time in ‘the great South Africa while having affordable egg donation treatment’.121 Media exposure for agencies has been heightened by the internet: a recent review article by influential industry figures expressed concern that agencies constitute the ‘least transparent party involved in the CBRC [cross-­ border reproductive care] industry’, noting that while ‘there is minimal data available about their legal and financial status, especially in less developed countries … it is very easy to find a CBRC broker or agency’.122 In a recent case, Cambodian authorities imprisoned an Australian nurse and surrogacy broker, Tammy Davis-Charles, along with two colleagues, for ‘being intermediaries between a pregnant woman and an adoptive

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parent, and fraudulently obtaining documents, including … birth certificates’ in relation to a surrogacy business.123 Davis-Charles had moved her business from Thailand after the laws there were changed in the wake of the Baby Gammy case.124 The United Nations has highlighted the importance of brokers in the area of needed reform, having the goal to regulate ‘all intermediaries involved in surrogacy arrangements, in regard to the financial aspects, relevant competencies, use of contractual arrangements, and ethical standards’.125

Travel for Non-Medical Gender Selection of Embryos Less common than CBRT for egg provision or surrogacy is travel to obtain embryos of a particular gender. In the last ten years, stories of a new pathology of ‘gender disappointment’ have begun to enter popular media discourse.126 The term ‘family balancing’, too, is used to reflect a wish to have either a boy or a girl, depending on the gender of children already in a family. The 2019 IFFS survey reports that the use of IVF for gender selection is gaining acceptance worldwide: ‘a two-fold increase has occurred over the past decade, primarily favoring selection of males’. The authors note that the trend ‘may have profound demographic and cultural implications, yet to be addressed’.127 The use of preimplantation genetic testing of embryos for non-medical gender selection is widespread, albeit that it is expressly permitted only in 44% of countries able to provide it.128 The high level of use is probably attributable to the fact that the gender of an embryo is revealed in the process of preimplantation genetic screening for aneuploidy (PGT-A), even when the investigation is being carried out for other reasons.129 In the United States, of nearly 500 clinics surveyed, more than 80% reported offering PGT-A for gender selection. Globally, of sixty-four clinics surveyed, twenty-four stated that they offer IVF/ICSI exclusively for the purpose of gender selection.130 In Australia, the federal government, reflecting the majority community view, bans sex selection for social reasons, with the result that people seeking the intervention are ‘flocking’ to US clinics where it is permitted.131 In Dubai, too, the service is legal, and many international clients travel there.132

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One clinic in Mexico specialises in IVF gender selection, offering a choice of three techniques (Ericsson, MicroSort and PGS/PGT-A) and positioning itself as a leader: ‘With the vast improvements in In Vitro Fertilization (IVF) technology and a greater demand for gender selection, the LIV Fertility Center in Puerto Vallarta has set the bar for itself—and the entire industry’. These advertisements are firmly targeted at an international clientele: ‘Located 15 minutes away from Puerto Vallarta airport’, with phone numbers to call from the United States and Canada.133 Incoming laws in India will prohibit sex selection, which some clinics had already specifically refused to do.134 A recent ESHRE task force reported similar concerns, with the committee being split on whether or not the practice is desirable.135 Such dissension reflects to some degree the ethical topography of the industry more widely. In a recent study, Hudson and Culley summarise some of the tensions in global practice, making the realistic observation that fertility treatment is a multibillion-dollar global capitalist enterprise in which patients’ interests may not always be paramount and where the potential for the exploitation of donors and surrogates is ever present … Efforts to minimize potential harm to individuals and damaging costs to public healthcare systems are important. However, ‘strong’ regulation at an international level is unlikely to emerge, not least because of different ideological contexts and perspectives on the role of the state and individual liberty.136

Industry, Feminist and Human Rights Commentary International feminism has had a complicated relationship to the history of AR. Abortion law reform was a key plank of feminism in the 1960s and 1970s, while use of the contraceptive pill reduced the likelihood of unwanted pregnancy. Assisted reproduction, however, encountered a significant measure of feminist scepticism, in the context of critiques of the medical industry that were also widely expressed in the 1960s and some feminist critics adopted an abolitionist view.137 Seen in the most

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affirmative light, the international expansion of AR has meant more provider gametes have been available for people hoping to have children as were more children through surrogacy, while presenting an alternative income source for gamete donors and birth mothers. People who are discriminated against in their own country, for example, on the basis of sexuality or marital status, have been able to travel to obtain AR. Academic commentators on AR often use the term ‘stratified reproduction’, coined by Shellee Colen, to highlight the social status issues embedded in the provision of oocytes or children through surrogacy.138 Such stratification can point equally to an abolitionist argument—that oocyte-selling and surrogacy are undesirable—or to a realist-regulatory argument: that paying women dignifies their biological work. Cases such as the ASRM court battle, discussed earlier in this chapter, over limits to payment for oocytes in the United States highlight the depth of social conversations that are all in different ways arguably feminist. As increasing numbers of social scientists study the experience of having AR, they learn more about diverse women’s perspectives. Even at the most basic level, as Sarah Franklin has argued, a feminist stance of any kind needs to take as real every woman’s expressed needs in relation to her own life.139 For many women, access to reproductive technologies can readily find a place alongside the same rights—such as access to abortion and contraception—for which women fought through much of the twentieth century. One feminist reading is that reproductive opportunities for clients and income opportunities for providers of eggs and children are liberating. In Romania, Poland and Latin America, for example, the fight for reproductive rights against religiously based regimes has situated AR alongside other more traditional feminist claims for reproductive control.140 Debora Spar and Charis Thomson argue that women providing reproductive services should be permitted to be paid for egg provision or surrogacy, but within a strong regulatory framework, because regulation can optimise protection, and Sharon Bassan has argued that both children and ‘assisting women’ should be protected by laws that embody ‘a comprehensive regulation addressing the recognition of all involved’.141 Some feminist researchers have drawn attention to strategic use of the language of commerce in relation to the sale of gametes and even of

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babies. Christina Weis has shown that for Russia surrogacy is understood as a commercial transaction, facilitating some women’s perception of their pregnancy and giving birth as service provision, not ‘baby selling’.142 Several feminist commentators urge greater recognition of egg selling and surrogacy  as forms of work, and the legitimacy of providers’ financial motives.143 Michal Nahman, writing on Romania, argues: ‘To say that the women are egg sellers is important’, as her interviews with providers have found such acknowledgement dignifies their role.144 Ecuadoran lawyer Sonia Merlyn Sacoto has contrastingly argued ‘against paid remuneration for egg donors on the grounds that in her view  the body should remain outside the sphere of commerce’.145 To argue that something should not occur, ideally, can have quite different consequences from banning  it, which, as we have seen, can be discriminatory or have unintended negative consequences for providers. As with so many of the ethical issues that have arisen in relation to women and AR, the problems of egg provision and surrogacy do not yield to simple solutions. The rapid expansion of CBRT and reports of problems have led industry peak bodies and human rights law reformers to encourage restraint, in the face of a vigorous and highly competitive market. The ASRM and ESHRE have issued policy statements that recognise the issues, while wanting to support those they position as the more responsible colleagues in the industry, and prospective parents. In the view of the ASRM, cross-border reproductive treatment ‘offers benefits and poses harms to ART stakeholders, including patients, offspring, providers, gamete donors, gestational carriers, and local populations in destination countries’.146 ESHRE sees it as a ‘second-best’ solution, urging a focus on ‘equity, safety, efficiency, effectiveness (including evidence-based care), timeliness and patient centeredness’.147 There is an implicit rebuke to fertility industry colleagues in both these statements. Such recommendations rely on moral suasion, which can be at odds with the realities of worldwide commercial competition. In CBRT, surrogacy is the issue that has created the most conspicuous concerns. Kathryn Webb Bradley argues that until ‘an international consensus about surrogacy is reached, through treaty or otherwise, there will continue to be cases in which the interests of the state, the intended parents,

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and the child are in conflict’.148 Sharmila Rudrappa, reflecting on India, suggests: One option is to negotiate multilateral agreements between countries to govern global surrogacy. Such international law would need to balance the rights of persons pursuing parenthood, children’s rights and surrogate mothers’ rights. But because of differences in countries’ norms on  gay rights and surrogacy, international agreements are difficult to forge.149

Similarly, Charis Thompson has argued for ‘supra-national, cross-­border oversight’ but acknowledges that it must be ‘sensitive enough to harmonize with the very different national settings and IVF regulatory regimes’.150 Elsewhere, she and her co-authors note that Even if global laws were to come into being, competing discourses of rights, to protect variously gamete providers, birth mothers and children, are not readily reconciled.151

One argument of promoters of legalised commercial surrogacy is that banning it will drive practices underground, a pattern this chapter has documented.152 Shutdowns in one place are routinely seen by agents and clinics as opening doors in others, and bans do not simply erase the infrastructure that has been established. In places where commercial surrogacy was once legal, the presence of clinics, expertise and expectations can leave an after-image once a new law takes effect: Rudrappa points to the fact that having once been legal in India, international commercial surrogacy has created a footprint of capacities and expectations.153 Surrogacy is never likely to be legalised globally, nor wholly banned globally, so a hidden market is likely to continue to exist because the clientele and the providers are there. Rudrappa argues, moreover, that prohibiting commercial surrogacy, as the new laws in India do, deprives women of the financial benefits many have gained, as well as entrenching the expectation that women owe it to friends or family to carry a child for them without compensation.154 In her view, regulated, legal commercial surrogacy would protect women more effectively than would the unfolding set of bans. Several researchers have observed that legal changes presented as being in the best interests of provider women have at times stood as alibis for defences of cultural self-image or even discriminatory views. Of Mexico,

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Carolyn Schurr has argued that new legal restrictions are ‘more about being against homosexual families’; Rudrappa has observed for India that expressly women-friendly new laws in India that narrow the number of potential client groups and endorse only unpaid surrogacy can be read equally for their active exclusion of gay or single clients; Andrea Whittaker has seen Thailand’s stance against surrogacy as being in part the product of a ‘nationalist discourse’ invested in particular views of ‘women’s bodies as symbolic boundaries of the state’.155 Realism is the emerging keynote in current debates, but if regulation is the answer to problems, on what basis should it be assumed that it will perform effectively the functions with which it is tasked? Regulation in and of itself is not effective without the will and capacity for enforcement, which can vary even within jurisdictions. Institutions in prohibitionist countries, even wealthy ones, have limited resources to address the issues here. And the evidence is strong that the market will always identify ways to optimise profit and visibility. The materials and networks are in place. There are severe limits on how well protected a child or oocyte or surrogacy provider can be, and the commercial foundations of the industry in some cases do seem to amount to human trafficking. It remains to be proven that the mere existence of a regulated legal industry, without vigilant and consistent oversight, will of itself provide any guarantee of protection of the rights and safety of intended parents, donors and children born of AR. The United Nations Special Rapporteur on the Sale and Sexual Exploitation of Children, Maud de Boer-Buquicchio, has suggested that the legality or otherwise of specific practices in AR is not the issue; the issue is the rights of the children involved, and the interests of the women providers and intended parents.156 Her conclusions derive ultimately from the view that moving neither towards nor away from prohibition will answer the most pressing questions. Rather, in order to protect ‘the rights and welfare of children, parents and other parties involved in the conception of a child, in line with international human rights standard’ she urges ‘the creation of rigorous storage and registration frameworks for this identity information to be collected, stored and acceded to’.157 The content of such frameworks would at minimum permit a child born in a surrogacy arrangement to be ‘informed at an appropriate age, of

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biological and genetic origins, as well as of the identity of the surrogate woman’.158 Along similar lines, a recent industry-based overview paper, making due acknowledgement of the work already being done by groups such as ESHRE, the ASRM, ICMART (the International Committee for Monitoring Assisted Reproductive Technology) and International Federation of Fertility Societies (IFFS), urged that it is ‘crucial to regulate the global market of CBRC on legal, economic, and ethical bases in order to increase harmonization and reduce any forms of exploitation. Establishment of accurate international statistics and a global registry will help diminish the current information gap surrounding the CBRC phenomenon’.159 Record-keeping does not of itself prevent harm and can be a potential smokescreen to cover permissiveness or deter public debate. The CDC records detailed information about clinics in the United States, but serious concerns remain, for example, about multiple birth rates, when the risk of these is well established. Damien Riggs and Clemence Due argue that ‘dominant discourses of family and consumerism produce vulnerabilities that impact on all people, albeit differently’, pointing to the inevitable observation of the ‘enmeshment’ of the surrogacy industry ‘with the machinations of capitalism’.160 Hypothetically, if commercial surrogacy were legal everywhere, there would still be commercial rivalry, leading to a ‘race to the bottom’, with the risk of harm to the women through excess oocyte stimulation and multiple births. If commercial surrogacy were illegal everywhere, in every form, it might take place less often but would possibly be more dangerous even than it has already proven to be. Clinical surveillance—to achieve the goal of limiting the risks of multiple births to mother and child and the risk of OHSS, for example—is potentially fraught, because of strong traditions within medicine of respect for the professional judgement of colleagues, within the unique clinician-patient space. When there are two kinds of patient—the intended parents and the physical providers of bio-labour—risks such as those described here complicate that relationship. With only a consent form separating the wishes of the intended parent and those of the provider of eggs or a child, the doctrine of patient autonomy can mask the immensity of the medical, industrial, ideological and political spheres that have brought those parties together in the first instance.161

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Notes 1. JSOG issued members with ‘nonbinding guidelines’ to prevent surrogacy, whether commercial or otherwise. Kari Points, ‘Commercial Surrogacy and Fertility Tourism in India: The Case of Baby Manji’, Institutions in Crisis Series, Kenan Institute for Ethics at Duke University, September 2009, http://www.duke.edu/web/kenanethics 2. Points, ‘Commercial Surrogacy and Fertility Tourism in India’; see also Vera Mackie, ‘Birth Registration and the Right to Have Rights: The Changing Family and the Unchanging Koseki’, in Japan’s Household Registration System and Citizenship: Koseki, Identification and Documentation, ed. David Chapman and Karl Jakob Krogness (Abingdon: Routledge, 2014), 203–20. 3. Sarah Franklin, Review of Louise Brown: My Life as the World’s First Test-­ Tube Baby, by Louise Brown and Martin Powell, Reproductive BioMedicine & Society Online 3 (2016): 142–44, 142. 4. See Z. B. Gürtin and M. C. Inhorn, eds., ‘Symposium: Cross-Border Reproductive Care’, special issue, Reproductive BioMedicine Online 23, no. 5 (2011). See also Amy Speier, Fertility Holidays: IVF Tourism and the Reproduction of Whiteness (New York: New York University Press, 2016); Merete Lie and Nina Lykke, eds., Assisted Reproduction across Borders: Feminist Perspectives on Normalizations, Disruptions and Transmissions, Routledge Advances in Feminist Studies and Intersectionality (New York: Routledge, 2016); Daisy Deomampo, Transnational Reproduction: Race, Kinship, and Commercial Surrogacy in India, Anthropologies of American Medicine: Culture, Power, and Practice (New York: New  York University Press, 2016); Marcia C. Inhorn, Cosmopolitan Conceptions: IVF Sojourns in Global Dubai (Durham, NC: Duke University Press, 2015). 5. Damien W. Riggs and Clemence Due, A Critical Approach to Surrogacy: Reproductive Desires and Demands, Critical Approaches to Health (Abingdon: Routledge, 2018). 6. ‘Oocyte’ is the technical term for the egg cells which are collected surgically as part of AR, just prior to when ovulation would occur. The ­pre-­ovulatory oocyte is often colloquially referred to as either an ‘egg’ or ‘ovum’. 7. J. Leeton, A. Trounson, and C. Wood, ‘The Use of Donor Eggs and Embryos in the Management of Human Infertility’, Australian and

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New Zealand Journal of Obstetrics and Gynaecology 24, no. 4 (1984): 265–270, 269; John Leeton, ‘The Early History of IVF in Australia and Its Contribution to the World (1970–1990)’, Australian and New Zealand Journal of Obstetrics and Gynaecology 44, no. 6 (2004): 495–501, 497. 8. Leeton, ‘The Early History of IVF in Australia’, 497. 9. Mark V. Sauer and Matthew A. Cohen, ‘Egg and Embryo Donation’, in Textbook of Assisted Reproductive Techniques, Fourth Edition, Volume 2: Clinical Perspectives, ed. David K. Gardner, Ariel Weissman, Colin M. Howles, and Zeev Shoham (Boca Raton, FL: CRC Press, 2012), 394–404, 394. 10. Peter Lutjen, Alan Trounson, John Leeton, Jock Findlay, Carl Wood, and Peter Renou, ‘The Establishment and Maintenance of Pregnancy Using In Vitro Fertilization and Embryo Donation in a Patient with Primary Ovarian Failure’, Nature 307, no. 5947 (1984): 174–75; Leeton, ‘The Early History of IVF in Australia’, 497. 11. Zev Rosenwaks, ‘Donor Eggs: Their Application in Modern Reproductive Technologies’, Fertility and Sterility 47, no. 6 (1987): 895–909. 12. Rosemary West, ‘Test Tube Researcher Quits in Moral Stand’, Age (Melbourne), 18 May, 1984. 13. Leeton, ‘Early History of IVF in Australia’, 498. 14. Institute of Medicine, National Research Council and Committee on the Basic Science Foundations of Medically Assisted Conception, Medically Assisted Conception: An Agenda for Research (Washington, DC: The National Academies Press, 1989), 19. 15. Patrick Lonergan and Trudee Fair, ‘Maturation of Oocytes In Vitro’, Annual Review of Animal Biosciences 4 (2016): 255–68. Around 2000 babies have been born. See also Satoshi Mizuno and Aisaku Fukuda, ‘In Vitro Maturation of Oocytes for IVF’, in Principles of IVF Laboratory Practice: Optimizing Performance and Outcomes, ed. Markus H.  M. Montag and Dean E.  Morbeck (Cambridge: Cambridge University Press, 2017), 125–31. 16. E. Blyth, ‘Subsidized IVF: The Development of “Egg Sharing” in the UK’, Human Reproduction 17, no. 12 (2002): 3254–59. 17. Ethics Committee of the American Society for Reproductive Medicine, ‘Financial Compensation of Oocyte Donors: An Ethics Committee Opinion’, Fertility and Sterility 106, no. 7 (2016): e15–e19, e16.

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18. Marika Dobbin, ‘IVF Treatment: South African Agency Flies Egg Donors to Australia’, Sydney Morning Herald, 8 February, 2016, https:// www.smh.com.au 19. Ethics Committee of the American Society for Reproductive Medicine, ‘Financial Compensation of Oocyte Donors’, e16; Debora L. Spar, ‘For Love and Money: The Political Economy of Commercial Surrogacy’, Review of International Political Economy 12, no. 2 (May 2005): 287–309, 297. 20. Catherine Waldby, The Oocyte Economy: The Changing Meaning of Human Eggs (Durham NC: Duke University Press, 2019); Ibis World, ‘Fertility Clinics in Australia—Market Research Report’, February 2019, https://www.ibisworld.com.au 21. ‘The latest HFEA figures show that, among those using their own eggs, out of 2265 embryo transfers in 2017, just 75 women aged 43 to 44 ended up with a baby’, ‘Older Women Exploited by IVF Clinics, Says Fertility Watchdog’, BBC, 22 April, 2019, https://www.bbc.com/ news/uk-48008635. See also Art L. Caplan and Pasquale Patrizio, ‘Are You Ever Too Old to Have a Baby? The Ethical Challenges of Older Women Using Infertility Services’, Seminars in Reproductive Medicine 28, no. 4 (2010): 281–86. 22. Victorian Assisted Reproductive Treatment Authority (VARTA), ‘Understanding IVF Success Rates’, April, 2016: 3, https://www.varta. org.au/resources/publications 23. The figure reflects findings from 93% of all clinics. Jennifer F. Kawwass, Michael Monsour, Sara Crawford, Dmitry M.  Kissin, Donna R. Session, Aniket D. Kulkarni, and Denise J. Jamieson, ‘Trends and Outcomes for Donor Oocyte Cycles in the United States, 2000–2010’, JAMA 310, no. 22 (2013): 2426–34, 2426. 24. ‘Egg Donor Information Project’, Stanford University, https://web. stanford.edu/class/siw198q/websites/eggdonor/home.html 25. ‘IVF Market Size worth $36.2 Billion By 2026 | CAGR: 102%’, Grand View Research, March 2019, https://www.grandviewresearch.com/pressrelease/global-ivf-market; Monash IVF Group, http://www.monashivfgroup.com.au; Monash IVF Group Limited, Prospectus, 2014, 5, http:// www.monashivfgroup.com.au/investor-centre/prospectus 26. Waldby, The Oocyte Economy. 27. Donna Dickenson, ‘Good Science and Good Ethics: Why We Should Discourage Payment for Eggs for Stem Cell Research’, Nature Reviews Genetics 10, no. 11 (2009): 743; Catherine Waldby, ‘Oocyte Markets:

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Women’s Reproductive Work in Embryonic Stem Cell Research’, New Genetics & Society 27, no. 1 (2008): 19–31. 28. Michelle J. Bayefsky, Alan H. DeCherney, and Benjamin E. Berkman, ‘Compensation for Egg Donation: A Zero-Sum Game’, Fertility and Sterility 105, no. 5 (2016): 1153–54, 1153. 29. Gina Kolata, ‘$50,000 Offered to Tall, Smart Egg Donor’, New York Times, March 3, 1999, https://www.nytimes.com; Clara Moskowitz, ‘Egg Donors Offered up to $50,000’, nbcnews.com, 26 March, 2010, http://www.nbcnews.com 30. Charis Thompson, ‘IVF Global Histories, USA: Between Rock and a Marketplace’, Reproductive BioMedicine & Society Online 2 (2016): 128–35, 134. See also Charis Thompson, ‘Skin Tone and the Persistence of Biological Race in Egg Donation for Assisted Reproduction’, in Shades of Difference: Why Skin Color Matters, ed. Evelyn Nakano Glenn (Palo Alto, CA: Stanford University Press, 2009), 131–47. 31. BioTexCom, Centre for Human Reproduction, ‘Surrogacy and Egg Donation’, http://biotexcom.com 32. Atlantic Reproductive Medicine Specialists, ‘Becoming an Egg Donor: Giving the Gift of Life’, https://www.atlanticfertility.com; Jacoba Urist, ‘How Much Should a Woman Be Paid for her Eggs?’, The Atlantic, 4 November, 2015, https://www.theatlantic.com/health/archive 33. Melinda Cooper and Catherine Waldby, Clinical Labor: Tissue Donors and Research Subjects in the Global Bioeconomy. Experimental Futures (Durham, NC: Duke University Press, 2014). 34. Sarah Ferber, Bioethics in Historical Perspective (Houndmills: Palgrave, 2013), 69–100. 35. Ethics Committee of the American Society for Reproductive Medicine, ‘Financial Compensation of Oocyte Donors’, e16. 36. European Society for Human Reproduction and Embryology (ESHRE), ‘ESHRE Fact Sheets 3, Egg Donation’, 2017, https://www. eshre.eu/Press-Room/Resources; Bayefsky, DeCherney, and Berkman, ‘Compensation for Egg Donation’. 37. Daisy Deomampo, ‘Race, Nation, and the Production of Intimacy: Transnational Ova Donation in India’, positions: asia critique 24, no. 1 (2016): 303–32, 318. 38. Michal Nahman, ‘Materializing Israeliness: Difference and Mixture in Transnational Ova Donation’, Science as Culture 15, no. 3 (2006): 199–213, 210.

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39. Sijia Li and Helen Roxburgh, ‘Affluent Single Chinese Women Seek Sperm Donors at Overseas Banks’, Japan Times, 6 December, 2019, https://www.japantimes.co.jp 40. Jinghua Qian, ‘The Lack of Diversity of Australia’s Sperm Banks’, ABC Life, 12 June, 2020, https://www.abc.net.au/life 41. Ethics Committee of the American Society for Reproductive Medicine, ‘Financial Compensation of Oocyte Donors’, e17; authors’ experience (SF); 42. Robert Winston, ‘Robert Winston: Why I’m Ashamed of the Exploitation in the IVF Industry’, Daily Mail, 4 May, 2017, https:// www.dailymail.co.uk 43. Cooper and Waldby, Clinical Labor, 52. 44. American Society of Reproductive Medicine, ‘Reproductive Facts’, https://www.reproductivefacts.org; Antony Barnett and Helena Smith, ‘Cruel Cost of the Human Egg Trade’, Guardian, 30 April, 2006, https://www.theguardian.com/uk 45. Barnett and Smith, ‘Cruel Cost of the Human Egg Trade’. See also Ben Jones, ‘Human Egg-Trafficking Scam Uncovered in Romania’, BioNews, no. 509, 3 August, 2009, https://www.bionews.org.uk; Ingrid Schneider, ‘Indirect Commodification of Ova Donation for Assisted Reproduction and for Human Cloning Research: Proposals for Supranational Regulation’, in Altruism Reconsidered: Exploring New Approaches to Property in Human Tissue, ed. Michael Steinmann, Peter Sýkora, and Urban Wiesing (Farnham, UK: Ashgate, 2009), 209–42;  Sarah Ferber, ‘As Sure as Eggs? Responses to an Ethical Question Posed by Abramov, Elchalal, and Schenker’, Journal of Clinical Ethics 18, no. 1 (2007): 35–48. 46. Daphna Birenbaum-Carmeli, ‘Thirty-Five Years of Assisted Reproductive Technologies in Israel’, Reproductive BioMedicine & Society Online 2 (2016): 16–23, 19; Judy Siegel-Itzkovich, ‘Israeli Infertility Experts Investigated for “Selling” Ova’, BMJ: British Medical Journal 320, no. 7247 (27 May, 2000): 1425. One leading doctor investigated in the Israel case who admitted such breaches later reported on the ‘alarming incidence of OHSS to epidemic levels’ around that time. Zion Ben-Rafael, ‘The Development of In-Vitro Fertilization in Israel’, in In-Vitro Fertilization: The Pioneers’ History, ed. Gabor Kovacs, Peter Brinsden, and Alan DeCherney (Cambridge, UK: Cambridge University Press, 2018), 132–40, quote at 134–35; Ran Reznick,

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‘Doctor Took Eggs Without Women’s Full Knowledge, Complaint Says’, Haaretz, 31 October, 2003, https://www.haaretz.com/1.4748507. Around this time, one commentary referred to the particular risks associated with stimulation ‘regimens employing gonadotrophin-releasing hormone (GnRH) analogues and high dose gonadotrophins’. Y.  Abramov, U.  Elchalal, and J.  G. Schenker, ‘Severe OHSS: An “Epidemic” of Severe OHSS: A Price We Have to Pay?, Human Reproduction 14, no. 9 (September 1999): 2181–83. 47. Liza Ireni-Saban, Umut Korkut, and Ben Herzberg, ‘“Think Globally, Act Ethically”: Towards Normative Assessment of Fertility Tourism Regulation in Europe’, International Journal of Humanities and Social Science Research 2 (2016): 114–24; Schneider, ‘Indirect Commodification of Ova Donation’, note 2. 48. Mary Ann Jolley and Liz Gooch, ‘Inside the World of India’s Booming Fertility Industry’, Al Jazeera, 5 September, 2016, https://www. aljazeera.com 49. West Coast Egg Donation, ‘Egg Donor Compensation at West Coast Egg Donation’, westcoasteggdonation.com 50. S. K. Majumdar, India’s Late, Late Industrial Revolution: Democratizing Entrepreneurship (Cambridge: Cambridge University Press, 2012), 3–5. 51. F.  Shenfield, J. de Mouzon, G.  Pennings, A.  P. Ferraretti, A.  Nyboe Andersen, G. de Wert, and V.  Goossens (The ESHRE Taskforce on Cross Border Reproductive Care), ‘Cross Border Reproductive Care in Six European Countries’, Human Reproduction 25, no. 6 (2010): 1361–68, 1363. 52. Mahmoud Salama, Vladimir Isachenko, Evgenia Isachenko, Gohar Rahimi, Peter Mallmann, Lynn M. Westphal, Marcia C. Inhorn, and Pasquale Patrizio, ‘Cross Border Reproductive Care (CBRC): A Growing Global Phenomenon with Multidimensional Implications (A Systematic and Critical Review)’, Journal of Assisted Reproduction and Genetics 35, no. 7 (2018): 1277–88, 1279; ESHRE, ‘ESHRE Fact Sheets 3’. See also Sara Degli-Esposti and Vincenzo Pavone, ‘Oocyte Provision as a (Quasi) Social Market: Insights from Spain’, Social Science & Medicine 234 (2019): 112381. 53. Michal Nahman, ‘Nodes of Desire: Romanian Egg Sellers, “Dignity” and Feminist Alliances in Transnational Ova Exchanges’, European Journal of Women’s Studies 15, no. 2 (2008): 65–82, 68. 54. Salama et al., ‘Cross Border Reproductive Care (CBRC)’, 1279.

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55. Salama et  al., ‘Cross Border Reproductive Care (CBRC)’, 1285; ‘Parenthood and Parental Orders (Surrogacy Law)’, Natalie Gamble Law, https://www.ngalaw.co.uk 56. See France Winddance Twine, Outsourcing the Womb: Race, Class and Gestational Surrogacy in a Global Market, 2nd ed. (New York: Routledge, 2015); Kimberly M.  Mutcherson, ‘Things That Money Can Buy: Reproductive Justice and  the  International Market for  Gestational Surrogacy’, North Carolina Journal of  International Law 43 (2018) 150–81; Sharmila Rudrappa and Caitlyn Collins, ‘Altruistic Agencies and  Compassionate Consumers: Moral Framing of  Transnational Surrogacy’, Gender & Society 29, no. 6 (December 2015): 937–59. See also Nicola J.  Marks, Vera Mackie, and  Sarah Ferber, ‘Modes of  Mobility: Tracing the  Routes of  Reproductive Travel in  the  AsiaPacific Region’, in  The Reproductive Industry: Intimate Experiences and  Global Processes, ed. Vera Mackie, Nicola J.  Marks, and  Sarah Ferber (Lanham, MD: Lexington, 2019), 145–74; Sonja van Wichelen, ‘Private International Law and  Cross-­ Border Surrogacy: The  Role of Analogy’, in Mackie, Marks, and Ferber, The Reproductive Industry, 109–24. The academic literature on surrogacy is extensive and growing rapidly. Google Scholar references from a Boolean search for ‘commercial surrogacy’ reveal a more than six-fold increase between the periods 1980 to 1999 (710) and 2000 to 2019 (4510), with a large majority appearing in the past ten years. To compare with an established research area, references for King Lear for the same periods increased by less than 1.5 times (14,600 to 21,200). 57. Françoise Shenfield, ‘Cross Border Reproductive Care: The Facts from the ESHRE Study’, (Strasbourg: European Society for Human Reproduction and Embryology (ESHRE), 2018); ‘Cross Border Reproductive Care’, ESHRE, ‘ESHRE Fact Sheets 1, January 2017’, https://www.eshre.eu/Press-Room/Resources 58. Zeynep B. Gürtin and Marcia C. Inhorn, ‘Introduction: Travelling for Conception and the Global Assisted Reproduction Market’, in Gürtin and Inhorn, ‘Symposium: Cross-Border Reproductive Care’, 535–37, 535. See also Salama et al., ‘Cross Border Reproductive Care (CBRC)’, 1278; International Federation of Fertility Societies (IFFS), ‘International Federation of Fertility Societies’ (IFFS) Surveillance 2019: Global Trends in Reproductive Policy and Practice, 8th Edition’, Global Reproductive Health 4, no, 1 (2019), 118–129.

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59. Salama et  al., ‘Cross Border Reproductive Care (CBRC)’, 1278. See also Patrick Präg and Melinda C.  Mills, ‘Assisted Reproductive Technology in Europe: Usage and Regulation in the Context of CrossBorder Reproductive Care’, in Childlessness in Europe: Contexts, Causes, and Consequences, ed. Michaela Kreyenfeld and Dirk Konietzka (Cham: Springer, 2017), 289–309. 60. Nicky Hudson and Loraine Culley, ‘Assisted Reproductive Travel: UK Patient Trajectories’, Reproductive BioMedicine Online 23, no. 5 (November 2011), 573–81, 579. 61. Tamar Lewin, ‘Pregnancy for Pay: Coming to U.S. for Baby, and Womb to Carry It’, New York Times, 5 July, 2014, https://www.nytimes.com 62. Spar, ‘For Love and Money’, 301. See also Debora L. Spar ‘Reproductive Tourism and the Regulatory Map’, New England Journal of Medicine 352, no. 6 (2005): 531–33. 63. Families through Surrogacy, ‘Surrogacy by Country’, http://www.familiesthrusurrogacy.com 64. Australian Government, Department of Home Affairs, ‘International Surrogacy Arrangements’, 5 March, 2020, https://immi.homeaffairs.gov.au 65. Spar, ‘For Love and Money’, 301. 66. Ori Lewis, ‘Israel Evacuates Surrogate-Born Babies and Israeli Parents from Nepal’, Reuters, 27 April, 2015, https://www.reuters.com 67. Daniella Cheslow, ‘Israel’s Nepal Rescue Mission: Infants Born to Gay Israelis Via Surrogate Mothers’, mcclatchydc.com, 28 April, 2015, https://www.mcclatchydc.com 68. Andrew E. Kramer, ‘100 Babies Stranded in Ukraine after Surrogate Births’, New York Times, https://www.nytimes.com 69. Spar, ‘For Love and Money’, 288. 70. Spar, ‘For Love and Money’, 294. 71. Spar, ‘For Love and Money’, 296. 72. Adeline A. Allen, ‘Surrogacy and Limitations to Freedom of Contract: Toward Being More Fully Human’, Harvard Journal of Law & Public Policy 41, no. 3 (2018): 753–811, 755; Centers for Disease Control and Prevention (CDC), ‘ART and Gestational Carriers’, 5 August, 2016, https://www.cdc.gov/art/key-findings/gestational-carriers.html; Lewin, ‘Pregnancy for Pay’; Families through Surrogacy, ‘Surrogacy by Country’. 73. Families through Surrogacy, ‘Surrogacy by Country’.

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74. Details are not wholly precise, with regions, states and nations at times conflated. Salama et  al., ‘Cross Border Reproductive Care (CBRC)’, 1282. 75. Viveca Söderström-Anttila, Ulla-Britt Wennerholm, Anne Loft, Anja Pinborg, Kristiina Aittomäki, Liv Bente Romundstad, and Christina Bergh, ‘Surrogacy: Outcomes for Surrogate Mothers, Children and the Resulting Families—A Systematic Review’, Human Reproduction Update 22, no. 2 (2016): 260–76. 76. Alan Hope, ‘Belgian’s [sic] Surrogacy Law under Pressure after “Men Having Babies” Conference’, Brussels Times, 25 September, 2019, https://www.brusselstimes.com 77. Families through Surrogacy, ‘Surrogacy in Greece’, http://www.familiesthrusurrogacy.com 78. Anita Stuhmcke, ‘The Regulation of Commercial Surrogacy: The Wrong Answers to the Wrong Questions’, Journal of Law and Medicine 23, no. 2 (2015): 333–45; Riggs and Due, A Critical Approach to Surrogacy; Sharmila Rudrappa, ‘Why India’s New Surrogacy Bill Is Bad for Women’, Huffpost, 27 August, 2016, https://www.huffpost.com 79. Stuhmcke, ‘The Regulation of Commercial Surrogacy’, 339; Söderström-Anttila et  al., ‘Surrogacy: Outcomes for Surrogate Mothers’, 274. See also Emily Jackson, Jenni Millbank, Isabel Karpin, and Anita Stuhmcke, ‘Learning from Cross-Border Reproduction’, Medical Law Review 25, no. 1 (2015): 23–46. 80. No single resource presents comprehensive statistics. The best is IFFS, ‘International Federation of Fertility Societies’  Surveillance  (IFFS) 2019’. For surrogacy, see 113–18; for CBRT, see 118–29. 81. Söderström-Anttila et  al., ‘Surrogacy: Outcomes for Surrogate Mothers’, 274. UK numbers went from 121 in 2011 to 368 in 2018. Claire Fenton-Glynn, ‘Surrogacy: Why the World Needs Rules for “Selling” Babies’, BBC News, 26 April, 2019, https://www.bbc.com/ news/health; for US numbers see Centers for Disease Control and Prevention (CDC), ‘ART and Gestational Carriers’. 82. Maud de Boer-Buquicchio, ‘All Rights for Surrogacy-Born Children Full Scale’, Netherlands Quarterly of Human Rights 37, no. 4 (2019): 275–81, 279. 83. Spar, ‘For Love and Money’, 298. 84. One clinic in the country of Georgia goes a step further, offering a ‘guaranteed healthy baby or full refund’. New Life Georgia, ‘Guaranteed Surrogacy’, https://www.newlifegeorgia.com/guaranteed-surrogacy;

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https://www.newlifegeorgia.com/ivf-legislation; Baby on Board, ‘Surrogacy in Ukraine’, https://ukrainesurrogacy.com/surrogacy 85. Pravin Patel and Manish Banker, ‘Gestational Carrier’, in In Vitro Fertilization: A Comprehensive Guide, ed. Elizabeth S.  Ginsburg and Catherine Racowsky (New York: Springer Science & Business Media, 2012), 177–92; Christopher Bobyn, ‘Inside Ukraine’s Surrogacy Industry Where Australians Are Travelling to Have a Family’, ABC News, 15 December, 2018, https://www.abc.net.au/news; ‘Help Wanted: As Demand for Surrogacy Soars, More Countries Are Trying to Ban It’, Economist, 13 May, 2017, https://www.economist.com 86. Reuters, ‘Thailand Bans Surrogacy for Foreigners in Bid to End “Rent-­ a-­Womb” Tourism’, ABC News, updated 20 February, 2015, https:// www.abc.net.au/news 87. Andrea Whittaker, ‘“Stop Thai Women’s Wombs from Becoming the World’s Womb”: Reproductive Nationalism and the Closure of Commercial Surrogacy in Thailand’, in Mackie, Marks, and Ferber, The Reproductive Industry, 125–44, at 128–29. 88. ‘Baby Gammy: Surrogacy Row Family Cleared of Abandoning Child with Down Syndrome in Thailand’, ABC News, 14 April, 2016, http:// www.abc.net.au/news. On Thai media reportage, see Whittaker, ‘“Stop Thai Women’s Wombs from Becoming the World’s Womb”’; Andrea M.  Whittaker, ‘Reproduction Opportunists in the New Global Sex Trade: PGD and Non-Medical Sex Selection’, Reproductive BioMedicine Online 23, no. 5 (2011): 609–17. 89. Whittaker, ‘“Stop Thai Women’s Wombs from Becoming the World’s Womb”’. See also Andrea Whittaker, ‘From “Mung Ming” to “Baby Gammy”: A Local History of Assisted Reproduction in Thailand’, Reproductive BioMedicine & Society Online 2 (2016): 71–78. 90. Daphna Birenbaum-Carmeli and Piero Montebruno, ‘Incidence of Surrogacy in the USA and Israel and Implications and Women’s Health: A Quantitative Comparison’, Journal of Assisted Reproduction and Genetics 36 (2019): 2459–69, 2459. 91. Centers for Disease Control and Prevention (CDC), ‘ART and Gestational Carriers’. 92. Salama et al., ‘Cross Border Reproductive Care (CBRC)’, 1282. 93. Allison Herrera, ‘In Ukraine, Surrogacy Is Legal, But Some Ask if It’s Exploitation’, PRI’s The World, June 29, 2018, https://www.pri.org/stories/2018-06-29/ukraine-surrogacy-legal-some-ask-if-its-exploitation 94. Patel and Banker, ‘Gestational Carrier’, 181.

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95. Herrera, ‘In Ukraine, Surrogacy Is Legal’. Christina Weis has found that the geographic isolation and economic deprivation of women in Russia and Ukraine can make them vulnerable. ‘Transnational Surrogacy in the Post-Soviet Sphere: Geographic and Geo-Political Stratifications amongst Migrant and Commuting Surrogacy Workers in Russia’, presentation at 4S (Society for Social studies of Science) 2018 Meeting in Sydney, Thursday 30 August, 2018; Christina Corinna Weis, ‘Reproductive Migrations: Surrogacy Workers and Stratified Reproduction in St Petersburg’ (PhD diss., De Montfort University, 2017). 96. Amy Sawitta Lefevre, ‘“Wombs for Rent” Business Flourishes in Communist Laos’, Reuters, 8 June, 2017, https://www.reuters.com. Troublingly, there are reports of ‘excess’ children being sold in the event of a multiple birth, suggesting that deliberate splitting of multiple births for surrogacy may also occur. De Boer-Buquicchio, ‘All Rights for Surrogacy-­Born Children Full Scale’, 277. 97. Pierre-Louis Caron, ‘France to Legally Recognize Surrogate Children as French Citizens’, Vice, 4 July, 2015, www.vice.com; Lewin, ‘Pregnancy for Pay’. 98. Yvette Tan, ‘Why One Man in Singapore Was Not Allowed to Adopt His Child’, BBC News, 21 January, 2018, https://www.bbc.com/news 99. ‘High Court Grants Gay Man’s Bid to Adopt Biological Son Born Via Surrogate Mother’, Today, 18 December, 2018, https://www.todayonline.com 100. Cecily Huang, ‘For Single Mothers and Lesbians in China, Accessing Fertility Treatment Is a Nightmare’. ABC News, 16 March, 2019. https://www.abc.net.au/news; Rosemary Bolger, ‘IVF Tourism: The Chinese Women Travelling to Australia for a Baby’. SBS News, 29 January, 2018. https://www.sbs.com.au 101. Huang, ‘For Single Mothers and Lesbians in China’. 102. De Boer-Buquicchio, ‘All Rights for Surrogacy-Born Children Full Scale’, 280–81. 103. Allen, ‘Surrogacy and Limitations to Freedom of Contract’, 757. 104. Burcu Mutlu, ‘Transnational Biopolitics and Family-Making in Secrecy: An Ethnography of Reproductive Travel from Turkey to Northern Cyprus’ (PhD diss., Massachusetts Institute of Technology, 2019). 105. Mutlu, ‘Transnational Biopolitics and Family-Making in Secrecy’. 106. Vinicius Lemos, ‘“Carrego seu filho por R$ 100 mil”: o mercado online da barriga de aluguel’, BBC News Brasil, 9 January, 2018, https://www. bbc.com/portuguese/brasil-42573751

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107. Lefevre, ‘“Wombs for Rent”’. 108. Lefevre, ‘“Wombs for Rent”’; James Pomfret, ‘Forced Abortions Shake Up China Wombs-for-Rent Industry’, Reuters, 30 April, 2009, https:// www.reuters.com 109. Mazhar Farooqui, ‘Indian Teacher in Dubai Becomes Single Dad Via Surrogacy’, Gulf News, 25 January, 2020, https://gulfnews.com/uae 110. Carolin Schurr, ‘The Baby Business Booms: Economic Geographies of Assisted Reproduction’, Geography Compass 12, no. 8 (2018): e12395. 111. Victoria Burnett, ‘Mexican State Cracks Down on Surrogacy, Traps Parents in Legal Nightmare’, Sydney Morning Herald, 24 March, 2017, https://www.smh.com.au 112. Sharmila Rudrappa, ‘Why Is India’s Ban on Commercial Surrogacy Bad for Women?’, North Carolina Journal of International Law 43 (2018): 70–94; Ryan Ross, ‘Trial Starts for Australian Nurse in Cambodia Surrogacy Case’, BioNews, no. 905, 19 June, 2017, https:// www.bionews.org.uk; Lefevre, ‘“Wombs for Rent”’; Sharmila Rudrappa, ‘India Outlawed Commercial Surrogacy—Clinics Are Finding Loopholes’, The Conversation, 24 October, 2017, https://theconversation.com 113. Lefevre, ‘“Wombs for Rent”’. 114. AFP New Delhi, ‘India Bans Foreigners from Hiring Surrogate Mothers’, Guardian, 28 October, 2015, https://www.theguardian.com 115. Vaibhav Tiwari and PTI, ‘Surrogacy Regulation Bill Passed in Lok Sabha: 10 Points’, NDTV, 19 December, 2018, https://www.ndtv.com 116. Lefevre, ‘“Wombs for Rent”’; Rudrappa, ‘India Outlawed Commercial Surrogacy’. 117. Erin Handley and Kong Meta, ‘Cambodian Surrogates Face an Impossible Choice—Forced Motherhood, Or Years in Prison’, ABC News, 12 May, 2019, https://www.abc.net.au/news 118. Handley and Meta, ‘Cambodian Surrogates Face an Impossible Choice’. 119. Spar, ‘For Love and Money’, 293. 120. Graham Bicknell, ‘Frank Monte: A Search for Surrogates’, New Idea, 21 May, 1988. 121. Jenny Currie, ‘Availability of Egg Donors in South Africa’, Ezine Articles, 7 January, 2009, https://ezinearticles.com and baby2mom, https://www.baby2mom.co.za. See also Amrita Pande, ‘Want Your

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Eggs Black or White?’, Mail and Guardian (South Africa), 1 February, 2019, https://mg.co.za 122. Salama et al., ‘Cross Border Reproductive Care (CBRC)’, 1284. 123. Candace Sutton, ‘Australian Nurse Tammy Davis-Charles Sentenced in Shock Verdict for Cambodian Child Surrogacy Racket’, news.com.au, 3 August, 2017, http://www.news.com.au. See also Australian Associated Press (AAP), ‘Australian Nurse Freed from Cambodian Jail but 43 Women Arrested Over Surrogacy’, Guardian, 14 November, 2018, https://www.theguardian.com. News reports vary as to the legality of surrogacy in Cambodia at the time of the arrest. 124. Agence France-Presse, ‘Australian Nurse Jailed over Cambodian Surrogacy Clinic Has Sentence Upheld’, Guardian, 8 January, 2018, https://www.theguardian.com; Sutton, ‘Australian Nurse Tammy Davis-­ Charles Sentenced’; Reuters, ‘Thailand Bans Surrogacy for Foreigners’. 125. United Nations, Human Rights Council, ‘Report of the Special Rapporteur on the Sale and Sexual Exploitation of Children, Including Child Prostitution, Child Pornography and Other Child Sexual Abuse Material’, https://www.ohchr.org/EN/Issues/Children/Pages/ ChildrenIndex.aspx 126. Tereza Hendl and Tamara Kayali Browne, ‘Sad about Having a Boy Not a Girl? Your Distress Might Be Real but “Gender Disappointment” Is No Mental Illness’, The Conversation, 10 March, 2020, https://theconversation.com; Whittaker, ‘Reproduction Opportunists’; Charlotte Kroløkke and Filareti Kotsi, ‘Pink and Blue: Assemblages of Family Balancing and the Making of Dubai as a Fertility Destination’, Science, Technology, & Human Values 44, no. 1 (January 2019): 97–117. Kroløkke and Kotsi here refer to gender, rather than sex selection, since the desire for this particular form of selection seems particularly tied up with culturally based gender expectations. See also Rajani Bhatia, ‘The Development of Sex-Selective Reproductive Technologies within Fertility, Inc. and the Anticipation of Lifestyle Sex Selection’, in Selective Reproduction in the 21st Century, ed. Ayo Wahlberg and Tine M.  Gammeltoft (Cham: Palgrave Macmillan, 2018), 45–66; Rajani Bhatia, Gender before Birth: Sex Selection in a Transnational Context (Seattle: University of Washington Press, 2018). 127. ‘International Federation of Fertility Societies’ (IFFS) Surveillance 2019’, e29, 105. In India and China, before the advent of IVF, the use of other antenatal technologies led to a decline in the proportion of

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females, until the governments undertook to control their use. Whittaker’s observation that the process is a medical intervention on a healthy body references a concern that has been present in IVF for almost its entire history. Whittaker, ‘Reproduction Opportunists’, 614. 128. Cf. Whittaker, ‘Reproduction Opportunists’. 129. IFFS,  ‘International  Federation of  Fertility  Societies’ Surveillance (IFFS)  2019’, 138. ‘PGT—Preimplantation Genetic Testing’ and ‘PGT-A—Preimplantation Genetic Testing for Aneuploidy Screening’, https://monashivf.com 130. IFFS, ‘International Federation of Fertilities Societies’ Surveillance (IFFS) 2019’, 105. 131. Gab Kovacs, Julian McCrann, Michele Levine, and Gary Morgan, ‘The Australian Community Does Not Support Gender Selection by IVF for Social Reasons’, International Journal of Reproductive Medicine 2013 (2013): article242174; Aisha Dow, ‘Australian Parents Flock to US Clinics to Choose Baby’s Gender’. Sydney Morning Herald, 26 August, 2018, https://www.smh.com.au 132. Kroløkke and Kotsi, ‘Pink and Blue’. 133. LIV Fertility Center Puerto Vallarta Mexico, ‘Gender Selection Mexico: LIV Fertility Center Puerto Vallarta’, YouTube, 24 July, 2017, https:// www.youtube.com. Only PGT-A requires IVF. 134. Authors’ sighting (SF). 135. W.  Dondorp, G.  De Wert, G.  Pennings, F.  Shenfield, P.  Devroey, B. Tarlatzis, P. Barri, and K. Diedrich, ‘ESHRE Task Force on Ethics and Law 20: Sex Selection for Non-Medical Reasons’, Human Reproduction 28, no. 6 (2013): 1448–54. 136. Hudson and Culley, ‘Assisted Reproductive Travel’, 579. 137. Stevienna de Saille, Knowledge as Resistance: The Feminist International Network of Resistance to Reproductive and Genetic Engineering (Houndmills: Palgrave Macmillan, 2017). 138. Shellee Colen, ‘“Like a Mother to Them”: Stratified Reproduction and West Indian Childcare Workers and Employers in New  York’, in Conceiving the New World Order: The Global Politics of Reproduction, ed. Faye D. Ginsburg and Rayna Rapp (Berkeley: University of California Press, 1995), 78–102, 100. 139. Sarah Franklin, ‘Transbiology: A Feminist Cultural Account of Being after IVF’. The Scholar and Feminist Online 9, nos. 1–2 (2010–2011), http://sfonline.barnard.edu/reprotech/franklin_01.htm

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140. Joanna Mishtal, ‘Reproductive Governance and the (Re)definition of Human Rights in Poland’, Medical Anthropology 38, no. 2 (2019): 182–94; Lynn M. Morgan and Elizabeth F. S. Roberts, ‘Reproductive Governance in Latin America’, Anthropology & Medicine 19, no. 2 (2012): 241–54. 141. Charis Thompson, ‘Why We Should, in Fact, Pay for Egg Donation’, Regenerative Medicine 2, no. 2 (2007): 203–09; Debora L.  Spar, The Baby Business: How Money, Science, and Politics Drive the Commerce of Conception (Boston: Harvard Business Review Press, 2006); Sharon Bassan, ‘Different but Same: A Call for a Joint Pro-Active Regulation of Cross-Border Egg and Surrogacy Markets’, Health Matrix 28, no. 1 (2018): 323–74, 362. 142. Weis, ‘Reproductive Migrations’, 54. 143. Bayefsky, DeCherney, and Berkman, ‘Compensation for Egg Donation’, 1154. 144. Bayefsky, DeCherney, and Berkman, ‘Compensation for Egg Donation’, 1154; Michal Nahman, ‘Nodes of Desire’, 68. 145. Elizabeth F. S. Roberts, God’s Laboratory: Assisted Reproduction in the Andes (Berkeley: University of California Press, 2012), 184. 146. Ethics Committee of the American Society for Reproductive Medicine, ‘Cross-Border Reproductive Care: A Committee Opinion’, Fertility and Sterility 100, no. 3 (September 2013): 645–50, 645. 147. ESHRE, ‘ESHRE Fact Sheets 1, January 2017: Cross Border Reproductive Care’; Shenfield, ‘Cross Border Reproductive Care’, Slide 19. Françoise Shenfield, Guido Pennings, Jacques De Mouzon, AnnaPia Ferraretti, V. Goossens, on behalf of the ESHRE Task Force, ‘Cross Border Reproductive Care’ (CBRC), ‘ESHRE’s Good Practice Guide for Cross-­Border Reproductive Care for Centers and Practitioners’, Human Reproduction 26, no. 7 (2011): 1625–27, 1625. 148. Kathryn Webb Bradley, ‘Surrogacy and Sovereignty: Safeguarding the Interests of Both the Child and the State’, North Carolina Journal of International Law 43 (2018): 1–37, 4. 149. Rudrappa, ‘India Outlawed Commercial Surrogacy’. 150. Thompson, ‘IVF Global Histories’, 134. 151. Marcin Smietana, Charis Thompson, and France Winddance Twine, ‘Making and Breaking Families–Reading Queer Reproductions, Stratified Reproduction and Reproductive Justice Together’,

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Reproductive BioMedicine & Society Online 7 (2018): 112–30; Riggs and Due, A Critical Approach to Surrogacy. 152. Anne Barker, ‘“Desperate” Australian Couples Unable to Leave Cambodia with Surrogate Babies’, ABC News, 23 February, 2017, https://www.abc.net.au 153. Sharmila Rudrappa, Discounted Life: The Price of Global Surrogacy in India (New York: New York University Press, 2015). 154. Rudrappa, ‘Why Is India’s Ban on Commercial Surrogacy Bad for Women?’. 155. Burnett, ‘Mexican State Cracks Down on Surrogacy’; Rudrappa, ‘Why Is India’s Ban on Commercial Surrogacy Bad for Women?’; Whittaker, ‘“Stop Thai Women’s Wombs from Becoming the World’s Womb”’, 140. 156. De Boer-Buquicchio, ‘All Rights for Surrogacy-Born Children Full Scale’. Ms. de Boer-Buquicchio ceased to hold the role as at April 2020. 157. De Boer-Buquicchio, ‘All Rights for Surrogacy-Born Children Full Scale’, 281. 158. De Boer-Buquicchio, ‘All Rights for Surrogacy-Born Children Full Scale’, 281. 159. Salama et al., ‘Cross Border Reproductive Care (CBRC)’, 1277; 1285. See also Bart C. J. M. Fauser, ‘Towards the Global Coverage of a Unified Registry of IVF Outcomes’, Reproductive BioMedicine Online 38, no. 2 (2019): 133–37. 160. Riggs and Due, A Critical Approach to Surrogacy, 131, 132. 161. Verena Namberger, The Reproductive Body at Work: The South African Bioeconomy of Egg Donation (Abingdon, UK: Routledge, 2019).

6 Testing Boundaries, Finding Limits

In October 2016, fertility treatment providers formally expanded the definition of infertility. In the UK, tabloid newspapers turned to capital letters for headlines such as ‘Failure to Find a Sexual Partner Is Now a DISABILITY Says World Health Organisation [WHO]’; these ‘barmy new guidelines’ mean that ‘PEOPLE who don’t have sex or struggle to find a sexual partner to have children with will now be considered as DISABLED’.1 The reports were referring to a new glossary of infertility, intended to guide treatment providers across the world. A key figure in this change, US clinician G. David Adamson explained: The definition of infertility is now written in such a way that it includes the rights of all individuals to have a family, and that includes single men, single women, gay men, gay women. It puts a stake in the ground and says an individual’s got a right to reproduce whether or not they have a partner. It’s a big change.2

The change was not in the end attributable to the WHO, but rather to the International Committee for Monitoring Assisted Reproductive Technologies (ICMART), with which the WHO has at times collaborated.3 When the glossary appeared several months later in a leading © The Author(s) 2020 S. Ferber et al., IVF and Assisted Reproduction, https://doi.org/10.1007/978-981-15-7895-3_6

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academic journal, the authors reinforced their perspective ‘that the failure to become pregnant does not always result from a disease, and therefore introduces the concept of an impairment of function that can lead to a disability’.4 The new definition reflects liberal values about sexuality and family-­ making. It also creates, through recognition of a newly capacious ‘disease entity’, the chance of access to medical insurance or public health schemes. For a country such as the United States, where health insurance is a key source of funding for private fertility treatment, the change has the potential to open up avenues for more people to obtain financial support for assisted reproduction (AR). The British tabloids were quick to point out that the new definition could place stress on the under-­ resourced fertility sector of the National Health Service (NHS).5 This claim, though referring credibly to public health funding problems, can also be read in the context of a thinly veiled attack on the ‘less deserving’ infertile, meaning prospective parents outside heterosexual marriages— including those unwilling to seek or simply unable to find a partner. Even when infertility is a consequence of biological incapacity, the problem AR exists to solve is a social one: lack of the capacity to create a family, when family is epitomised by the creation of children. The fundamentally social nature of infertility has been dormant in much of the debate about AR. What the new glossary does is to reveal it. Those wanting to use AR have, quest by individual quest, opened out the boundaries of what constitutes (in)fertility and family-making. These boundaries include assumptions about: who should be permitted to become parents; who has the responsibility for reproduction, especially in relation to gender roles; age limits for women to give birth; the use of the gametes of deceased persons; even the limits for clinicians and clients in the pursuit of a successful treatment. Within all these conversations lies the question of when to stop unsuccessful fertility treatment, when to cross the line back from the status of prospective parent to a permanent identity as infertile, or as an ‘incomplete’ person or family. Broad social agreement on any one of these issues is unlikely to eventuate, but as practices expand, the potential exists for both acceptance and negative judgements to intensify. If AR has exposed the limits of supposedly shared assumptions about the nature of family and of fertility status, it has also created new markets

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by testing them. This chapter provides background on the changing experience of infertility in the age of AR, including the emergence of new client groups, such as gay men, lesbians and single people. It investigates ways in which AR has extended former modes of reproduction beyond temporal boundaries, practices such as social egg freezing, older women giving birth and the use of AR to bring about ‘posthumous reproduction’. It considers the importance of AR for male factor infertility in relation to gender roles surrounding reproduction, and notes the emergence of intra-cytoplasmic sperm injection (ICSI) as the AR treatment of choice, surpassing the use of IVF. It describes recent debates about adjuvant treatments (‘add-ons’), and considers factors working against making the choice to cease unsuccessful fertility treatment.

The Experience of Infertility in the Age of AR Stories of family and lineage are among the great unifying and dividing tales of world history, narrative highways that link the past to the future. Since the first IVF births, individual and familial aspirations have tested many conventional notions of what defines a family. Assisted reproduction has made it possible to challenge and extend these ideas, in the process complicating links between physical genetic relatedness and the status of legally recognised social family. Assisted reproduction has materially disconnected the idea of the social family from what is in many (but not all) cultures the essential prerequisite of family: genetic kinship.6 As anthropologists have long observed, however, defining family has always been a legal or customary undertaking, never just a matter of genetics. What the advent of AR has done is to lay bare the fact that ‘family’ is a structure based primarily on social rather than biological relations, in a way that some people have found to be unsettling, others enabling or even liberating. If the birth of a child has seemed to convert a social relationship (a partnership) into a biological one (a family), the increasing use of AR demonstrates that the family, too, is a social rather than a biological structure. Once the singular patient became the social dyad of the male-female couple, first through the practice of sperm donation and later via IVF, the social bond between intending parents and the child

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took pre-eminence over the physiological cause of the infertility. The tabloid media’s repudiation of an explicit recognition of this longstanding but counterintuitive reality, as revealed in the new definition of infertility, is more an index of contemporary cultural politics than it is a demand to restore the link between biological fertility and the creation of a family. The isolation of oocyte and sperm in the laboratory was both a scientific and a social act, the first step in what might be described as the ‘modularisation’ of reproductive relations. It not only separated sexual relations from reproduction, but each new AR process isolated every stage of reproduction from others, beginning with the gametes in the laboratory and ending, in the case of surrogacy, in childbirth itself.7 The same doorway presented new vistas to quite different people. IVF is a commercial and clinical transaction between a provider and a client that has been multiplied through a range of AR transactions, while further multiplier effects have come into being as a consequence of auxiliary technologies, such as air transport, clinical freezing, hormonal stimulation and the internet.8 Assisted reproduction has provided ways for individuals and couples to think of themselves as the creators of family, when this previously would have been either difficult or impossible. Not only has the technology come along at a time of changing familial practices, it has provided the basis for people to perceive themselves anew as eligible to be reproductive beings. As individuals, couples, communities, religions and indeed nations saw ways in which AR after IVF might fulfil their reproductive goals, new markets have opened up across the world. Segments of societies that previously stood outside the reproductive world—notably same-­ sex couples and single people—can now identify as being among the infertile, entitled to the same access to fertility services as others.9 At the same time, AR has been able to buttress what are seen as traditional or even at times conservative reproductive priorities. Groups constrained by religious or other cultural barriers, for whom not all forms of treatment are acceptable, have seen in AR new opportunities to procreate within their own definitions of what reproduction should entail. Redrawing the line between fertile and infertile repositions the experience of a desire to parent as either legitimate or illegitimate.

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Family exists as much because it exists at law or in culture as because of biology, as Marilyn Strathern observed in relation to AR in the 1990s.10 As earlier chapters have shown, legitimacy is something governments declare upon in a social context: a parent is a parent because the law says they are; because nations exist, families exist. There is a common assumption in the promotion of ‘family values’ that the family is the building block of the nation, but the reverse is the case—nation, as it turns out, builds family. Genetic connectedness is still highly relevant, however, in the cultural, emotional and also strictly medical discourses of AR. It is important in relation to the quest of donor-conceived people to find gamete-provider parents or genetic siblings; in the use of means to ensure a genetic connection between father and child, for example, through the use of intra-cytoplasmic sperm injection (ICSI) in preference to sperm donation; in the use of preimplantation genetic testing techniques to prevent the transmission of serious genetic disease and in the occasional practice of creating ‘saviour siblings’, children born from embryos genetically matched to a living child, to provide donor tissue.11 From early in its history, IVF has made human infertility a subject suitable for public discussion, with the potential to engage people beyond the initial cohort of heterosexual couples. A preliminary search for ‘infertility’ and ‘fertility’ in a major database of English-language newspapers conveys a clear impression that human fertility made a transition from being a topic most likely raised in relation to the global population profile in the 1970s to one focused on the experience and medical treatment of infertility.12 This was both a public-facing and private-facing achievement of IVF: a person’s ‘fertility status’, even if they are not in a relationship and considering conception, can become part of individual identity in a way that was less evident forty years ago than now. The idea of ‘reproductive rights’, in turn, applied to AR, has opened up pathways that were previously unimagined or physically impossible. The success of IVF as the creator of new possibilities, perhaps more than as a treatment intervention, lies in a capacity to elicit expectation even for those living outside biologically imposed barriers to conception. As commentators have observed for many years, infertility in that sense, more than any other medical condition, can ‘come into being’ because of the existence of an available response, in the form of AR. ‘Fertility status’

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is now a part of selfhood and clients can become adept at self-­identification through their clinical profile: as one online poster introduced herself, when seeking advice from an AR expert: ‘I am Age 35yo w/DOR: AMH 0.55 ng. FSH 15-18, LH 5-6. AFC 6-9. No male factor contributions’.13 In the sphere of emotion, a tight knot binds the experience of an unfulfilled wish to have a child to the conditions of operation of industry, as well as to the choices of governments and clinical providers. The life experience of being unable to become a parent when one wishes to has a powerful impact, on individuals, couples, and wider family and community networks. According to interviews with people who have had unsuccessful fertility treatments, when no child eventuates, the experience of loss of the potential parenthood (a future self ) or of an imagined child is intense. As one review study observed, ‘failed fertility treatment represents the loss of biological parenthood, or parenthood in general, and usually triggers intense and prolonged grief reactions’.14 An incapacity to achieve conception can be experienced as acute emotional suffering caused by a threat to an individual’s sense of self, to the durability of a couple’s or family’s relationship, or to the acceptance of a person—usually, but not always, a female—within an extended family or community. Entry to the fertility marketplace can be both a welcome opportunity and deeply confronting.

Gay Men, Lesbians and Single People Making the term ‘infertility’ broader, to cover multiple client categories, posits that it is fair for people to seek parenthood regardless of their sexuality or marital status. Thus, women who are domestic partners might look to use IVF with donor sperm and potentially the oocytes of one partner for implantation in the other woman. Equally, solo women can become parents using donor sperm. Gay male couples can engage a woman to have a child for them, potentially using the sperm of one or both. One legal commentator in 2003 speculated that access to AR would expand for people not living in heterosexual relationships and the legalisation of same-sex marriage in some key AR markets, along with the wider range of treatment options afforded through reproductive travel, have indeed coincided to enhance family-building within some LGBT+

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communities.15 Yet since that time, several jurisdictions have created or reversed laws, either explicitly or tacitly with the aim of excluding gay, lesbian or single people from parenting. As we have seen, specific jurisdictions aiming to preserve AR for legally married heterosexual couples have made a statement about that place as a particular kind of moral community. Others have permitted change along certain lines but not others: France in 2019 permitted single women and lesbians to access AR, but does not allow surrogacy, either for gay males or other people. In Poland, single women who had frozen embryos created legally, with their own eggs and donor sperm, were in 2019 prohibited from accessing them after a new conservative government ruled that only married heterosexual couples could use the women’s embryos. In Israel state-supported access to commercial surrogacy within the country’s borders was extended from married heterosexual couples to single women in July 2018. Same-sex marriage is recognised as legal in Israel, but a male couple was still not permitted to employ a woman in Israel in a surrogacy arrangement. As gay male couples were excluded from the newly liberalised law, LGBT+ activists organised a ‘nationwide strike’ in protest.16 In February 2020, however, following the recognised route of case law challenges against legislation, the High Court ordered in favour of male plaintiffs, on the grounds that the law was discriminatory. The court obliged the Knesset to bring in a new law.17 Gay activists in Australia have argued similarly against the illegality of commercial surrogacy itself, which they see as discriminatory.  Taken together, these changes and reversals highlight the political volatility to which certain kinds of prospective parent are exposed.18

 eproduction Beyond Temporal Boundaries: R Egg Freezing, Older Women and Posthumous Reproduction For individuals, couples and families, the prospect of creating or preserving family has led people to try to have babies at an advanced age; to take measures to keep open the ‘fertility window’, and try to obtain access to the gametes of a deceased partner or family member in order to bring

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about a birth. Assisted reproduction has also challenged the limits of the human reproductive age span, and even of life itself, as some have sought to use the gametes of deceased partners or offspring.19 Transforming temporality by confounding the categories not only of youth and age, but even life and death, challenges social ideas of what constitutes suitable parenting and raises questions about the limits to which procreative capacities should be extended using AR.

Egg Freezing and Fertility Preservation Some women look to extend their reproductive capacity into the future by so-called egg-banking, using freezing technology to store eggs for use later in life. Clinicians originally proposed egg freezing for women who were about to undergo some kind of medical intervention, such as cancer treatment, which would impact on their subsequent capacity to ovulate normally. Freezing of oocytes was for many years one of the most intractable technical challenges of AR.  The first birth took place following freezing in 1986, but an egg bank established in the 1980s in Victoria reported no live births for more than a decade.20 The advent of a new rapid-freezing technique known as vitrification has made egg freezing without fertilisation more effective.21 Even today, however, the success rate for fertility treatments using frozen eggs is not as high as those for frozen sperm or embryos, and less likely to contribute to the creation of a child than IVF with fresh oocytes.22 With provider eggs at a premium in AR, ‘fertility preservation’ through egg freezing is meant to hedge against the risk of infertility. In more affluent countries, many women’s decisions to pursue a career or to stabilise their personal situation have led them to seek egg provision from younger women or, more recently, to try to ‘extend’ their fertility by freezing their own ova. Sociologist Laura Briggs attributes the growing use of AR by such women to what she refers to as ‘structural infertility’, what she calls ‘the failure of the workplace to accommodate reproduction and the reality that humans, and households, care for children and other kinds of dependents’.23 In the United States, medical insurance to cover egg-freezing procedures is not widely available,  although major corporations such as

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Facebook and Apple have announced that they would cover some costs of egg-freezing services for their employees.24 The companies cast this as a female-friendly policy, increasing choices and supporting women by enabling freezing or ‘banking’ of younger and healthier eggs, so that they could then later have children through IVF.  The argument is that by postponing pregnancy, women are not forced to choose between family and career. However, critics argue that, far from offering women choice, this technology does not address key socio-cultural reasons for delayed childbearing, carries the same clinical risks as other AR interventions to obtain multiple in vitro oocytes, and has the potential to be subtly coercive in the context of the workplace.25 (The provision of free childcare might be another option.) There is a range of reasons that women may choose to freeze their eggs: some women do not do so for career reasons, for example, but because they have yet to find the ‘right’ partner.26 A woman pursuing so-called social egg freezing in order to access those eggs later in life, for personal, rather than, medical reasons, is effectively a one-person egg donation program, from a young woman to her older self.27 In New York, women who might once have hosted Tupperware parties now host ‘egg freezing parties’, social events at which they share tips on how to store their remaining eggs.28 The Pentagon piloted egg and sperm cryopreservation for its military service personnel, to encourage female staff retention and also in case of injury or death whilst on deployment.29 The British Fertility Society has also included guidelines supporting trans-gender females undergoing medically assisted transition, in relation to freezing their eggs or ovarian tissue in advance of gender reassignment.30 In 2018, the United Arab Emirates authorised egg cryopreservation in recognition of the place of women in the workforce, their trying for children later, and of the rise of infertility.31 State funding for the cryopreservation of eggs, however, is available only in some places around the world.32 A survey from the United States of 200 women found that some regretted their decision to freeze their eggs. Key factors included low numbers of oocytes, and perceived lack of information and support.33 The study’s authors also identified ‘unrealistic expectations’ as a possible trigger for regret in the future, with some women seeming to assume a child was more or less guaranteed. They observe, ‘Although the average estimate of

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live birth per oocyte banked (5.9%) was consistent with available publications … 13 women (6%) ages 34.3 – 40.6 years who banked between 10 and 34 eggs estimated their likelihood of having a baby at 100%’.34 In the UK some women now face the decision of what to do as they reach the end of the time the Human Fertilisation and Embryology Authority (HFEA) will let their oocytes be stored (ten years). The time limit is also a disincentive for younger women, whose eggs are more likely to contribute to a pregnancy after freezing.35 Storage itself is costly, adding further pressure to decision-making.

Older Women Giving Birth Using AR, women beyond the customary child-bearing age, and in some cases over seventy, have given birth following the use of donor eggs, either in order to bring up the children themselves, or to provide them to a family member. As fertility is often associated with specific life stages, such events can challenge family structures and disrupt notions of the passage of time, causing temporal overlaps in what convention would keep separate. In 2019, an Australian woman of sixty-one gave birth to a girl on behalf of her gay married son. In Japan, there are several reported cases of mothers who have given birth in order to provide a child for their daughters. Such births are effectively a form of surrogacy, in which the daughter must formally adopt the child.36 Stories of older mothers, whose pregnancies require intensive hormonal treatment as well as egg donation, remain newsworthy, such as the sixty-five-year-old woman in Germany who gave birth to quadruplets after receiving fertility treatment in Ukraine, or a fifty-five-year-old mother who gave birth to triplets in the UK, reportedly ‘smashing the British record’.37 A doctor who helped bring about a birth for a previously childless woman of seventy in India notified the Guinness Book of Records.38 In India, there are clinics focusing on the national market of older women wanting children.39 In 2020, however, the Assisted Reproductive Technology Bill proposed to ‘set 50 as the upper age limit for women to undergo these procedures’.40 Some clinicians have raised concerns about the health effects of pregnancy and birth on older women,

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as well as their ability to parent, and the health risks faced by the young egg sellers. Countervailing forces, however, include the cultural stigma surrounding childlessness, as well as the wish of older couples to have a child, sometimes after decades together without having been able to have one.41

Posthumous Reproduction The idea of new technology being used to extend the boundaries of life is more than two centuries old, dating at least  from Mary Shelley’s Frankenstein; or, The Modern Prometheus (1818), Dr Frankenstein making his monster from dead tissue and then bringing him to life, defying time and fate.42 Widespread use of cryopreservation of embryos, eggs and sperm has opened up the possibility of their use for reproduction after the death of one or both biological parents or prospective biological parents. Cryopreservation techniques, which can keep gametes viable after a person has died, also enable the maintenance of reproductive cells acquired posthumously, or from a person, often a comatose male, which can then be implanted using AR.43 Two court cases in Australia were won by women attempting to gain access to sperm that had been removed posthumously. In 2011, the Supreme Court in the state of New South Wales allowed a woman to use the sperm some months after her partner was killed in a workplace accident, the couple having attended a fertility clinic.44 In 2018, a woman in the state of Queensland won a ‘landmark’ court battle to be given access to her partner’s sperm, after he had suicided. Nearly two years later, she was granted the right to use the material to have a child.45 Even within national borders, different laws can apply. A woman from Perth in Western Australia had sperm extracted from her husband upon his death from a heart attack. She was eventually allowed to transfer it to the Australian Capital Territory (ACT) which, unlike Western Australia, permits the posthumous use of reproductive material.46 People wishing to undertake IVF with sperm from a dead partner sometimes choose to do so in jurisdictions more permissive than their own: another kind of cross-border reproduction.47 A Spanish woman

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whose partner died while the couple lived in France was initially not allowed to use the sperm of her partner, having had it cryopreserved before he underwent chemotherapy. The woman was eventually allowed to bring the sperm home to Spain after the French Conseil d’État judged the initial decision a ‘grossly excessive interference with the right to respect for private and family life’.48 In Japan, posthumous reproduction is complicated by Article 772 of the Civil Code, which states that a child born more than 300 days after the end of a marriage (as a result of either death or divorce) will not be recognised as the child of the former husband.49 There have been at least three court cases in Japan relating to the paternity of children born through IVF after the death of the father. Each time, the paternity of the child was eventually denied by the courts, even in one case when the father had explicitly consented to his wife having a child after his death.50 It is not only surviving spouses who hope to gain access to preserved gametes. In December 2017, a baby was born four years after both parents died in a car crash. The two sets of grandparents, both living in China, fought a protracted court battle to gain use of the existing frozen embryos, then engaged the services of a gestational mother from Laos to carry a baby for them. The Intermediate Court of Wuxi had allowed the use of the embryos on the basis that ‘the embryos left by Shen and Liu are the only carriers of the two families’ bloodlines, and they carry the memories of their parents and can provide emotional consolation to them’.51 Other cases of posthumous use of sperm have made the news around the world, including a case in India where a grandmother used her son’s sperm and the services of a gestational mother and an egg donor to have twin grandchildren.52 In 2017, the Israeli appeal court overturned a decision that had allowed parents to extract their son’s sperm and use it for posthumous procreation with a commercially obtained oocyte and a gestational mother. They had been planning to raise the grandchild themselves.53 Posthumous genetic ‘motherhood’ is rarer, partly because egg retrieval without ovarian stimulation is more problematic. In Israel, a court initially allowed the retrieval of eggs from a seventeen-year-old woman who had died in a car crash, but subsequently did not permit their fertilisation.54 In 2016, the United Kingdom’s Court of Appeal overturned a decision by the HFEA that had prevented a mother from using her deceased daughter’s eggs. The daughter had had the eggs cryopreserved

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whilst undergoing chemotherapy and had consented to her mother carrying any future embryos if she herself was too ill. After the daughter’s death, the HFEA had refused to let the mother take the eggs to the United States to have them fertilised with a sperm donor and be carried by a gestational mother, on the grounds that ‘effective consent’, an HFEA requirement under British law for posthumous reproduction, had not been obtained.55

Male Factor Infertility Assisted reproduction has brought to light the importance of male factor infertility, an issue that had relatively little prominence in the early years of IVF, because of widespread social assumptions that reproduction was the responsibility of women. Greater recognition of male infertility as an indication for AR and increased research on its causes have begun to reorient widespread and long-held perceptions of infertility as a ‘women’s’ problem. Providers of IVF have long been aware that male factor infertility is a major issue to which treatment could be directed: the Steptoe-­ Edwards-­Purdy team referred to this prospect as early as 1979.56 Male factor infertility is a key reason for heterosexual couples to experience infertility, involving around 20–30% of cases.57 In many cultures, the infertility of a couple has been attributed to the female, reflecting both the evident absence of a child being carried by a woman and a deeper view that the female’s primary role is to carry children. Conversely, a reluctance to attribute, investigate or treat an incapacity in males to provide sperm that can result in a pregnancy is often bound up with images of masculinity, whether held by the client, clinicians or both. When the first IVF clinic opened in Zimbabwe in 1987, an anthropologist provided two arresting comments to the media, depicting extreme cultural views of female and male infertility. He said that in a system where men purchase their wives, the woman’s fertility is assumed, that a man has paid ‘for the wife assuming her potential productivity [meaning if ] she doesn’t produce offspring he’s paid for nothing’. Of male infertility, he had observed it was seen as ‘an absolute disgrace, the worst paradigm of weakness and timidity’.58

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Such views are dramatic, indeed inhumane. Yet in many cultures similar assumptions unconsciously underpin attitudes to women’s and men’s fertility, such that female and male gender identity is often deeply implicated in a person’s feelings about their reproductive capacity. Marcia Inhorn has conducted several major studies on men’s experience of infertility, a relatively new field of inquiry in comparison with the study of women’s experiences.59 Her research on men in the Middle East and men from the Middle East living  in the United States undergoing AR has opened up the emotional worlds of hitherto under-documented gender and social groups. According to Inhorn, men in Egypt have generally expected their wives to absorb the stigma of infertility; now, she says, it is more likely that men will understand and acknowledge the medical issues. She argues that in many countries ‘male infertility remains a hidden, highly stigmatized problem—laden with feelings of inadequacy, confused with impotence and often spoken of, derogatorily, as “shooting blanks.”’60 Meanwhile, studies also show a decline worldwide in the capacity of sperm to bring about fertilisation.61 According to Inhorn, ‘across Europe, North America, Australia and New Zealand’ sperm counts fell by 50–60% between 1973 and 2011.62 In light of these trends, Inhorn threw down the gauntlet to men in the United States in an upbeat piece in the New York Times on the issue of male infertility. Noting that the ‘Middle East has been grappling with serious problems for decades’, she suggested that awareness of the risk of infertility among men in that region might provide an example to men in the United States less well schooled in how to deal with their own fertility issues.63 According to one study, ‘Men aspire to parenthood as much as women do but have limited knowledge about the factors that influence fertility’.64 Other scholars have identified the impact on some men’s sense of their identity as male, after having been treated for infertility.65 Their experience of infertility has stronger resemblances to that of females than might have been predicted, with ‘desires to experience parenthood that are similar to those of their female counterparts’ and concomitant sadness when the desire for a child cannot be fulfilled.66 Researchers are paying more attention to the stigma and anxiety surrounding male as well as female infertility in a range of places including the UK, Iran, Saudi

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Arabia, China and Malawi.67 There are now more messages targeted at men about looking after their fertility and not waiting too long to reproduce.68 According to andrologists (scientists of reproductive biology in men) knowledge about the aetiology (causes) of male infertility is still needed. Two recent studies of male factor infertility identified difficulties in determining clearly either the prevalence and impact of causes, or the relative value of interventions.69 One of the reviews concluded that owing to the very low quality of evidence … it is not currently possible to determine an unbiased prevalence of male infertility within the global, regional or national populations, including neglected individual populations. Additionally, it is not currently possible to determine what proportion of infertility in heterosexual couples is attributable to the male partner.70

Something as seemingly basic as the analysis of sperm capacity can, according to one group, vary from laboratory to laboratory or even between technicians in the same laboratory.71 Making the case for more and better research, andrologist John Aitken argues that society is now currently resolving [male infertility] … by basically working on the female partner. So she has to go through an IVF cycle because we don’t understand what’s wrong with the male. And it will be like that until we start to really investigate why it is that so many men are not necessarily infertile, but subfertile.72

Aitken has urged a better understanding of male infertility at the biological level, rather than having the industry rely on its resolution through the use of ICSI.73

Intracytoplasmic Sperm Injection for Male Infertility: ‘The Second IVF Revolution’ From the early 1980s, fertility scientists began to investigate the possibility of inserting an individual sperm directly into an ovum in the

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laboratory, rather than leaving the sperm and ovum to interact and merge as they would in vivo or in ‘traditional’ IVF.74 On a physiological level, the incapacities of sperm would be bypassed; on the social level, the man would be able to father his own genetic child. Microinjection went through several developmental phases before the first successful use of ICSI in 1992, in Belgium.75 Men provide sperm for microinjection either in the same way as for IVF, through masturbation, or, when this is not possible—or is not culturally sanctioned—through surgical intervention. ICSI, which has been called ‘the second IVF revolution’, has enabled many infertile men to become genetic fathers, reducing the requirement for sperm donation.76 It has particular appeal in communities in which the provision of donor sperm is not regarded as an option, although concerns remain about its possible impact. In the light of evidence that genetic preconditions for male infertility can be passed on to male children, John Aitken has criticised its rise: ‘the more you use assisted conception in one generation’, he observed, ‘the more you’re going to need it in the next’.77

 djuvant Treatments and A ‘Final Disappointments’ Non-Male-Factor Use of ICSI The prevalence of the use of ICSI even for non-male factor infertility has led some medical critics to see it as equivalent to a kind of adjuvant or ‘add-on’ treatment, that is, a treatment path determined on the basis of factors other than immediate clinical indications. There are different kinds of adjuvants in AR, and the reasons for their use can range from their actual or reputed clinical benefits to a role in optimising the value of expensive treatments. ICSI has now on average overtaken IVF as the basic technique of choice for AR, including for cases other than those in which male factor infertility is an indication.78 Its popularity relates in part to the relative scarcity of suitable eggs, as it is used to ‘increase the fertilization rate of the limited egg supply’.79

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Geoffrey Sher, a long-time IVF provider in the United States, maintains that the technique has improved over time and argues for the use of ICSI in all fertility treatments. He claims that ‘pregnancy rates achieved by this method of fertilization are as high, if not higher, than those of conventional IVF performed in cases of non-male-factor infertility’. Sher goes on to defend the practice on the basis that: ‘First, it is mandated for the treatment of all cases of male infertility, anyway. Second, … it is not the procedure of ICSI itself that causes complications, but rather the indication [condition] for which ICSI is done’.80 One UK-based fertility travel company adds another layer of complexity to the decision by extolling ICSI as ‘potentially boosting pregnancy rates and addressing certain egg-related problems’ on the one hand, but on the other advising that British clinics do not generally provide it as part of a standard IVF treatment package, adding to the cost of treatment for UK locals. The company is then able to direct clients to facilities in the Czech Republic as a more economical option.81 Commentators within the fertility professions have expressed misgivings about the growing use of ICSI for cases other than those in which there is a diagnosis of severe male infertility.82 To date, there appears to be no evidence that ICSI is superior to IVF in the treatment of infertility.83 One report that compared the cumulative live birth rate of ICSI to IVF for non-male factor cases found it provided no increase in the long-term likelihood of a live birth.84 Such observations have led to significant challenges within the medical profession, where many see ICSI as being used for reasons such as cost-saving, with little benefit in terms of live birth rate. Paul Devroey, a member of the Belgian team that first used the procedure, argues doctors should use ICSI only if it is necessary. He linked the choice of ICSI to the potential cost of repeat IVF treatments, observing, ‘When people have to pay for treatment out of their own pockets, they can afford maybe one or two cycles, and so of course they want to avoid failure’.85 One editorial in a major fertility journal questioned the increasing use of ICSI as a default treatment, referring acerbically to the trend as little more than a case of ‘therapeutic illusion’.86 Assisted reproduction has a capacity to both respond to and create medical markets, in ways rare among medical interventions. Many AR providers continue to express concern that the industry moves too fast;

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that clients can be disrespected in pursuit of gain and that the science is not always as certain as some colleagues assert, lacking substantiation from strong studies. This difference of view is likely to remain part of the internal and sometimes public dialogues informing AR practice. One question that has been raised in this context is the extent to which adjuvant treatments, which add to the cost of AR, should be offered if their use is not backed up by robust research demonstrating effectiveness. The media and some medical professionals have criticised one such treatment, the use of so-called ‘embryo glue’—said to help with attachment in the womb—that may have no medical benefit.87 Other procedures include ‘fertility measurement’, therapies to block ‘NK cells’ and pre-­implantation genetic testing.

Fertility Measurement: NK Cells ‘Fertility measurement’ is a developing area, with advertisements encouraging women to check their ‘biological clock’ to ensure they do not leave it ‘too late’.88 One test measures the levels of anti-Müllerian hormone (AMH) in a woman’s blood, as a proxy for the number of oocytes she has left. The test results may be confusing, however: high levels of AMH can indicate a high number of eggs, but also conditions like polycystic ovary syndrome (PCOS). Women with PCOS may find it easier to get pregnant when they are older, and their AMH levels have dropped.89 Another controversial intervention involves ‘natural killer’ cells or NK cells, some of which reside in the uterus, that are part of the body’s system of immune response. Based on studies that have been small and, some argue, inconclusive, many IVF clinics are offering therapies to block the uterine NK cells in case they cause damage to the newly implanted embryo.90 Laboratory scientists Ashley Moffett and Norman Shreeve called for tighter regulation of this kind of treatment, but their views were not shared by all clinicians.91 Gavin Sacks, for example, urged that the ‘point about NK testing (if it is done well, with the technical issues … taken into consideration) is that it can give patients confidence that their clinician is at least thinking about their very frustrating problem. Where is the

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harm in that?’92 The harm,  Moffett and Shreeve suggested, ‘is in the financial and emotional cost of an unproven investigation and the perpetuation of an acceptance that a clinician should bend to a patient’s will and not try to protect them (sometimes from themselves)’.93 Such an exchange highlights the historical paradox of patients’ rights claims, when patients drive the treatment process in a commercially oriented industry with high costs. This kind of debate has in turn led some providers to argue that negative coverage of add-ons is unhelpful and confusing to would-be patients.94

 reimplantation Genetic Testing P for Aneuploidies (PGT-A) The technique of preimplantation genetic testing for aneuploidy (PGT-­ A, formerly referred to as preimplantation screening, or PGS), offered as an intervention with the potential to optimise the overall chances of a live birth, has also come under scrutiny.95 In PGT-A, embryos are screened for chromosomal abnormalities, which tend to be linked with increased maternal age.96 A 2016 report observed, ‘PGS is being increasingly used on the premise of improving PRs [pregnancy rates] in women of advanced maternal age and those with repeated implantation failure or miscarriage’ even as its ‘overall clinical role … remains largely unknown with few randomized trials having been reported in a fertility clinic setting’.97 Some embryos, for example, may be ‘mosaic’, meaning that not all their cells are genetically identical. The biopsied cells thus may not be representative of the embryo as a whole, leading to the risk of both false-­ positive—in effect, risking the non-implantation of suitable embryos—and false-negative results.98 One leading provider estimated that people using PGT-A ‘could lose between 20 and 30% [of embryos] which might otherwise have implanted’, decreasing the cumulative pregnancy rate.99 The European Society for Human Reproduction and Embryology (ESHRE), along with the American Society for Reproductive Medicine (ASRM), has urged caution in the use of PGT-A, suggesting that the ‘benefits are being exaggerated and the costs underestimated by those

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promoting aneuploidy testing to clinics and patients’.100 The Victorian Assisted Reproductive Treatment Authority (VARTA) highlights the difficulties of establishing effectiveness: It is hard to determine if IVF with PGT-A improves success rates. This is because different studies use different methods, different aged women and different definitions of ‘success’. For example, some studies define success as successful implantation of an embryo in the uterus, while others define it as a live birth per cycle or a live birth per transferred embryo.101

As is the case with many AR adjuvants, the value of PGT-A can depend on the specific clinical profile of the woman, and on whether the procedure itself provides an accurate diagnosis. Corporatisation, in which AR conglomerates in some cases provide clinics with key performance indicators (KPIs), on measures such as number of cycles and profit per cycle, has posed challenges to providers focused more on overall alleviation of infertility, in which AR might be one option.102 One senior clinician has rebuked colleagues for trying to ‘differentiate themselves from other doctors’, referring to them as ‘snake oil salesmen’, but adding that, in his view, ‘unfortunately the patients are the ones who are pushing for it’.103 Australian treatment provider Rob Norman has argued that the use of add-ons, or potentially the need for AR at all, could be mitigated by greater recognition ‘that the environment around us and our personal habits, including pesticides, smoking, alcohol, weight, stress, caffeine and many other substances impact significantly on the way that human reproduction succeeds or fails’.104 Norman maintains that many patients may become pregnant without recourse to AR, while some prospective parents achieve pregnancy spontaneously after having undergone unsuccessful treatment.105 Given that some AR professionals dispute the clinical merits and the ethics of different interventions, divergent views from credentialed providers can make well-informed decision-making difficult. However, a study undertaken at the University of Oxford, commissioned by the BBC and published in the British Medical Journal, showed that most add-ons lacked any benefit for the patient.106 As a result, the UK’s HFEA publishes information about add-ons on its website, including a system

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rating individual practices. It has also announced it will release clear rules in this area. Meanwhile the President of the International Federation of Fertility Societies (IFFS), Richard Kennedy, has called for a reduction in their use.107 The dynamics between patient demand, technical innovation and clinical ambition or restraint have been central to the history of AR. Sarah Franklin sums up the story in the following terms: the emergence of IVF can be analyzed as a continuous but dialectical history of biotechnical innovation that derives from deliberate human intentions, and responds to specific desires and hopes, while simultaneously transforming the terms through which new aspirations are imagined, and changing the meaning of the biological connections such interventions are aimed to make, alter, or improve.108

Franklin situates this conclusion within the wider story AR—its involvement in the process of reinventing infertility itself, as a consequence of the interaction of individuals with the innovations offered by the  AR industry, shaped also by the dynamics of regulation and its associated debates over the nature of family and who has the right to parent.

When to Stop? In Australia in 1983, when Louis Waller was conducting interviews with Melbourne’s fertility treatment providers about a new oocyte donation program, he raised with them the broader question of how to deal with the reality that not all fertility treatments can succeed and that, for many, a process that was intended to overcome the inability to conceive a child will end with no baby being born. He expressed the question delicately: What I was trying ultimately to get at, but it’s probably too speculative and not worth pursuing, is whether you have, even at this stage, any strategy for dealing with what I might call final disappointments?109

In response,  Carl Wood advised the committee that they would be likely to limit donation cycles to six, then ‘drop them out and give

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someone else a chance’ with the help of general practitioners ‘to counsel people out of therapy’.110 Ian Johnston of Melbourne’s Royal Women’s Hospital referred to his team’s awareness of the potential damage of openended fertility treatment, reflecting, ‘if you go on and on and on and on and on, we think that is psychologically bad for the patient because it is holding some sort of carrot in front of them with very little chance of success’.111 More than thirty years later, Alan Trounson commented: If they’re continuing just to treat you and treat you and treat you until you give up: um, that seems really hard and unreasonable. And I think it’s unfair. You know, I think it’s really tough on, on, particularly on the women who are doing this: very, very tough.112

As one client expressed it, ‘One of the hardest things is knowing when to get off the bus, like knowing when to stop’.113 The name of a recent online film, One More Shot, encapsulates this sense of irresolution in infertility issues, when the technology appears to offer the potential for the birth of a child.114 For all its promised and achieved successes, AR is a last resort that, instead of a narrative of closure, may produce only the jagged edge of loss. Franklin comments on this ability of AR to fulfil hopes or to intensify sorrow; its paradoxical capacity to take ‘away something you did not even realize you could lose, which is … the prospect of closure to the pain of infertility’ when treatment has led not to the imagined outcome. What Waller called ‘final disappointment’ is something for which, Franklin suggests, ‘it is impossible to be prepared’.115

Conclusion Assisted reproduction is in some way creating the means for individuals, couples and groups of many kinds to be the human bridge between past and future, to be part of a story they see as theirs, whether of a particular social group, a particular gender, or of their immediate forebears. Several scholars alongside Franklin, notably Marcia Inhorn, Catherine Waldby and Charis Thompson, have shown that identity and the integration of

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personality and sense of place in the world are created through such stories.116 Paradoxical as it seems, with new products come new feelings. The emotion that attempts to contain emotion relies on a capacity to find new stories of one’s life externally, doors to which, also paradoxically, AR can at once open and close. For the infertile, the transactional nature of AR always renders reproduction ‘public property’ to some extent. Facilitated by media discussions of fertility, AR is capable of eliciting expectations and a sense of opportunity, but also of making intending parents vulnerable not only to clinical uncertainty, but to the vicissitudes of the politics that has accompanied this history from the beginning. As the controversy over the definition of infertility, with which this chapter began, has shown, even at the highest level of expertise and governance, the meanings of fertility and infertility are open to debate. This has consequences for those whose status can shift from one side to the other of the line that defines social legitimacy.117 Categories of inclusion and exclusion affect lives and identities, and can be drawn into public judgements of life choices and opportunities. The existence and promise of AR might have led to an intensification of the experience of heterosexual infertility in people of conventional reproductive age, which might not have attended on the experience of infertility in the past. The advent of new technology has created a social space in which infertility is being perceived anew, prioritised differently, generating new emotions in social groups: men, gays and singles, and older women. This opportunity to respond to long-endured social stigma might also be at once a burden and a benefit. Each new or evolving technique has both absorbed and reflected back, often in a new light, the ‘reproscape’ around it. Assisted reproduction has paradoxically heightened awareness of genetic ties at the same time as side-lining them: people look to ICSI, for example, to ensure that the social father is the biological father, in the interests of family and lineage, while elsewhere the quest for donor ova asks both provider and client to set aside genetics, in the interests of creating social parenthood. For individuals, the experience of infertility can become caught in a feedback loop via the fertility industry itself. The European Society for Human Reproduction and Embryology’s upbeat motto, ‘Science moving people moving science’, encapsulates some of this flow between market and

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laboratory, as well as patient and market.118 At the nucleus of AR are those who have committed to involvement in the process for reasons they might deem highly personal and private, but whose experiences are shaped by and within the clinical, commercial, regulatory and scientific engines of the reproductive industry.

Notes 1. Rebecca Perring, ‘Failure to Find a Sexual Partner Is Now a DISABILITY Says World Health Organisation’, Express (UK), 24 October 2016, https://www.express.co.uk 2. Henry Bodkin, ‘Single Men Will Get the Right to Start a Family under New Definition of Infertility’, Telegraph (London), 20 October, 2016, https://www.telegraph.co.uk. News service AFP followed up the story three years later with a Fact Check, finding that the WHO had not changed its definition, something the organisation had also asserted at the time. What was new was the definition in the International Committee for Monitoring Assisted Reproductive Technology (ICMART) glossary. See note 4. Mary Kulundu, ‘No, Being Unable to Find a Sexual Partner Will Not Make You “Disabled” under New World Health Organization Guidelines’, AFP Factcheck, 12 July, 2019, https://factcheck.afp.com. The discussions seem to reflect some of the variants in global conversations around homophobia and conventional gender roles that have also arisen in relation to cross-border surrogacy laws in several countries. See Chap. 5. Anna Louie Sussman, ‘The Case for Redefining Infertility’, New Yorker, 18 June, 2019, https://www. newyorker.com. We thank Dr G.  David Adamson for drawing our attention to this article. 3. As at June 2020, the World Health Organization (WHO) website on infertility links through only to the 2009 glossary, of which the organisation was a co-author. https://www.who.int/reproductivehealth/publications/infertility/art_terminology2/en, accessed 15 June 2020. F.  Zegers-Hochschild, G.  D. Adamson, J. de Mouzon, O.  Ishihara, R. Mansour, K. Nygren, E. Sullivan, and S. van der Poel, ‘International Committee for Monitoring Assisted Reproductive Technology (ICMART) and the World Health Organization (WHO) Revised Glossary of ART Terminology, 2009’, Human Reproduction 24, no. 11

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(2009): 2683–87. Simultaneously published Fertility and Sterility 92, no. 5 (2009): 1520–24. 4. Fernando Zegers-Hochschild, G.  David Adamson, Silke Dyer, Catherine Racowsky, Jacques de Mouzon, Rebecca Sokol, Laura Rienzi, Arne Sunde, Lone Schmidt, Ian D.  Cooke, Joe Leigh Simpson, and Sheryl van der Poel, ‘The International Glossary on Infertility and Fertility Care, 2017’, Human Reproduction 32, no. 9 (2017): 1786–1801. Simultaneously published Fertility and Sterility 108 no. 3 (2017): 393–406. 5. Bodkin, ‘Single Men Will Get the Right to Start a Family’. 6. Marilyn Strathern, ‘Displacing Knowledge: Technology and the Consequences for Kinship’, in Conceiving the New World Order: The Global Politics of Reproduction, ed. Faye D. Ginsburg and Rayna Rapp (Berkeley: University of California Press, 1995), 346–63. 7. It was some years between the first IVF births and the permitted use of IVF for non-heterosexual couples. Irma van der Ploeg observes that the use of ‘the couple’ readily hides that most of the intrusive work is done on women’s bodies. Prosthetic Bodies: The Construction of the Fetus and the Couple as Patients in Reproductive Technologies (Dordrecht: Kluwer, 2001), 83, 87. 8. Sarah Franklin, Biological Relatives: IVF, Stem Cells, and the Future of Kinship (Durham, NC: Duke University Press, 2013), 9, 119, 128. 9. Marcin Smietana, ‘Procreative Consciousness in a Global Market: Gay Men’s Paths to Surrogacy in the USA’, Reproductive BioMedicine & Society Online 7 (2018): 101–11. 10. Strathern, ‘Displacing Knowledge’. 11. Michelle Taylor-Sands, Saviour Siblings: A Relational Approach to the Welfare of the Child in Selective Reproduction (Milton Park, Abingdon, UK: Routledge, 2013). 12. A search using newspapers.com website (7 July 2019) shows that for the periods between 1971–1975 and 1986–1990, mentions of ‘infertility’ increased from 7623 to 62,508; and of ‘in vitro fertilization’ from 100 to 19,283. Mentions of ‘fertility’ and ‘overpopulation’ decreased from 1228 to 492. 13. DOR is diminished ovarian reserve; AMH is anti-Müllerian hormone; FSH is follicle stimulating hormone; LH is luteinizing hormone; AFC is antral follicle count. Geoffrey Sher, ‘Routine Fertilization by

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Intracytoplasmic Sperm Injection (ICSI): An Argument in Favor’, Dr. Sher Blog, 26 May, 2016, https://drgeoffreysherivf.com 14. Sofia Gameiro and Amy Finnigan, ‘Long-Term Adjustment to Unmet Parenthood Goals Following ART: A Systematic Review and Meta-­ Analysis’, Human Reproduction Update 23, no. 3 (2017): 322–37, 323. See also Karen Throsby, When IVF Fails: Feminism, Infertility and the Negotiation of Normality (Houndmills: Palgrave Macmillan 2004) and Renate Klein, The Exploitation of a Desire: Women’s Experiences with In Vitro Fertilisation: An Exploratory Survey (Geelong: Women’s Studies Summer Institute, distributed by Deakin University Press, 1989). 15. Shaun D. Pattinson, ‘Current Legislation in Europe’, in The Regulation of Assisted Reproductive Technology, ed. Jennifer Gunning and Helen Szoke (Aldershot: Ashgate, 2003), 7–19, 15. 16. Agence France-Presse in Paris, ‘French MPs Approve IVF Draft Law for Single Women and Lesbians’, Guardian, 27 September, 2019, https:// www.theguardian.com; Anna Louie Sussman, ‘When the Government Seizes Your Embryos: In Poland, Single Women Who Have Frozen Embryos Are Now Barred from Accessing Them’, New Yorker, 22 October, 2019, https://www.newyorker.com; Times of Israel Staff, ‘Thousands to Join Day-Long Strike Sunday by LGBT Community Over Surrogacy Law’, Times of Israel, 21 July, 2018, https://www.timesofisrael.com. Legalising surrogacy in any form is not unproblematic, however, as discussed in Chap. 5. 17. TOI  Staff, ‘High Court Extends Surrogacy Rights to Gay Couples, Single Men’, Times of Israel, 27 February, 2020, https://www.timesofisrael.com 18. Parliament of Australia, Surrogacy Matters: Inquiry into the Regulatory and Legislative Aspects of International and Domestic Surrogacy Arrangements, report tabled 4 May 2016, submissions 97 (Rainbow Families NSW) and 98 (Gay Dads NSW), https://www.aph.gov.au/ Parliamentary_Business/Committees/House/Social_Policy_and_ Legal_Affairs/Inquiry_into_surrogacy/Submissions 19. Michiko Ishii, ‘Medically Assisted Reproduction and Family Law in Japan’, in Japanese Family Law in Comparative Perspective, ed. Harry N.  Scheiber and Laurent Mayali (Berkeley: Robbins Collection Publications, 2009), 175–201. 20. John Leeton, ‘The Early History of IVF in Australia and Its Contribution to the World (1970–1990)’, Australian and New Zealand Journal of Obstetrics and Gynaecology 44, no. 6 (2004): 495–501, 499.

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21. Vitrification is ‘the practice of freezing an egg or embryo with extremely rapid cooling  – so fast that ice crystals never form’. ‘What is Vitrification?’, Fertility Associates of Memphis, https://www.fertilitymemphis.com/vitrification 22. Christopher Chen, ‘Pregnancy after Human Oocyte Cryopreservation’, Lancet 327, no. 8486 (1986): 884–86; Catrin E.  Argyle, Joyce C. Harper, and Melanie C. Davies, ‘Oocyte Cryopreservation: Where Are We Now?’, Human Reproduction Update 22, no. 4 (2016): 440–49; Katie Howe, ‘Fresh Donor Eggs Better for IVF Than Frozen’, BioNews, no. 1035, 17 February, 2020, https://www.bionews.org.uk 23. Laura Briggs, How All Politics Became Reproductive Politics: From Welfare Reform to Foreclosure to Trump, Reproductive Justice: A New Vision for the 21st Century 2 (Oakland: University of California Press, 2018), 111. 24. ‘Here’s Why Private Equity Companies Are Buying Fertility Clinics’, Market Watch, posted 6 April, 2018, https://www.marketwatch.com/ video/sectorwatch; Jessica Bennett, ‘Company-Paid Egg Freezing Will Be the Great Equalizer’, Time, 15 October, 2014, http://time. com/3509930 25. Claudia Bozzaro, ‘Is Egg Freezing a Good Response to Socioeconomic and Cultural Factors That Lead Women to Postpone Motherhood?’, Reproductive BioMedicine Online 36, no. 5 (2018): 594–603; Christopher Mayes, Jane Williams, and Wendy Lipworth, ‘Conflicted Hope: Social Egg Freezing and Clinical Conflicts of Interest’, Health Sociology Review 27, no. 1 (2018): 45–59; Heidi Mertes, ‘Does Company-Sponsored Egg Freezing Promote or Confine Women’s Reproductive Autonomy?’, Journal of Assisted Reproduction and Genetics 32, no. 8 (2015): 1205–09; Emily Jackson, ‘The Ambiguities of “Social” Egg Freezing and the Challenges of Informed Consent’, BioSocieties 13, no. 1 (2018): 21–40; Françoise Baylis, ‘Left out in the Cold: Arguments against Non-Medical Oocyte Cryopreservation’, Journal of Obstetrics and Gynaecology Canada 37, no. 1 (2015): 64–67. 26. Kylie Baldwin, ‘Conceptualising Women’s Motivations for Social Egg Freezing and Experience of Reproductive Delay’, Sociology of Health & Illness 40, no. 5 (2018): 859–73; Catherine Waldby, ‘“Banking Time”: Egg Freezing and the Negotiation of Future Fertility’, Culture, Health & Sexuality 17, no. 4 (2015): 470–82; Kylie Baldwin, Lorraine Culley, Nicky Hudson, Helene Mitchell, and Stuart Lavery, ‘Oocyte Cryopreservation for Social Reasons: Demographic Profile and Disposal

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Intentions of UK Users’, Reproductive BioMedicine Online 31, no. 2 (2015): 239–45. See also Jamie Rickman, ‘Event Review: The Future of Female Fertility? Egg Freezing and Social Change’, BioNews, no. 895, 3 April, 2017, https://www.bionews.org.uk 27. M.  C. Inhorn, D.  Birenbaum-Carmeli, J.  Birger, L.  M. Westphal, J. Doyle, N. Gleicher, D. Meirow, M. Dirnfeld, D. Seidman, A. Kahane, and P.  Patrizio, ‘Elective Egg Freezing and Its Underlying Socio-­ Demography: A Binational Analysis with Global Implications’, Reproductive Biology and Endocrinology 16, no. 1 (2018): article 70. 28. Jessica Glenza, ‘Fertility and Canapés: Why Egg Freezing Parties Are a Hot Item on Wall St’, Guardian, 2 January, 2018, https://www.theguardian.com 29. Lisa Ferdinando, ‘Carter Announces 12  Weeks Paid Military Maternity Leave, Other Benefits’, DoD News, 28 January, 2016, https://www.defense.gov/Explore/News/Article/Article/645958; Michael S. Schmidt, ‘Pentagon to Offer Plan to Store Eggs and Sperm to Retain Young Troops’, New York Times, 3 February, 2016, https:// www.nytimes.com 30. Ephia Yasmin, Neerujah Balachandren, Melanie C. Davies, Georgina L.  Jones, Sheila Lane, Raj Mathur, Lisa Webber, and Richard A. Anderson, ‘Fertility Preservation for Medical Reasons in Girls and Women: British Fertility Society Policy and Practice Guideline’, Human Fertility 21, no. 1 (2018): 3–26, 16–17; Sabrina Barr, ‘Transgender Patients Should Have Their Eggs Frozen, Advises British Fertility Society’, Independent (UK), 4 January, 2018, https://www.independent.co.uk; Damien W.  Riggs, ‘An Examination of “Just in Case” Arguments as They Are Applied to Fertility Preservation for Transgender People’, in The Reproductive Industry: Intimate Experiences and Global Processes, ed. Vera Mackie, Nicola J. Marks, and Sarah Ferber (Lanham, MD: Lexington, 2019), 67–78. 31. Shireena Al Nowais, ‘Woman Permitted to Freeze Embryos in Major Changes to UAE Health Regulations’, The National (UAE), 22 May, 2018, https://www.thenational.ae/uae/ The criteria were expected to exclude younger single women in good health, however. 32. Marcia C. Inhorn, Daphna Birenbaum-Carmeli, Lynn M. Westphal, Joseph Doyle, Norbert Gleicher, Dror Meirow, Hila Raanani, Martha Dirnfeld, and Pasquale Patrizio, ‘Medical Egg Freezing: How Cost and

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Lack of Insurance Cover Impact Women and Their Families’, Reproductive BioMedicine & Society Online 5 (2018): 82–92. 33. Eleni A. Greenwood, Lauri A. Pasch, Jordan Hastie, Marcelle I. Cedars, and Heather G.  Huddleston, ‘To Freeze or Not to Freeze: Decision Regret and Satisfaction Following Elective Oocyte Cryopreservation’, Fertility and Sterility 109, no. 6 (2018): 1097–104, e1. 34. Greenwood et al., ‘To Freeze or Not to Freeze’, 1102. 35. Zeynep Gürtin, Venessa Smith, and Kamal Ahuja, ‘The Social Pioneers of Egg Freezing Are Facing Tough Choices’, BioNews, no. 960, 30 July, 2018, https://www.bionews.org.uk 36. Nicola McCaskill, ‘Meet the 61-Year-Old Who Gave Birth to Her Own Granddaughter’, Insight, SBS, 21 October, 2019, https://www. sbs.com.au/news/insight; Vera Mackie, ‘Science, Society and the Sea of Fertility: New Reproductive Technologies in Japanese Popular Culture’, Japan Forum 26, no. 4 (2014): 441–61, 455. Nikki Watkins and Michelle Morgan Davies, ‘“The Greatest Gift” My Mum, 55, Gave Birth to My Daughter Because I Can’t Have Kids’, Sun (UK), 28 March, 2019, https://www.thesun.co.uk; ‘61-Year-Old Gave Birth to Her Grandchild’, CBS News, 21 August, 2008, https://www. cbsnews.com 37. Ana Ilic, ‘German Grandmother, 65, Gives Birth to Quadruplets’, BioNews, no. 804, 1 June, 2015, https://www.bionews.org.uk; Patrick Sawer, Nikki Watkins, and Emma Ponsford, ‘Gran, 55, Gives Birth to Triplets, Smashing British Record … and Looks Her Best for Birth with Botox’, Sun (UK), 6 April, 2016, https://www.thesun.co.uk/ archives 38. ‘Indian “Is the World’s Oldest Mother”’, BBC News, 9 April, 2003, http://news.bbc.co.uk 39. Muneeza Naqvi, ‘The “Rogue Doctor” Using IVF to Bring Hope to Older Women in India’, Independent (UK), 25 May, 2017, https:// www.independent.co.uk 40. Pratul Sharma, ‘Cabinet Clears Assisted Reproductive Technology Bill’, The Week, 19 February, 2020, https://www.theweek.in/news/india 41. Caroline Davies, ‘Indian Woman in Her 70s Gives Birth to Healthy Baby Boy’, Guardian, 10 May, 2016, https://www.theguardian.com; Mary Ann Jolley and Liz Gooch, ‘Inside the World of India’s Booming Fertility Industry’, Al Jazeera, 5 September, 2016, https://www. aljazeera.com

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42. Referring to the research of Erasmus Darwin, Shelley wrote: ‘Perhaps a corpse would be reanimated; galvanism had given token of such things. Perhaps the component parts of a creature might be manufactured, brought together and endued with vital warmth’. Mary W. Shelley, Frankenstein (London: Colburn and Bentley, 1831), x. 43. Sara E. Barton, Katharine F. Correia, Shirley Shalev, Stacey A. Missmer, Lisa Soleymani Lehmann, Divya K. Shah, and Elizabeth S. Ginsburg, ‘Population-Based Study of Attitudes toward Posthumous Reproduction’, Fertility and Sterility 98, no. 3 (2012): 735–40. 44. AAP, ‘Widow Wins Right to Use Dead Husband’s Frozen Sperm’, Sydney Morning Herald, 23 May, 2011, https://www.smh.com.au 45. Ashleigh Stevenson and Laura Gartry, ‘Toowoomba Woman Wins Court Bid to Use Her Dead Boyfriend’s Sperm to Have a Baby’, ABC News, 20 June, 2018, http://www.abc.net.au/news 46. Garrett Mundy, ‘Perth Woman Wins Right to Take Dead Partner’s Frozen Sperm to ACT in Bid to Have His Child’, ABC News, 20 March, 2018, http://www.abc.net.au/news 47. Elodie Pajot, María Teresa Muñoz Sastre, and Etienne Mullett, ‘Mapping French People’s Views Regarding Posthumous Reproduction’, Journal of Reproductive and Infant Psychology 35, no. 5 (2017): 524–37. See list of countries at: Jenny Morber, ‘Dead Man’s Sperm’, New Republic, 26 April, 2016, https://newrepublic.com 48. AFP, ‘Spanish Widow Wins Right to Use Dead Husband’s Sperm’, The Local, 1 June, 2016, https://www.thelocal.es; Beatrice Credi, ‘French Judges Authorise Use of Dead Husband’s Sperm for IVF’, West, 1 June 2016, https://www.west-info.eu 49. Mayumi Mayeda, ‘Present State of Reproductive Medicine in Japan— Ethical Issues with a Focus on Those Seen in Court Cases’, BMC Medical Ethics 7 (2006): article 3. See also Ishii, ‘Medically Assisted Reproduction and Family Law in Japan’; Vera Mackie, ‘Family Law and Its Others’, in Scheiber and Mayali, Japanese Family Law, 139–64. 50. Ishii, ‘Medically Assisted Reproduction’, 194–96; Vera Mackie, ‘Birth Registration and the Right to Have Rights: The Changing Family and the Unchanging Koseki’, in Japan’s Household Registration System and Citizenship: Koseki, Identification and Documentation, ed. David Chapman and Karl J.  Krogness (London: Routledge, 2014), 203–20, 211–12.

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51. ‘Baby Born 4 Years after His Parents’ Death in Road Accident in China’, Straits Times, 11 April, 2018, https://www.straitstimes.com/asia/ east-asia 52. ‘Pune Woman Becomes Grandmother with Dead Son’s Preserved Semen’, The Hindu, 15 February, 2018, https://www.thehindu.com/ sci-tech/health 53. Antony Starza-Allan, ‘Court Rules Israeli Parents Cannot Use Dead Son’s Sperm’, BioNews, no. 857, 6 February, 2017, https://www. bionews.org.uk 54. Ayesha Ahmad, ‘Landmark Case Allows Israeli Family to Freeze Their Dead Daughter’s Eggs’, BioNews, no. 620, 15 August, 2011, https:// www.bionews.org.uk 55. Antony Starza-Allan, ‘Woman Wins Daughter’s Frozen Eggs Appeal’, BioNews, no. 858, 4 July, 2016, https://www.bionews.org.uk. See also R (on the application of Mr. and Mrs. M.) v Human Fertilisation and Embryology Authority [2016] EWCA Civ 611, 25 May, 2016, http:// www.bailii.org/ew/cases/EWCA/Civ/2016/611.html; Antony Starza-­ Allan, ‘HFEA Allows Mother to Export Dead Daughter’s Eggs’, BioNews, no. 869, 19 September, 2016, https://www.bionews.org.uk 56. AAP-Reuters, ‘Test Tube Baby Doctors Plan Clinic’, Sydney Morning Herald, 17 January, 1979. 57. ESHRE, ‘ART Fact Sheet’ 2020, https://www.eshre.eu/Press-Room/ Resources; Amy Packham, ‘Male Infertility Most Common Reason for IVF Treatment, UK Audit Reveals’, Huffington Post UK, 14 March, 2018, https://www.huffingtonpost.co.uk. See also Naina Kumar and Amit Kant Singh, ‘Trends of Male Factor Infertility, an Important Cause of Infertility: A Review of Literature’, Journal of Human Reproductive Sciences 8, no. 4 (2015): 191–96, 191; Ashok Agarwal, Aditi Mulgund, Alaa Hamada, and Michelle Renee Chyatte, ‘A Unique View on Male Infertility around the Globe’, Reproductive Biology and Endocrinology 13, no. 1 (2015): article 37; Santiago Brugo-Olmedo, Claudio Chillik, and Susana Kopelman, ‘Definition and Causes of Infertility’, Reproductive BioMedicine Online 2, no. 1 (2001): 173–85. 58. Jan Raath, ‘First Test-Tube Pregnancy Under Way in Black Africa’, Times (London), 23 October, 1987. 59. See also Lorraine Culley, Nicky Hudson, and Maria Lohan, ‘Where Are All the Men? The Marginalization of Men in Social Scientific Research on Infertility’, Reproductive BioMedicine Online 27 (2013): 225–35;

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Practices Challenged: A Response’, BioNews, no. 880, 5 December, 2016, https://www.bionews.org.uk 88. Laura Stott, ‘When Is It Too Late for You to Have a Baby?’, Sun (UK), 25 February, 2014, https://www.thesun.co.uk/archives 89. Aria Pearson, ‘Youthful Infertility Balanced by Late-Blooming Ovaries’, New Scientist, 25 February, 2009, https://www.newscientist.com 90. Ashley Moffett and Norman Shreeve, ‘First Do No Harm: Uterine Natural Killer (NK) Cells in Assisted Reproduction’, Human Reproduction 30, no. 7 (2015): 1519–25; Annabel Kemp and Tarek El-Toukhy, ‘A Narrative Review of Adjuvants in In Vitro Fertilisation: Evidence for Good Clinical Practice’, Journal of Obstetrics and Gynaecology 40, no. 3 (2020): 295–302. 91. Moffett and Shreeve, ‘First Do No Harm’; Ashley Moffett and Norman Shreeve, ‘Reply: First Do No Harm: Continuing the Uterine NK Cell Debate’, Human Reproduction 31, no. 1 (2016): 218–19. 92. Gavin Sacks, ‘Enough! Stop the Arguments and Get On with the Science of Natural Killer Cell Testing’, Human Reproduction 30, no. 7 (2015): 1526–31, 1529. 93. Moffett and Shreeve, ‘Reply: First Do No Harm’, 219. 94. Balen, ‘IVF Practices Challenged: A Response’. 95. Norbert Gleicher and Raoul Orvieto, ‘Is the Hypothesis of Preimplantation Genetic Screening (PGS) Still Supportable? A Review’, Journal of Ovarian Research 10, no. 1 (2017): 21. 96. Victorian Assisted Reproductive Treatment Authority (VARTA), ‘The Pros and Cons of Pre-Implantation Genetic Testing for Aneuploidy (PGT-A)’, 2019, https://www.varta.org.au/resources/publications 97. S. Dyer, G. M. Chambers, J. De Mouzon, K. G. Nygren, F. Zegers-­ Hochschild, R. Mansour, O. Ishihara, M. Banker, and G. D. Adamson, ‘International Committee for Monitoring Assisted Reproductive Technologies. World Report on Assisted Reproductive Technologies: 2008, 2009 and 2010’, Human Reproduction 31, no. 7 (2016): 1588–1609, 1607. 98. Gleicher and Orvieto, ‘Is the Hypothesis of Preimplantation Genetic Screening (PGS) Still Supportable?’; Susan M.  Maxwell and James A.  Grifo, ‘Should Every Embryo Undergo Preimplantation Genetic Testing for Aneuploidy? A Review of the Modern Approach to In Vitro Fertilization’, Best Practice & Research Clinical Obstetrics & Gynaecology 53 (2018): 38–47.

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99. ESHRE, ‘Vienna Annual Meeting: Still a Gap between Hype and Science in PGT-A’, Focus on Reproduction, 26 June, 2019, https:// www.focusonreproduction.eu/article/ESHRE-Meetings-PGTA19 100. ESHRE, ‘Vienna Annual Meeting: Still a Gap between Hype and Science in PGT-A’. 101. VARTA, Understanding the Genetic Health of Embryos: Preimplantation Genetic Testing for Aneuploidy, May 2018, https:// www.varta.org.au/resources/publications, 6. 102. ‘Baby Business’, ABC Four Corners, 30 May, 2016, https://www.abc. net.au/4corners/the-baby-business-promo/7449646. The speaker was leading AR figure Gabor Kovacs. 103. ‘Baby Business’, ABC Four Corners, 30 May, 2016. 104. ‘Endorsement of the REACT-ANZ Group by Professor Rob Norman’, https://www.fertilitysociety.com.au/home/special-interest-groups/ react-anz. Accessed 5 Nov. 2017. 105. ‘IVF Doctors Misleading Women about Success Rates, Industry Experts Say’, ABC News, 30 May, 2016, https://www.abc.net.au; Adam P. Marcus, Diana M. Marcus, Salma Ayis, Antoinette Johnson, and Samuel F.  Marcus, ‘Spontaneous Pregnancies Following Discontinuation of IVF/ICSI Treatment: An Internet-Based Survey, Human Fertility 19, no. 2 (2016): 134–41. 106. Spencer, et  al., ‘Claims for Fertility Interventions’; Kemp and El-Toukhy, ‘A Narrative Review of Adjuvants in In Vitro Fertilisation’. 107. ‘Treatment Add Ons’, Human Fertilisation and Embryology Authority, https://www.hfea.gov.uk; Hannah Devlin and Ian Sample, ‘UK Fertility Regulator to Issue New Rules on Expensive IVF Add-Ons’, Guardian, 9 July, 2018, https://www.theguardian.com; Richard Kennedy, ‘Back to Basics: Improve Access to Fertility Care by Subtracting the “AddOns”’, BioNews, no. 942, 19 March, 2018, https://www.bionews.org.uk 108. Franklin, Biological Relatives, 35. 109. Carl Wood, Interview with Waller Committee 15 June 1983, in ‘Folder of Minutes of the Inaugural Meeting (25 May 1982) to the Minutes of the 47th Meeting (9 August 1984) of the Committee to Examine In Vitro Fertilisation’, VARTA Collection, Melbourne, Folder 22, 6. 110. Wood, Interview with Waller Committee 15 June 1983. 111. Ian Johnston, Interview with Waller Committee 15 June 1983, in ‘Folder of Minutes of the Inaugural Meeting (25 May 1982) to the Minutes of the 47th Meeting (9 August 1984) of the Committee to

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Examine In Vitro Fertilisation’, VARTA Collection, Melbourne, Folder 22, 4. Johnston was in this instance referring to continuing with donor insemination beyond twelve attempts. 112. ‘Baby Business’, ABC Four Corners, 30 May 2016. 113. ‘Baby Business’, ABC Four Corners, 30 May 2016. 114. One More Shot: A Film about Making Modern Families, directed by Noah Moskin (2017, Distribber, http://www.onemoreshotfilm.com) 115. Franklin, Biological Relatives, 218–19. See also Robyn Morris, ‘IVF and the “Promise of Happiness”’, in Mackie, Marks, and Ferber, The Reproductive Industry: Intimate Experiences and Global Processes, 97–108. 116. Catherine Waldby, The Oocyte Economy: The Changing Meaning of Human Eggs (Durham, NC: Duke University Press, 2019); Charis Thompson, Making Parents: The Ontological Choreography of Reproductive Technologies (Cambridge, MA: MIT Press, 2005). 117. In 2013 the Ethics Committee of the American Society for Reproductive Medicine argued that fertility treatment should not be restricted to married heterosexual couples. Ethics Committee of the American Society for Reproductive Medicine, ‘Access to Fertility Treatment by Gays, Lesbians, and Unmarried Persons: A Committee Opinion’, Fertility and Sterility 100, no. 6 (2013): 1524–27. 118. ESHRE, Focus on Reproduction, January, 2018. https://www.eshre.eu/ Publications

7 Thresholds of the Future: New Directions in Assisted Reproduction

Early in the twentieth century, scientists were developing new reproductive possibilities in the laboratory, and in their writing they contributed to a process of reflection on the possible social consequences of this work. Over the last forty years, the science of assisted reproduction (AR) has been neither unerring in its changes nor undeterred; the medicine has been contentious; and the politics has by turns reflected, entrenched and defied former political alliances and ways of thinking. Some developments have been anticipated, others not. The social prophesy that accompanied the development of AR has been a logical consequence of the fact that the subject is how the human race is able to reproduce itself, singly and collectively, and the implications of these techniques and practices for labour, gender relations, sexuality and human identity. In 1981, a prominent Australian IVF clinician, William Walters, predicted a range of research directions for AR, and noted potential issues associated with them. He observed, for example, that sending human IVF embryos into space to populate new human colonies would be a future possibility. He noted that the British were already planning to send mammalian embryos into space, to test their ability to survive there. The prospect of ‘humans crossed with animals’ © The Author(s) 2020 S. Ferber et al., IVF and Assisted Reproduction, https://doi.org/10.1007/978-981-15-7895-3_7

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reportedly horrified him, but was nonetheless potentially only a few decades away. He argued that genetic engineering to control hereditary diseases, through embryo manipulation, posed ‘problems, benefits and disadvantages’. Of ‘ectogenesis’, the complete process of fertilization, gestation and birth outside the human body, Walters remarked that neonatal care of premature babies already used a kind of artificial womb. Embryos could, in his estimation, ‘be reared artificially in a nursery, although this would create ethical difficulties’. Walters was keenly aware that several of these themes recalled Aldous Huxley’s Brave New World (1932), and he remarked: ‘I am not trying to inject sensationalism. … I am trying to state what is already being stated by the science fiction writers. These people are often prophetic’.1 Fast forward to 2020 and many of Walters’ projections are edging towards reality. A group of Chinese researchers has sent 6000 mouse embryos into space, with colonisation of the moon one of the project’s explicit long-term rationales.2 NASA has sent human sperm into space, to explore ‘the potential viability of reproduction in reduced-gravity conditions’.3 In a report on Japanese research using mouse embryos, NASA’s website poses coyly the time-honoured question ‘Where do babies come from?’ and answers: ‘Soon, they may be coming from space!’ The researchers’ report states in more detail the goal of the project, including ‘ultimately to attempt to produce live offspring under space conditions’.4 Contrastingly, the birth of offspring resulting from mixing human and animal gametes, so-called cross-species fertilisation, has not occurred and seems unlikely to, for social, cultural, as well as biological reasons.5 However, embryos with genetic material from humans and other animals can be created using human embryonic stem cell technologies; this research explores early human development, along with the ways that organs generate and develop in the body, with the ultimate goal of producing organs for transplantation into humans. In 2017, a team from the United States, Spain and Japan injected human stem cells into early-stage animal embryos, the human cells then contributing (inefficiently) to the further development of these embryos in pigs.6 Team leader J. C. Izpisua Belmonte reported injecting human stem cells into monkey embryos in

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2019.7 Scientists and clinicians are genetically modifying embryos in a number of ways, including to remove disease traits, whilst moving towards replication of more steps of human reproduction outside the body. These steps include the creation and development of human egg and sperm outside the body, and the growth of human and animal foetuses to full term. The generation of ever more intricate understandings of gametes and embryos and expanded applications in new environments is occurring in the context of both current science and new market directions for AR. This final chapter identifies some key areas of reproductive technology on the horizon, commencing with some contemporary aspects of the transition from embryo selection to embryo design in the form of gene ‘editing’, and mitochondrial donation or so-called ‘three-parent’ embryos. It outlines recent research that may have the potential to lead to full reproduction outside the body, beginning with laboratory-created gametes and embryos (including from same-sex gametes) and ending with the possibility of artificial wombs. Each of these techniques would open up new niche patient markets and could obviate current aspects of the AR industry. This closing chapter then turns to the broadening of AR global markets through plans for new low-cost forms of IVF, as well as expanded government support for higher levels of genetic testing of couples prior to conception, guiding them subsequently towards IVF with genetic testing and selection of embryos. It concludes by summarising some key themes from early fictional accounts that are finding their way into reality, and with some brief reflections on the story of AR told in this book.

From Embryo Selection to Embryo Design In February 2020, the Union Cabinet of India approved the Assisted Reproductive Technology Regulation Bill, the stated aim of which is to bring AR under tighter ethical control. The bill makes the testing of pre-­ implantation embryos for genetic disease ‘mandatory’ in a bid to ‘avoid any genetic disease’.8 Although compulsion is new, the idea of embryo testing and selection being part of IVF is not. Robert Edwards imagined

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the benefits that could come from being able to select embryos on the basis of their genetic profile. French researcher Jacques Testart, active at the same time as Edwards, feared the eugenic consequences of this work, ultimately leaving the field.9 Their stories are emblematic of the mixed views, even within science, to which AR has given rise. Research into changing the constitution of the human embryo prior to implantation during an AR process, rather than excluding embryos on the basis of their genetic or chromosomal makeup, is one of the key and most controversial areas of current laboratory research.

Gene ‘Editing’ Altering the genetic profile of embryos before their insertion in the uterus of a woman to bring to term has long been on the horizon for AR. Today, science and medical practitioners select embryos as part of IVF, and some have started editing them to remove disease traits. Such work introduces changes to the genes not only of the child who is born, potentially with unpredictable outcomes, but of any future offspring who inherit the modifications. Altering human embryos is controversial even among scientists, many believing that ‘rigorous public and scientific oversight of these technologies is vital to ensure that scientific advances are tempered with the best interests of society in mind’.10 Nonetheless, the ability to ‘edit’ embryos is a key plank of current AR research, in particular using the technique known as CRISPR-Cas9, a novel system that enables targeted changes in the DNA of organisms. The first report of human embryo editing in China in 2015 was hailed as a breakthrough, but also criticised. The scientists responsible highlighted the difficulties in using CRISPR-Cas9  in live organisms, stating that it was not yet ready for clinical use.11 However, in a heavily populated research field, competition is strong: for some practitioners, taking risks can seem worthwhile. Events surrounding the experiments of He Jiankui are a case in point. In November 2018, Professor He of the Southern University of Science and Technology in Shenzhen announced that he had used CRISPR-Cas9 to edit the DNA of embryos, with the intention of endowing them with HIV resistance. The embryos were implanted, resulting in the birth of

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twin girls. He, a biologist, faced strong criticism in the People’s Republic of China and elsewhere, but defended his actions.12 He then disappeared from public view, being kept ‘under guard’ in his university home, while his work was scrutinised by authorities.13 In December 2019, a Shenzhen court found He and two colleagues guilty of ‘illegal medical practices’, imposed heavy fines and sentenced each of them to gaol terms, the longest being He’s sentence of three years.14 In March 2019, an international group, including scientists, ethicists and a health-consumer advocacy leader, had written a commentary in the journal Nature that urged both a moratorium on gene editing of human embryos intended for implantation and the creation of a global regulatory structure to protect the credibility of the research.15 Endorsing this restraint, Alan Trounson observed that these recent  events had strong echoes of the early years of IVF, with public controversy about the ethics of what treatments to undertake and when.16 Concerns remain over editing efficiency, unintended modifications to the DNA, mosaicism (where some but not all cells of the embryo are edited) and lack of adequate regulatory oversight for heritable genetic modifications. Nonetheless, some in the research community are charting paths for the safer development of these technologies.17

‘Three-Parent’ Embryos or Mitochondrial Donation Mitochondrial donation, which also involves heritable genetic changes, remains a somewhat controversial area of contemporary AR. In 2016, a team led by John Zhang in New York City announced that a ‘three-­ parent’ baby had been born to a Jordanian couple in Mexico. The child inherited most of his genetic material from his social and genetic father and from his social, genetic and birth mother—who had previously lost four pregnancies and two children—but also inherited a small amount of DNA from a female gamete provider. The children who had died were diagnosed with a neurological condition known as Leigh syndrome, which typically will end the life of a child in their first two or three years. Some of the genes that can cause Leigh syndrome are found in mitochondrial DNA.18

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Mitochondria are small organelles present in the cytoplasm of all cells of the body, and in oocytes, though not in sperm cells. They encode DNA for proteins that provide energy to the cell, the rest of the DNA required to build a whole person being contained in the cell’s nucleus.19 These mitochondria are passed on to children through the mother’s oocyte. The aim of creating embryos through mitochondrial donation, colloquially known as ‘three-parent’ embryos, is to replace diseased mitochondria—those encoding for abnormal proteins—with those of a donor. Zhang had previously attempted the procedure in China using ‘pronuclear transfer’, a technique that involves fertilising the donor egg before transfer, then removing the nuclear  DNA post-fertilisation. After five embryos had been implanted into the patient, a triplet pregnancy ensued, but no live births.20 The technique used for the successful birth was ‘oocyte spindle transfer’ or ‘spindle nuclear transfer’, which involves removing the oocyte nuclear DNA of the woman who has the mitochondrial disease leaving behind the egg cytoplasm where the diseased mitochondria are. This nuclear DNA is then placed in a donor egg from which the nuclear DNA has been removed, but which retains its mitochondrial DNA. The combined egg can then be fertilised by the sperm of the (social and genetic) father.21 Mitochondrial donation is not without limitations. Because some of the mother’s mitochondria were transferred at the same time as her nuclear DNA, it is unclear whether the baby boy will be free of Leigh syndrome. In addition, the interaction between nuclear and mitochondrial DNA is still poorly understood, and in vitro experiments suggest that, as cells divide, donor mitochondria tend to be lost.22 Zhang  also conducted the actual transfer in Mexico, as the procedure was not allowed in the United States where the work had begun. The editors of the journal in which the research was published highlighted this, as well as limitations in the informed consent procedures, as issues that would need to be overcome in future; similar to gene editing, some doctors have also called for better regulation of the process internationally.23 Mitochondrial DNA donation might not be the only potential response to diseases like Leigh syndrome, if DNA editing techniques improve.24 And as is the case for most AR techniques, mitochondrial

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DNA donation might have potential for other patient groups. In 2017, Zhang established a company called Darwin Life that would offer mitochondrial transfer to older women wishing to have genetically related children with a donor enucleated egg.25 The argument is that older women would be able to combine their own nuclear DNA with the younger mitochondria of the enucleated donor egg, the resulting egg in some ways being younger and healthier. This in turn would make it more likely to produce a live birth, although this has yet to be demonstrated. In 2019, a trial began to investigate the use of spindle nuclear transfer to improve fertility for women who have had unsuccessful IVF.26 DNA editing and spindle nuclear transfer are quite distant from what is now called ‘traditional IVF’ but they rely on many protocols developed for it, such as the retrieval of oocytes from females after superovulation using gonadotrophins.

Reproduction Beyond the Body Scientists and fiction writers have been preoccupied with ectogenesis since long before the birth of the first IVF babies. Speculative fiction has never been far from the realm of scientific work itself, as science relies in part on the power of the imagination to generate innovation, and prediction has also always been possible from within the realm of science itself. Scientist J. B. S. Haldane speculated in 1923 that ovarian tissue could be used to create eggs.27 In 1932 Brave New World depicted a society in which children are gestated in hatcheries. The potential to relocate the human reproductive process in its entirety to places outside the human body has enabled feminist writers to speculate on the potential impact of such a development on the status of women. Some forty years after Huxley, Shulamith Firestone in The Dialectic of Sex (1970) and Marge Piercy in Woman on the Edge of Time (1976) re-imagined extra-­ corporeal gestation in radically re-organised societies as a way of ending inequalities between men and women. Women would no longer have to bear the cost of biological reproduction, nor would they hold the female-­ specific power of giving birth.28 Today, more and more steps of

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reproduction, from the creation of eggs and sperm through to gestation, are becoming possible in the laboratory. This new research has diverse implications for the place of different women, and men, within the current reproductive marketplace.

Laboratory-Made Gametes The use of pluripotent stem cells—cells that in theory have the potential to turn into any kinds of cells of the body—is a cornerstone of recent work on the creation of gametes and embryos in the laboratory. Pluripotent stem cells can be created by removing the ‘inner cell mass’ from embryos and turning it into ‘embryonic stem cells’. Pluripotent stem cells can also be created from specialised cells (such as skin cells) that are manipulated into having similar characteristics to embryonic stem cells; these are called ‘induced pluripotent stem cells’.29 Scientists use these pluripotent stem cells in research aimed at better understanding the processes of cell specialisation, along with organ and whole body development. Research teams from a number of regions around the world are on the path to creating versions of oocytes and sperm in the laboratory, either from pluripotent stem cells or from gamete precursor cells (such as those found in ovarian tissue). To date, researchers have reported the creation of gametes in mice. In 2016, a team from China produced functional sperm-like cells from embryonic stem cells that were capable of undergoing meiosis.30 Meiosis is a complex biological process whereby sperm (or egg) precursor cells, which contain two full sets of chromosomes—one set from each biological parent—divide into germ cells (gametes) with only one set of chromosomes.31 The sperm-like cells were capable of giving rise to fertile offspring after intra-cytoplasmic sperm injection (ICSI). Similar results have been harder to achieve in humans: researchers have grown sperm from testicular tissue in the laboratory, but are yet to encounter success with pluripotent stem cell-derived sperm.32 Scientists have enabled the growth and maturation of oocyte precursor cells into functioning oocytes in a completely in vitro system.33 Also in 2016, a team from Japan reported the creation of mature mice oocytes from

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embryonic stem cells and from induced pluripotent stem cells. They claim to have reproduced, in vitro, ‘the entire cycle of the mouse female germ line’.34 Some of the same team produced oocyte precursor cells from induced pluripotent stem cells in 2018.35 To date, there have not been published reports of pluripotent stem cell-derived functional oocytes in humans, and a number of barriers remain.36 In vitro gametogenesis (IVG, the creation of gametes) using pluripotent stem cells could, according to Alan Trounson, be used for patients who, for some reason, are unable to provide gametes as part of an AR treatment.37 It could reduce AR’s reliance on egg providers, in particular. Some scientists are calling for more public discussion in this area, ‘with an eye toward minimizing potential untoward post hoc regulatory or statutory impositions’. They suggest, for instance, that IVG could raise concerns about one member of a same-sex couple creating gametes (of the opposite sex) from their skin cells, in order to give rise to embryos genetically related to both parents. IVG could also enable post-menopausal women to generate new oocytes. This type of research is, however, a long way from having direct clinical applications for people who cannot produce their own gametes, or who might want to produce gametes of the opposite sex. At present, it is still at the stage of shining a light on the complex processes that underpin the creation of functional eggs and sperm, processes that can be explored through the creation of embryos from two oocytes, or two sperm.38

Same-Sex Laboratory Reproduction In October 2018, news reports appeared with headlines such as ‘Same-­ Sex Mouse Parents Give Birth via Gene Editing’, ‘Scientists Use Stem Cells and Gene Editing to Make Mice with Two Mums’ and ‘Male Obsolescence Approaches as Mice with Two Mums Are Created in China’.39 These rather sensational claims refer to a scientific publication which describes the birth of mice made from either two female biological parents or two male biological parents.40 Such a simple description belies the complexity of the experiment.

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Most cells of the body are diploid: their nuclear DNA is organised into two sets of chromosomes, one inherited from each parent. Gametes (as a result of meiosis) contain only one set of chromosomes; they are haploid. When gametes combine, they give rise to an organism with two sets of chromosomes in each cell. In mammalian heterosexual reproduction, genes on the chromosomes are switched on or off during embryo development depending on which parent the genes were inherited from. This is called ‘imprinting’; failures in this process can lead to severe developmental defects, thus making same-sex reproduction in mammals seem impossible.41 In the same-sex reproduction experiments, ‘bimaternal’ mice were created using oocyte-derived cells that the scientists modified using CRISPR-­ Cas9: regions of the chromosomes that would be imprinted if the cells had been paternally inherited were deleted. The resulting cells, now resembling (but still different from) sperm cells, were then injected into oocytes, each one containing one set of unmodified chromosomes. This gave raise to diploid embryos. Of 210 transferred bimaternal embryos, twenty-nine mice were born alive, with a normal weight. Some went on to reproduce.42 The ‘bipaternal’ mice were also created using CRISPR-­Cas9: sperm cell-derived cells this time were edited in the maternally imprinted regions of the chromosomes, to make them more closely resemble oocytes. Each of these haploid cells, as well as an unmodified sperm cell, was then injected into an enucleated oocyte (with its nuclear DNA removed) to give rise to a diploid embryo. There were twelve births from 1023 embryos. Their body weight was twice that of normal pups at birth, and they all died shortly thereafter. Further modifications to the protocol led to a couple of pups surviving beyond two days, but not into adulthood.43 Although far from clinical use, this research shows the elaborate ways in which gametes of one sex can be manipulated into creating viable embryos in mice. The experiments provide new insight into gametogenesis, fertilisation and early mammalian development. In theory at least, the research could point to obviating the need for donor gametes in same-sex parenting. Many clinicians have been critical of such applications, some calling them ‘implausible’ in the ‘near future’ due to the complexities of human imprinting.44 Nonetheless, professor of medical science Eli Adashi and professor of law Glenn Cohen argue that ‘the

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prospect of assisted human same-sex reproduction can no longer be dismissed’.45 Newspaper headlines such as ‘Male Obsolescence Approaches’ indicate that the link between this research and same-sex human reproduction is readily made.46 Research into creating embryos in vitro without using sperm or oocytes has also made headlines in the last few years.

Creating and Growing Embryos in Laboratories Laboratory creation of embryos was achieved through in vitro fertilisation in 1969. One of the key achievements this led to was the derivation of stem cells from embryos, which Robert Edwards had anticipated as one of the non-reproductive potentials of IVF. In 2014, the research in a sense came full circle: a team in the United States was able to take human embryos, turn them into embryonic stem cells, then coax these to develop and organise back into something resembling an embryo in vitro. These entities had the same cellular patterns as embryos, but not the same three-­ dimensional structure.47 Between 2017 and 2018, research teams in the UK and the Netherlands, using mice, grew three-dimensional structures in the laboratory that increasingly closely resemble mouse embryos.48 A US-based team implanted a pluripotent stem cell-derived embryo into a female mouse; it grew to become a foetus (albeit with many abnormalities).49 At the time of writing, none of this research had been replicated with human pluripotent stem cells, in part because human embryos organise into three-dimensional structures with specialised cells around fourteen days, the time at which human embryo experimentation must legally stop in most jurisdictions.50 Laboratories have also improved the culture conditions enabling the growth of IVF embryos in vitro. As a result, embryos can survive much longer under laboratory conditions without needing to be implanted into female bodies. In 2016, a Cambridge  (UK) team led by Magdalena Zernicka-Goetz and another led by Ali H. Brivanlou in New York each published research showing they had grown human embryos for twelve to thirteen days (previously, one week had been the maximum). This enabled a first look at how human embryos organise their cells in the second week of development, and after the moment when they would

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attach to the uterus in vivo.51 In 2018 Brivanlou’s team combined human stem cells with chicken embryos, ‘sidestepping’ the fourteen-day rule and enabling researchers to examine more closely the ways in which human cells organise in the early (but post-fourteen-day) embryo.52 The main stated purpose of these experiments is not to develop future adult humans in hatcheries, nor to birth human-animal hybrids, but to better understand early human cellular and molecular development. This knowledge can have implications for understanding developmental disruptions and miscarriages, and could also help optimise IVF protocols.53 The developments have led some researchers to open discussions about re-assessing the fourteen-day rule, established in 1990 in the UK, which requires that embryos should not be grown in vitro beyond fourteen days.54 Some argue that the current legal definition of an embryo does not accurately reflect the latest research findings in relation to embryonic development, in particular the potential for stem cells to turn into embryos.55 Besides this work on early embryos, scientists are also exploring ways of supporting foetal development just before birth, in particular in the context of premature births.

Artificial Wombs and Full Ectogenesis As embryos can develop for longer in the laboratory, and as premature babies can be kept alive from earlier gestational ages, we can see an increasing number of steps of reproduction occurring outside the body. Howard Jones, who, together with Georgeanna Seegar Jones led the use of AR in the United States for many decades, argued in his 2014 memoir that  full ectogenesis  including birth might have clinical benefits and should not be rejected out of hand. He regretted that no scientific efforts are being made with ectogenesis to my knowledge. That is a pity, because although it is horror fiction in Brave New World, there are some good reasons why the development of fetuses in vitro is a desirable technology, although not for the purposes that Aldous Huxley had in mind. The technical challenges will be colossal but, if they can be overcome, women who lack a uterus will no longer require human surro-

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gacy, fetuses would not be exposed to risks from their mothers’ choice of diet and addictions, and the abandonment of pregnancy to the laboratory by others would be the final liberation for women from their biology.56

With clear nods to science fiction, feminist concerns and medical issues, Jones highlights some of the reasons why ectogenesis captures the imagination. Today, artificial wombs are at a stage that premature foetal lambs have developed normally ex utero, in what the researchers called ‘biobags’. The lambs were at  the equivalent of twenty-three weeks’ gestation. Functioning human laboratory placentas were also developed in 2018.57 Complete ectogenesis has not taken place in animals or humans, but its clinical rationale would include avoiding the perceived need for uterine transplants. All the above research delves ever deeper into the intricacies of human reproduction at the cellular and molecular levels. Besides providing new knowledge, this research might improve IVF protocols and lead to better understandings of miscarriages. Most of the above developments also open up the (distant) possibility of new markets for IVF and have the potential to change whose bodies and which parts are required for AR. As an example, there could be a reduction in reliance on gamete provision, especially oocyte provision, if gametes can be created from oocyte precursors in ovarian tissue or even from skin cells of commissioning parents. Mitochondrial donation and in vitro oocyte creation from stem cells could offer hope (if perhaps not solutions) to older women wishing for biological children. Another (unlikely) possibility is the creation of embryos for same-sex couples or singles without the requirement of gamete or surrogacy providers, and perhaps a reduction in the use of uterine transplants through advances in ectogenesis. There are other areas where market expansions are not only imaginable, but already taking place, such as with advances in low-cost IVF and pre-implantation genetic screening.

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 roadening Markets: Assisted Reproduction B for All? Assisted reproduction is expanding along two different lines. In one, IVF becomes simpler and cheaper; in the other, cutting-edge techniques are enabling high-throughput genetic testing, in turn making state-supported large-scale genetic testing of would-be parents financially and practically feasible.

Low-Cost AR Providers of AR have long recognised that the cost of even basic treatment is prohibitive for most people. Within the United States this has led some entrepreneurs to argue that there is a good business case for funding to expand the industry.58 Some doctors are also urging US health insurers to cover costs of infertility investigation and treatment for men on par with women.59 In the UK, the media regularly features stories about people not being able to access IVF because it is not funded in their local area—the so-called postcode lottery. While some councils are cutting IVF support, notably Cambridgeshire (the ‘birthplace’ of IVF), some politicians are trying to make IVF more accessible country-wide.60 These funding difficulties could lead to the closing down of ‘UK’s oldest NHS fertility clinic’ in Manchester.61 More recently, COVID-19 has made it difficult for many to access IVF treatment, at the same time as it has led to rises in the sale of home sperm collection kits for cryopreservation as some American men feared for their fertility.62 The highest rates of infertility globally are on the African continent, and the International Federation of Fertility Societies (IFFS) held its first sub-Saharan conference in 2018 in Uganda in recognition of the issues in the region.63 Infertility rates among women are especially high as a result of sexually transmitted infections. Marcia Inhorn and Pasquale Patrizio have argued that a suitable approach to these problems would entail the introduction of low-cost IVF (LCIVF), at the same time as providing increased research and action in relation to preventing infertility. They

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also observe that AR itself, with its low success rates, is not a panacea for the kind of discrimination that women, in particular, often encounter when they are unable to bear children.64 Belgian fertility specialist William Ombelet, an important figure in the LCIVF movement, established the not-for-profit Walking Egg Project in 2010, to develop a ‘simplified’ ‘IVF culture system’ suitable for many (but not all) infertility cases.65 It involves a ‘shoebox-sized IVF laboratory’, using simple equipment and consumables such as glass tubes, baking soda and citric acid. According to the scientists who led the research, ‘pregnancy rates matched those from a standard laboratory and set-up costs are 85–90% lower’.66 Alan Trounson founded ‘The Low Cost IVF Foundation’ which has been piloting an effective low-tech IVF, Trounson having suggested that its use should ‘be made available to all women— particularly those in developing countries and on low incomes’.67 If and when low-cost IVF becomes available in resource-poor communities, there will still be issues regarding access to high-cost services such as neonatal care for premature infants, emergency obstetric care and treatment for ovarian hyperstimulation syndrome. One other way to expand the use of AR is to encourage clients with uncomplicated fertility issues to visit clinics that specialise in simple, generic IVF protocols. Centres that specialise in these plainer protocols are becoming popular in lower- to middle-income areas of countries such as the United States and Australia.68 One ‘no frills’ clinical initiative, advocated by French IVF specialist René Frydman and others, is INVOcell, a device that enables fertilisation and early embryo development to take place in a woman’s vaginal cavity, rather than in a laboratory dish. It is much easier and cheaper than usual IVF protocols, and is similarly effective.69 Other medical professionals see techniques less reliant on the laboratory as important alternatives or complements to IVF.70

Widened Scope for Genetic Testing Lowering the cost of treatment through low-tech approaches is not the only way AR can expand its client base. Some countries are also looking at using recent advances in genetic screening methods to encourage more

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couples with no signs of infertility to undergo genetic tests prior to starting a family. If they are found to be carriers of genetic diseases, the prospective parents are encouraged towards IVF and embryo selection. One such country is Australia, where provision was made in the 2018 federal budget for a trial to increase access to preconception genetic screening. This $20 million project, part of the government’s ‘$500 million Australian Genomics Health Futures Mission’, was dubbed ‘Mackenzie’s Mission’, a response to the death of seven-month-old Mackenzie Casella from spinal muscular atrophy, a rare and incurable neuromuscular disease. Although they had not known it, both of Mackenzie’s parents were unaffected carriers of one defective copy of the SMN1 gene; their daughter inherited both.71 The idea behind preconception screening is to examine whether would-be biological parents are carriers of genes that can cause autosomal recessive diseases  (diseases that only manifest if the child inherits one  defective gene from each parent). If the testing were to show that both parents have defects in the same gene, they would then have the option of using IVF and embryo selection.72 A group of Australian scientists have estimated that about one in twenty people are carriers of the three most common autosomal recessive diseases, meaning that preconception screening could see a large proportion of the fertile population encouraged to use IVF.73 The budget announcement generated excitement, including amongst some healthcare professionals, who described the national genomics mission as an opportunity to better integrate genomics into everyday clinical practice.74 In contrast to genetics, which tends to focus on single genes, genomics examines the ways in which different genes interact within organisms. Clinical genomics, and routine preconception screening in particular, would be made possible by low-cost genome sequencing, based on elaborate so-called ‘next generation’ DNA sequencing platforms.75 This differs from the simpler approaches to IVF advocated above, and from the more basic pre-conception screening that has been occurring in Israel for decades—although in Israel, too, there is a turn towards high-throughput genomic techniques.76 ‘Mackenzie’s Mission’ remains in its early stages and IVF might not provide an automatic solution to carriers hoping for healthy children given that its success rates remain low.77

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Reflections We have seen, then, that scientists are not only excluding embryos with faulty genes from implantation for reproduction, but also trying to ‘fix’ the embryos. They can do this by editing genes using molecular processes such as CRISPR-Cas9. They can also keep the healthy nuclear genome and replace the faulty mitochondria through mitochondrial donation. Researchers are creating functioning mammalian gametes in the laboratory. They are growing human embryos that survive for increasingly long times outside the body and developing mammalian foetuses in artificial wombs. Clinicians, investors, researchers and governments are aiming to increase the number of people who have access to AR. This can be through ‘no frills’ IVF protocols, better state support, or changes in insurance schemes. It can be by encouraging fertile prospective parents to access preconception genetic screening. Artificial wombs, functioning human laboratory placentas, laboratory gametes and mitochondrial donation have obvious potential applications for people suffering from infertility or carrying genetic diseases. They also have broader imaginable markets, from older women who might consider combining their genetic material with ‘younger’ mitochondria, to people seeking to avoid biological gestation (perhaps because they do not have a uterus, or because they do not want to be pregnant), to same-sex couples wishing to pass on both prospective parents’ genetic material. Many hurdles, including biological ones, would need to be overcome before most of these options could become possible and widespread. Recent research using IVF embryos and pluripotent stem cells highlights the intricacies of mammalian reproduction. Processes such as meiosis, imprinting and the three-dimensional organisation of embryos in humans, so essential for genetic material to pass from one generation to the next, are proving difficult to replicate in the laboratory. Scientists are developing complex interventions, such as editing certain regions of the genome to reset imprinting. They are studying early human embryo development by inserting human biological material into animal embryos. The human material often disappears as the embryo develops though, hinting at further complexities that might be explored.78

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This book has focused on the application of IVF to human reproduction and its intersection with the politics that have accompanied it over nearly half a century and across the globe. It has been, by definition, the history of a commercial undertaking carried out in wealthy environments—that is, reliant on substantial payment from would-be parents— but which is also in many of its forms reliant on exploiting wealth disparities between women to further commercial goals. In the time that AR has become a taken-for-granted medical procedure, a way of thinking and speaking has developed that relies on medical market rhetoric. This market rhetoric naturalises IVF and in turn positions any place or group of people as ‘under-serviced’ if they do not have the same AR options as others. But as we have seen, the problems regularly associated with AR— ovarian hyperstimulation syndrome (OHSS) and multiple births chief among them, along with the ethical complexities of gamete donation and surrogacy—suggest a need to continue to see the idea of ‘access’ in the light not only of the ‘rights’ of would-be parents, but of all those involved in the AR industry, including the children who are the ‘products’. Today, it is hard to envision reproduction without the option of in vitro fertilisation. Some studies project up to 3.5% of the world’s population could owe their lives to assisted reproduction by the end of the twenty-first century.79 Yet in spite of huge technical strides, IVF is still not a baby guarantee and has not ‘fixed’ infertility for everyone. ‘Miracle babies’ remain elusive for most AR clients, at the same time as markets are growing worldwide and stories of eventual success remain prominent.80 Fertility treatment is increasingly a series of transactions, in which the process of creating a child is carried out by several people involved in physical, financial and clinical relationships. Some medical practitioners continue to encourage people who have experienced failed AR to keep on trying, on the principle that more treatment cycles can increase the take-­ home baby rate. And the idea that persistence pays off, along with the emotional and financial investment needed for most forms of treatment, perhaps can make it hard for people to make the decision to stop having IVF.81 But such a decision also entails changed identities and newly imagined futures: from potential parent or parents, to childless person or couple.

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Story-telling by writers of speculative fiction contributes to the IVF imaginary and is partly based on the stories told by scientists about what the knowledge that they are developing could lead to, and how it could affect the social world. Although the technical details of the futures imagined by William Walters, Aldous Huxley, J.  B. S. Haldane, Robert Edwards, Shulamith Firestone, Marge Piercy and others are not exactly those that eventuated, many of their overarching themes are reflected in AR’s contemporary developments. Those fictional scenarios did more than  speculate about or predict the future, however. They most likely helped it come into being by influencing the way scientists, journalists and others think about medical science, see certain things as problems that need to be solved or interpret experimental findings. As several commentators have observed, the story of AR since 1978 is as much about what has changed, as about what seemed to have caused no social change at all. In that sense, the clinical practice of AR has been all the more revolutionary for having been able to seem routine.82 One reason for this seeming paradox is that those who seek assistance through AR do so to create connections in their lives between past and future, according to a sense of what is normal and natural. As one Israeli patient said: ‘All I ask for is to have a family and be a parent like any other parent in Israel’.83 Clients and providers alike are invested in representing the use of AR as business as usual. Every wish to procreate belongs to a process of assimilation of past and future into existing stories. At the same time, those outside the immediate patient-client space, such as religious groups and regulatory authorities, declare its use to be a sign of change, of special interest to church and state. Over time, reproductive technology has interacted with developments in spheres beyond the strictly reproductive, such as an increase in religious influence on the public sphere; social movements such as patients’ rights and women’s rights; neo-liberal economic policies, which reject regulation of commerce; anti-regulatory views within and in relation to the healthcare industries; emergent bio-commerce, such as trade in transplants; and the internet. In the 1980s, same-sex marriage was nowhere permitted. The optimism that has ensued from successful campaigns against homophobia has not spread uniformly. Indeed, the success of these campaigns in some places has contributed to backlash elsewhere,

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including in relation to the use of reproductive technologies by those outside the heterosexual nuclear family. The rise of religious conservatism was clearly in evidence among Christian groups in the 1970s in debates on the contraceptive pill and abortion law reform, but within Islam and Judaism, for example, the ways in which reproductive technology would be absorbed were less easy to anticipate. Now, religious views can underpin both the acceptance and the rejection of assisted reproductive practices. The history of AR now, therefore, is a story of many stories. These include those of people seeking children through medical assistance, of the children who have been born and of children who have been imagined, who have been lost or who never came into being. This history also includes the stories of the clinical providers and scientists who seek to assist them. Assisted reproduction is a story of industry, too: at the level of physical manufacture, and of where investors put their money. It is the story of the work of religions to mediate innovations which represent, in their eyes, threats and promises. It is the story of governments and bureaucracies and legal authorities, who are positioned as mediators between powerful interest groups, and whose task it is to limit the damage that can arise in relations between citizens. The history of public regulation shows that AR itself has exposed the limits and vulnerabilities of authorities’ attempts to act as brokers of human reproductive relations. Influential lobby groups, increasingly centralised industry and a discourse of individual choice all challenge ideas of state legitimacy and notions of the public interest. In that respect, the fragmented, decentralised trajectory of AR on the global scale has been the precise opposite of the scenario anticipated in Brave New World. And AR has tended not to reduce the biological labour of women, as 1970s science fiction had speculated it could given the right social context, but has displaced it across new social formations. A history of AR is also the story of the stories themselves, as represented in media, in choices of words, in decisions about whose story is the main story, and about whether innovation is to be feared or welcomed, or is merely the focus of intrigue. Looking over the more than forty years since the first IVF births, these stories can be seen from above, as it were, across the decades, each moving, adjusting and recalibrating,

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with reference to the other. In any one place, these stories, told in many different ways, all jostling to be heard, shape and reshape that place’s reproductive history, one life at a time. From a ‘wide angle’ view, it is the story of interpreters of change, of scholars such as anthropologists and sociologists, who have sought to provide a public-sphere perspective on the most private of spaces, and whose voices have increasingly contributed to the understanding and even the directions of AR. Shift to ‘closeup’ on the individual, or multiply any one of these stories across state lines or across national borders to reach across the globe, and one can begin to have a sense of the complexity of what AR means in the world today.

Notes 1. ‘Truth Stranger Than Science Fiction, Expert Predicts Embryos to Colonise Space?’, Sydney Morning Herald, 5 June, 1981. 2. Lei Xiaohua, Yujing Cao, Ying Zhang, and Enkui Duan, ‘Advances of Mammalian Reproduction and Embryonic Development under Microgravity’, in Life Science in Space: Experiments on Board the SJ-10 Recoverable Satellite, ed. Enkui Duan and Mian Long (Singapore: Springer, 2019), 281–315. 3. ‘Micro-11: Do Sperm Squirm the Same in Space?’, NASA, 3 April, 2018, https://www.nasa.gov/ames/micro-11. See also recent findings presented at the 2019 Annual Meeting of the European Society of Human Reproduction and Embryology on sperm in micro-gravity: European Society of Human Reproduction and Embryology, ‘Frozen Sperm Retains Its Viability in Outer Space Conditions: Human Sperm Samples Exposed to Microgravity Are Just as Active and Concentrated as on Earth’, ScienceDaily, 24 June 2019, https://www.sciencedaily.com 4. Teruhiko Wakayama, ‘Effect of Space Environment on Mammalian Reproduction’, NASA, 19 September, 2018, https://www.nasa.gov. See also Sayaka Wakayama, Yuko Kamada, Kaori Yamanaka, Takashi Kohda, Hiromi Suzuki, Toru Shimazu, Motoki N.  Tada, Ikuko Osada, Aiko Nagamatsu, Satoshi Kamimura, Hiroaki Nagatomo, Eiji Mizutani, Fumitoshi Ishino, Sachiko Yano, and Teruhiko Wakayama, ‘Healthy Offspring from Freeze-Dried Mouse Spermatozoa Held on The

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International Space Station for 9  Months’, Proceedings of the National Academy of Sciences of the United States of America 114, no. 23 (2017): 5988–93. 5. J.  Michael Bedford, ‘Why Mammalian Gametes Don’t Mix’, Nature 291, no. 5813 (1981): 286–88; Enrica Bianchi and Gavin J.  Wright, ‘Cross-­Species Fertilization: The Hamster Egg Receptor, Juno, Binds the Human Sperm Ligand, Izumo1’, Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences 370, no. 1661 (2015): 20140101; Yuhkoh Satouh and Masahito Ikawa, ‘New Insights into the Molecular Events of Mammalian Fertilization’, Trends in Biochemical Sciences 43, no. 10 (2018): 818–28. 6. Jun Wu, Aida Platero-Luengo, Mashiro Sakurai, Atsushi Suguwara, Maria Antonia Gil, Takayoshi Yamauchi, Keiichiro Suzuki, Yanina Soledad Bogliotti, Cristina Cuello, Mariana Morales Valencia, Daiji Okumura, Jingping Luo, Marcela Vilariño, Inmaculada Parrilla, Delia Alba Soto, Cristina A.  Martinez, Tomoaki Hishida, Sonia SánchezBautista, M.  Llanos Martinez-Martinez, Huili Wang, Alicia Nohalez, Emi Aizawa, Paloma Martinez-Redondo, Alejandro Ocampo, Pradeep Reddy, Jordi Roca, Elizabeth A. Maga, Concepcion Rodriguez Esteban, Travis W.  Berggren, Estrella Nuñez Delicado, Jeronimo Lajara, Isabel Guillen, Pedro Guillen, Josep M. Campistol, Emilio A. Martinez, Pablo Juan Ross, and Juan Carlos Izpisua Belmonte, ‘Interspecies Chimerism with Mammalian Pluripotent Stem Cells’, Cell 168, no. 3 (2017): 473–85.e15. See also Erin Blakemore, ‘Human-Pig Hybrid Created in the Lab—Here Are the Facts’, National Geographic, 26 January, 2017, https://news.nationalgeographic.com; Katy Sinclair, ‘HFEA Authorises Research Using Human-Animal Hybrid Embryos’, BioNews, no. 441, 21 January, 2008, https://www.bionews.org.uk; Sara Reardon, ‘Hybrid Human–Chicken Embryos’, Nature, 23 May, 2018, https://www.nature. com; David Cyranoski, ‘Japan Approves First Human-Animal Embryo Experiments’, Nature, 26 July, 2019, https://www.nature.com; Cynthia Morata Tarifa, Luis López Navas, Garikoitz Azkona, and Rosario Sánchez Pernaute, ‘Chimeras for the Twenty-First Century’, Critical Reviews in Biotechnology 40, no. 3 (2020): 283–91. 7. Manuel Ansede, ‘Spanish Scientists Create Human-Monkey Chimera in China’, El País, 31 July, 2019, https://english.elpais.com/elpais/2019/ 07/31/inenglish/1564561365_256842.html

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8. ‘Assisted Reproductive Technology Regulation Bill, 2020. Why in News’, Drishti IAS, https://www.drishtiias.com/printpdf/assisted-reproductivetechnology-regulation-bill-2020; ‘Cabinet Approves the Assisted Reproductive Technology Regulation Bill 2020’, PMINDIA, 19 February, 2020, https://www.pmindia.gov.in/en/news_updates 9. See Chap. 2. 10. Yulian Zhao, Paul Brezina, Chao-Chin Hsu, Jairo Garcia, Peter R. Brinsden, and Edward Wallach, ‘In Vitro Fertilization: Four Decades of Reflections and Promises’, Biochimica et Biophysica Acta  – General Subjects 1810, no. 9 (2011): 843–52, 849. 11. Puping Liang, Yanwen Xu, Xiya Zhang, Chenhui Ding, Rui Huang, Zhen Zhang, Jie Lv, Xiaowei Xie, Yuxi Chen, Yujing Li, Ying Sun, Yaofu Bai, Zhou Songyang, Wenbin Ma, Canquan Zhou, and Junjiu Huang, ‘CRISPR/Cas9-Mediated Gene Editing in Human Tripronuclear Zygotes’, Protein & Cell 6, no. 5 (2015): 363–72; David Cyranoski and Sara Reardon, ‘Chinese Scientists Genetically Modify Human Embryos’, Nature News, 22 April, 2015, https://www.nature.com/news; David Cyranoski and Sara Reardon, ‘Embryo Editing Sparks Epic Debate’, Nature 520, no. 7549 (2015):593–94; Kevin Loria, ‘Chinese Scientists Just Admitted to Tweaking the Genes of Human Embryos for the First Time in History’, Business Insider Australia, 23 April, 2015, https://www. businessinsider.com.au 12. Suzanne Sataline and Ian Sample, ‘Scientist in China Defends Human Embryo Gene Editing’, Guardian, 28 November, 2018, https://www. theguardian.com/science; Michael Standaert, ‘“Extremely Abominable”: Chinese Gene-Editing Scientist Faces Law’, Al Jazeera, 30 November, 2018, https://www.aljazeera.com/news; Belinda Smith and Natasha Mitchell, ‘Gene Editing Babies Was Irresponsible, Risky and Unnecessary, Say Experts. Why?’, ABC News, 1 December, 2018, https://www.abc. net.au/news/science; Ayo Wahlberg, ‘Did Human Embryo Editing Just Get Platformed?’ Changing (In)Fertilities Project, 4 December, 2018, https://www.cifp.sociology.cam.ac.uk 13. ‘Rogue Chinese Gene Scientist He Jiankui Who Edited Babies’ Genes under Guard as Work Is Probed’, Straits Times, 11 January, 2019, https:// www.straitstimes.com/asia/east-asia 14. Ian Sample, ‘Chinese Scientist Who Edited Babies’ Genes Jailed for Three Years’, Guardian, 30 December, 2019, https://www.theguardian.com

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15. Eric S. Lander, Françoise Baylis, Feng Zhang, Emmanuelle Charpentier, Paul Berg, Catherine Bourgain, Bärbel Friedrich, J. Keith Joung, Jinsong Li, David Liu, Luigi Naldini, Jing-Bao Nie, Renzong Qiu, Bettina Schoene-Seifert, Feng Shao, Sharon Terry, Wensheng Wei, and Ernst-­ Ludwig Winnacker, ‘Adopt a Moratorium on Heritable Genome Editing’, Nature 567, no. 7747 (2019): 165–68. 16. Alan Trounson, ‘It’s Time for a Worldwide Moratorium on Editing Human Embryos’, BioMelbourne Network, 2 April, 2019, https:// biomelbourne.org/opinion 17. For example, see Benjamin Davies, ‘The Technical Risks of Human Gene Editing’, Human Reproduction 34, no. 11 (2019): 2104–11; Vivien Marx, ‘A Rocky Road for the Maturation of Embryo-Editing Methods’, Nature Methods 16, no. 2 (2019): 147–50; George Q.  Daley, Robin Lovell-Badge, and Julie Steffann, ‘After the Storm—A Responsible Path for Genome Editing’, New England Journal of Medicine 380, no. 10 (2019): 897–99; Eli Y.  Adashi and I.  Glenn Cohen, ‘Therapeutic Germline Editing: Sense and Sensibility’, Trends in Genetics 36, no. 5 (2020): 315–17. 18. Jessica Hamzelou, ‘Exclusive: World’s First Baby Born with New “ThreeParent” Technique’, New Scientist, 27 September, 2016, https://www. newscientist.com; John Zhang, Hui Liu, Shiyu Luo, Zhuo Lu, Alejandro Chávez-Badiola, Zitao Liu, Mingxue Yang, Zaher Merhi, Sherman J. Silber, Santiago Munné, Michalis Konstantinidis, Dagan Wells, Jian J. Tang, and Taosheng Huang, ‘Live Birth Derived from Oocyte Spindle Transfer to Prevent Mitochondrial Disease’, Reproductive BioMedicine Online 34, no. 4 (2017): 361–68; ‘Leigh Syndrome’, Genetics Home Reference, https://ghr.nlm.nih.gov 19. Heidi Chial and Joanna Craig, ‘mtDNA and Mitochondrial Diseases’, Nature Education 1, no. 1 (2008): 217, https://www.nature.com/scitable/topicpage/mtdna-and-mitochondrial-diseases-903/ 20. John Zhang, Guanglun Zhuang, Yong Zeng, Jamie Grifo, Carlo Acosta, Yimin Shu, and Hui Liu, ‘Pregnancy Derived from Human Zygote Pronuclear Transfer in a Patient Who Had Arrested Embryos after IVF’, Reproductive BioMedicine Online 33, no. 4 (2016): 529–33; Lyndsey Craven, Helen A. Tuppen, Gareth D. Greggains, Stephen J. Harbottle, Julie L. Murphy, Lynsey M. Cree, Alison P. Murdoch, Patrick F. Chinnery, Robert W. Taylor, Robert N. Lightowlers, Mary Herbert, and Douglass M.  Turnbull, ‘Pronuclear Transfer in Human Embryos to Prevent

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Transmission of Mitochondrial DNA Disease’, Nature 465, no. 7294 (2010): 82–85; César Palacios-González, ‘Are There Moral Differences between Maternal Spindle Transfer and Pronuclear Transfer?’, Medicine, Health Care, and Philosophy 20, no. 4 (2017): 503–11. 21. Zhang et al., ‘Live Birth Derived from Oocyte Spindle Transfer’; Sara Reardon, ‘“Three-Parent Baby” Claim Raises Hopes—and Ethical Concerns’, Nature News, 29 September, 2016, https://www.nature.com. There are other ways of creating ‘three-parent’ embryos. One is cytoplasmic transfer, which has been used at least since the 1990s. It involves adding cytoplasm (which contains mitochondrial DNA, or mtDNA) from a donor, to the social mother’s egg, to increase the number of healthy mitochondria. Jason A.  Barritt, Carol A.  Brenner, Henry E.  Malter, and Jacques Cohen, ‘Mitochondria in Human Offspring Derived from Ooplasmic Transplantation: Brief Communication’, Human Reproduction 16, no. 3 (2001): 513–16. 22. Mina Alikani, Bart C. J. Fauser, Juan Antonio García-Valesco, Joe Leigh Simpson, and Martin H.  Johnson, ‘First Birth Following Spindle Transfer for Mitochondrial Replacement Therapy: Hope and Trepidation’, Reproductive BioMedicine Online 34, no. 4 (2017): 333–36; Reardon, ‘“Three-Parent Baby” Claim’; Gary Polakovic, ‘Mitochondrial DNA and Nuclear DNA: Not So Independent after All’, USC News, 5 July, 2018, https://news.usc.edu 23. Alikani et al., ‘First Birth Following Spindle Transfer’; Tetsuya Ishii and Yuri Hibino, ‘Mitochondrial Manipulation in Fertility Clinics: Regulation and Responsibility’, Reproductive Biomedicine & Society Online 5 (2018): 93–109. 24. Sandra R. Bacman, Johanna H. K. Kauppila, Claudia V. Pereira, Nadee Nissanka, Maria Miranda, Milena Pinto, Sion L. Williams, Nils-Göran Larsson, James B. Stewart, and Carlos T. Moraes, ‘MitoTALEN Reduces Mutant MtDNA Load and Restores tRNAala Levels in a Mouse Model of Heteroplasmic mtDNA Mutation’, Nature Medicine 24, no. 11 (2018): 1696–700; Payam A.  Gammage, Carlo Viscomi, Marie-Lune Simard, Ana S. H. Costa, Edoardo Gaude, Christopher A. Powell, Lindsey Van Haute, Beverly J. McCann, Pedro Rebelo-Guiomar, Raffaele Cerutti, Lei Zhang, Edward J.  Rebar, Massimo Zeviani, Christian Frezza, James B.  Stewart, and Michal Minczuk, ‘Genome Editing in Mitochondria Corrects a Pathogenic MtDNA Mutation in Vivo’, Nature Medicine 24, no. 11 (2018): 1691–95; James Heather, ‘Genome Editing Works in

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Mitochondrial DNA for First Time’, BioNews, no. 969, 1 October, 2018, https://www.bionews.org.uk 25. Emily Mullin, ‘The Fertility Doctor Trying to Commercialize Three-­ Parent Babies’, MIT Technology Review, 13 June, 2017, https://www. technologyreview.com; Darwin Life, https://www.darwinlife.com 26. Helen Thomson, ‘First 3-Parent Baby Born in Clinical Trial to Treat Infertility’, New Scientist, 11 April, 2019, https://www.newscientist.com 27. J. B. S. Haldane, Daedalus or Science and the Future; A Paper Read to the Heretics, Cambridge, on February 4th 1923 (London: Kegan Paul, Trench, Trubner, 1923), 63–64. 28. Kathy Rudy, ‘Ethics, Reproduction, Utopia: Gender and Childbearing in Woman on the Edge of Time and The Left Hand of Darkness’, NWSA Journal 9, no. 1 (1997): 22–38. 29. United States. Department of Health & Human Services (HHS), ‘Stem Cell Basics’, https://stemcells.nih.gov/info/basics.htm. These definitions are simplified. The different traits that scientists focus on as central to particular stem cells can depend on context. Nicola J.  Marks, ‘Defining Stem Cells? Scientists and Their Classifications of Nature’, Sociological Review 58, no.1_suppl (2010): 32–50.  See  also Charis Thompson, Good Science: The Ethical Choreography of Stem Cell Research (Cambridge, MA: MIT Press, 2013). 30. Quan Zhou, Mei Wang, Yan Yuan, Xuepeng Wang, Rui Fu, Haifeng Wan, Mingming Xie, Mingxi Liu, Xuejiang Guo, Ying Zheng, Guihai Feng, Qinghua Shi, Xiao-Yang Zhao, Jiahao Sha, and Qi Zhou, ‘Complete Meiosis from Embryonic Stem Cell-Derived Germ Cells in Vitro’, Cell Stem Cell 18, no. 3 (2016): 330–40; Andy Coghlan, ‘Artificial Tail-Less Sperm Is the Best Test-Tube Sex Cell Yet’, New Scientist, 25 February, 2016, https://www.newscientist.com 31. ‘Meiosis’, Scitable, https://www.nature.com/scitable/definition/meiosis-88 32. Jess Buxton, ‘Creating Life in the Lab: In Vitro Gametogenesis (IVG) and Synthetic Human Entities with Embryo-Like Features (SHEEFs)’, BioNews, no. 932, 8 January, 2018, https://www.bionews.org.uk; Hannah Devlin, ‘Scientists a Step Closer to Mimicking Way Human Body Creates Sperm’, Guardian, 1 January, 2018, https://www.theguardian.com/science; Fang Fang, Zili Li, Qian Zhao, Honggang Li, and Chengliang Xiong, ‘Human Induced Pluripotent Stem Cells and Male Infertility: An Overview of Current Progress and Perspectives’,

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Human Reproduction 33, no. 2 (2018): 188–95; Michele Boiani, ‘Building Tomorrow’s in Vitro-Derived Germ Cells on Today’s Solid Facts’, Molecular Human Reproduction 24, no. 7 (2018): 341–42; Andy Coghlan, ‘Human Sperm Grown in a Lab for the First Time, Claims Study’, New Scientist, 12 September, 2016, https://www.newscientist. com; Andy Coghlan, ‘Patent for First Method to Create Human Sperm, But Does It Work?’, New Scientist, 17 September, 2015, https://www. newscientist.com; Marie-Hélène Perrard, Nicolas Sereni, Caroline Schluth-Bolard, Antonine Blondet, Sandrine Giscard d’Estaing, Ingrid Plotton, Nicolas Morel-Journel, Hervé Lejeune, Laurent David, and Philippe Durand, ‘Complete Human and Rat Ex Vivo Spermatogenesis from Fresh or Frozen Testicular Tissue’, Biology of Reproduction 95, no. 4 (2016): 1–10. 33. M. McLaughlin, D. F. Albertini, W. H. B. Wallace, R. A. Anderson, and E. E. Telfer, ‘Metaphase II Oocytes from Human Unilaminar Follicles Grown in a Multi-Step Culture System’, Molecular Human Reproduction 24, no. 3 (2018): 135–42; Kelly Servick, ‘These Lab-Grown Human Eggs Could Combat Infertility—If They Prove Healthy’, Science, 8 February, 2018, http://www.sciencemag.org/news; Alex MatthewsKing, ‘Fertility “Breakthrough” as Human Eggs Grown in Lab for First Time’, Independent (UK), 9 February, 2018, https://www.independent. co.uk. This kind of oocyte growth and maturation is a more advanced achievement than the in vitro maturation of cells from ovarian tissue discussed in Chap. 5 (which has already produced live human births) because it starts with cells that are more immature and the whole process is completed outside the supportive environment created by ovarian tissue. 34. Orie Hikabe, Nobuhiko Hamazaki, Go Nagamatsu, Yayoi Obata, Yuji Hirao, Norio Hamada, So Shimamoto, Takuya Imamura, Kinichi Nakashima, Mitinori Saitou, and Katsuhiko Hayashi, ‘Reconstitution In Vitro of the Entire Cycle of the Mouse Female Germ Line’, Nature 539, no. 7628 (2016): 299–303; Adam Watkins, ‘First Working Eggs Made from Stem Cells Points to Fertility Breakthrough’, The Conversation, 18 October, 2016, https://theconversation.com 35. Chika Yamashiro, Kotaro Sasaki, Yukihiro Yabuta, Yoji Kojima, Tomonori Nakamura, Ikuhiro Okamoto, Shihori Yokobayashi, Yusuke Murase, Yukiko Ishikura, Kenjiro Shirane, Hiroyuki Sasaki, Takuya Yamamoto, and Mitinori Saitou, ‘Generation of Human Oogonia from

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Index1

A

Abortion anti-abortion lobby, 112, 118 law reform, 258 selective foetal reduction, 134 Activism in AR history feminist, 114, 127, 128, 179 LGBT+, 207 medical, 14, 91, 113, 127, 128, 140, 205, 258 patient, 4, 14, 86, 140, 241 religious, 15, 95, 114, 123, 124 Adamson, G. David, 17n14, 201 Adashi, Eli, 248 Add-ons, see Adjuvant treatments Adjuvant treatments, 138, 203, 216–222 Adoption, 40 Adultery, 112, 115, 116, 124

Advertising, 136, 138, 162, 175 Advocacy in AR AR clinician, 5, 89, 94, 140 feminist, 113, 127, 180 fertility patient, 45 non-AR clinician, 76, 77, 126 public health, 15, 73 religious, 15, 95, 114, 122–124, 140 Aeres-Serono, 87 See also Serono Africa, continent of, 39, 85, 95, 252 See also Benin; Cameroon; Congo Brazzaville; Democratic Republic of the Congo; Egypt; Gabon; Ghana; Kenya; Malawi; Mali; Niger; North Africa; Senegal; South Africa; Sub-Saharan Africa; Togo; Uganda; Zimbabwe

 Note: Page numbers followed by ‘n’ refer to notes.

1

© The Author(s) 2020 S. Ferber et al., IVF and Assisted Reproduction, https://doi.org/10.1007/978-981-15-7895-3

341

342 Index

Agarwal, Kanupriya (‘Baby Durga’), 1, 28, 31, 34, 48, 51–53, 76, 89 Agricultural Research Council, Unit of Reproductive Physiology and Biochemistry, University of Cambridge, 30 Aitken, John, 215, 216 Akanksha Hospital and Research Institute, Anand (India), 159 Albury, Rebecca, 127 Altruistic surrogacy, see Surrogacy American Fertility Society (AFS), 82, 136 American Society for Reproductive Medicine (ASRM), 82, 133, 135, 155n150, 164, 181, 184, 219, 237n117 Analogy, role in thinking about AR, 11–12 Anand Kumar, Trichnopoly Chelvaraj (T. C.), 47, 50, 52, 60n58 Anglicanism, 116, 123 Animal research in debate over early IVF births, 30 in development of IVF, 30, 33 Anonymity client wish for, 166 gamete donor, 113, 114, 131, 134, 135 legality of, 167 surrogacy provider, 135, 166 Anti-Müllerian hormone (AMH), 206, 218, 225n13 Antral follicle count (AFC), 206, 225n13 Apple (company), 209

Artificial insemination (AI), 30, 33, 44, 56n17, 81, 83 by donor (AID), 83 Artificial womb, see Ectogenesis Asia, 39 See also Cambodia; Central Asia; China; India; Japan; Laos; Nepal; Singapore; South Asia; Sri Lanka; Thailand Asia Pacific Initiative on Reproduction (ASPIRE), 83 Assisted reproduction (AR) activism, 114 as business, 13, 257 complications, 8 early moves towards government regulation of, 125 expansion in early 1980s, 5, 14 as ‘intimate industry,’ 14–15 marketing of, 88, 163, 167 quest for peer regulation of, 10, 114, 202 Assisted reproductive technology/ technologies/treatment(s) (ART), see Assisted reproduction (AR) Associated Newspapers, 71 Associated Press, 89, 107n124 Auckland Infertility Society (New Zealand), 86 Austin, Colin Russell, ‘Bunny,’ 35, 49, 104n88 Australia, 2, 11, 16n6, 16n7, 23n51, 29, 36, 37, 40, 41, 43, 46, 48, 61n68, 68n162, 71, 74, 77–79, 83, 84, 86, 87, 90, 95, 104n88, 112, 113, 116–120, 126, 127, 132, 135, 138, 162,

 Index 

164–166, 168, 170, 171, 177, 178, 207, 210, 211, 214, 221, 253, 254 Australian Capital Territory (ACT), 211 Australian Competition and Consumer Commission (ACCC), 138 Australian Obstetrical and Gynaecological Research Society, 83 Australian Society of Reproductive Biology, 83 Austria, 35, 41, 42, 64n105, 75, 78 B

Baby Business, The (Debora Spar), 13 Baby Durga, see Agarwal, Kanupriya Baby Gammy, 171 ‘Baby in the Factory, The,’ 14 Baby Manji, 159, 160, 173 Baby Pipah, 171 Baby Victoria, 74, 75 Baldwin, Vicki, 90 Balen, Adam, 165 Bärnreuther, Sandra, 51 Barren Foundation, 49 Basescu, Traian, 94, 109n152 Bassan, Sharon, 180 Bavister, Barry, 36, 37 Belgium, 4, 41, 133, 166, 170, 173, 216 Belmonte Izpisua, Juan Carlos, 240 Benin, 105n96 Bergmann, Sven, 124 Bewley, Susan, 150n99 Bharadwaj, Aditya, 9

343

Bhattacharya, Saroj Kanti, 1, 28, 29, 50, 52 Biggers, John, 35, 50, 51, 57n25 Bigman, Fran, 32 Biobags, see Ectogenesis Biological labour, 14, 167, 258 BioTexCom (Ukraine), 172 Birth caesarean section, 49, 50, 53 defects, 113 first using IVF (1978), 6, 43, 114 legal status of children at, 175 multiple, frequency in AR (see Risks of AR, legal, to children; Risks of AR, legal, parents) premature, 250 singleton as recommended, 132, 133 Birth certificate, importance in surrogacy, 170–171, 174 Birth control, research funding also assisting development of IVF, 39 See also Population, control Birth mothers in surrogacy, 159, 166, 169–172, 180, 182 Blakeslee, Howard, 107n124 Blakeslee, Sandra, 107n124 Bologna (Italy), 83 Bourn Hall Clinic establishment of, 71, 78–80 early IVF activity, 72, 79, 84 Bourn Hall meeting, 1981, 78–80 See also Meetings and conferences, as foundation of fertility industry Bradley, Kathryn Webb, 181 Britain, 38, 91 See also United Kingdom (UK)

344 Index

Brave New World (Aldous Huxley), 6, 10, 32, 76, 89, 240, 245, 250, 258 Brazil, 175 Briggs, Laura, 141, 208 British Broadcasting Corporation (BBC), 220 British Fertility Society, 209 British Medical Association (BMA), 76, 77 British Medical Journal, 220 Brivanlou, Ali H., 249, 250 Brown, James Boyer, 80 Brown, John, 1, 27 Brown, Lesley, 1, 27, 49 Brown, Louise, 1, 20n31, 27, 28, 34, 36, 37, 40, 42, 46–50, 52, 53, 61n68, 90, 91 Buddhism, 124 Bulgaria, 85 C

Cairo (Egypt), 83 Calcutta University (Kolkata), 47 Cambodia, 169, 176, 197n123 Cambodian Centre for Human Rights (CCHR), 177 Cambridge (UK), 11, 39, 43, 49, 50, 71, 72, 86, 104n88, 249 Cameroon, 105n96 Canada, 77, 120, 126, 179 See also Quebec (Canada) Canberra (Australia), 23n52, 87 Capacitation, see Sperm Capitalism, 184 Case law, compared to statute law, 117, 130 Casella, Mackenzie, 254 Catholic Church, 121, 128, 129

Catholics, 113, 122, 123, 127 See also Donum Vitae (The Gift of Life) (1987) Centers for Disease Control and Prevention (CDC), 137, 172, 184 Central and Eastern Europe, 3 See also Austria; Czech Republic; Georgia; Germany; Hungary; Poland; Switzerland; Ukraine; Russia Central Asia, 3 Central Park (New York), 90, 91 Centre d’étude et de conservation des oeufs et du sperme humains (CECOS), 30 Chang, Min Chueh (M. C.), 30, 35, 36, 40, 49 Chapman, Michael, 162 Charlesworth, Max, 127 Children abandonment or unwanted retention of AR-created-, 161, 179, 251 birth certificates, 170–171, 174 Chimera, see Human-animal hybrid China, 4, 19n28, 41, 85, 92, 93, 108n149, 120–122, 164, 173–175, 197n127, 212, 215, 242–244, 246, 247 See also Hukou; Hunan Province (China); Intermediate Court of Wuxi; Shenzhen (China) Choice, reproductive, see Rights, discourse of; Rights, reproductive Christianity, 121 Christianity, Coptic, 116 Chromosomes, 246, 248 Citizenship, 111, 167, 172–174

 Index 

state policies on AR births, 173, 174 Clarke, Adele, 38 Clinical labour, in work of Catherine Waldby and Melinda Cooper, 8 Cochrane International Review, 138 Cohen, Glenn, 248 Cohen, Jean, 29, 72, 79, 83, 90, 99n25, 101n51 Colen, Shellee, 23n44, 180 Colombo Plan, 50 Colpotomy, 2, 53 Columbia University (New York), 40 Comité Consultatif National d‘Éthique, France (CCNE), 114 Commercialism, 96 Complications of AR, see Risks Confucianism, 121 Congo Brazzaville (Republic of the Congo), 105n96 Conseil d’État (France), 212 Contraception research, implications for IVF research, 31, 34 Cooper, Melinda, 165 Couple(s), 2, 3, 9, 15, 20n33, 38, 43, 45, 74, 76, 81, 90, 92, 97, 120, 121, 123, 124, 128, 130, 136, 159, 167, 173, 174, 176, 203–207, 211–213, 215, 222, 225n7, 237n117, 241, 243, 247, 248, 251, 254–256 Court cases, 211, 212 Court(s), role of, 113, 117, 128, 130, 207, 211, 212, 243 See also Case law, compared to statute law; Court cases

345

COVID-19 pandemic, 4, 168 Craft, Ian, 79 CRISPR-Cas9, 242, 248, 255 Cross-border reproductive care (CBRC), see Cross-border reproductive treatment (CBRT) Cross-border reproductive tourism, see Cross-border reproductive treatment (CBRT) Cross-border reproductive treatment (CBRT) anonymity as positive aspect of, 166 calls for greater regulation of, 167 children obtained through surrogacy in, 172–174 expansion, 181 legal and regulatory aspects, 168 reasons for undertaking, 167 responses to changing laws on, 170, 173 risks to children, women and clients in, 172, 173 women providers of eggs or children through surrogacy in, 178, 181 Cross-species fertilisation, 240 Cryobiology, 6 Cryopreservation, see Egg(s); Gamete(s); Sperm Culture media (laboratory) ‘Barry’s magic culture fluid,’ 36 ‘French Champagne’ (Ménézo’s B2 medium), 36 Tyrode’s solution, 36 Cyprus, 175 Czech Republic, 217

346 Index D

Daedalus or Science and the Future (J. B. S. Haldane), 31, 32 Daily Mail, 27, 71 Darwin Life, 245 Data-keeping, role in soft regulation, 114 Davis-Charles, Tammy, 177, 178 De Boer-Buquicchio, Maud, 183, 195n96 De Jonge, Christopher, 36 DeCherney, Alan, 88, 136 Declaration of Helsinki (1964), 38, 40, 61n69 Democratic Republic of the Congo, 105n96 Denmark, 2–4, 17n12, 83, 106n117, 154n144, 166 Deomampo, Daisy, 26n72, 164, 188n37 Developmental biology, 29 Devroey, Paul, 84, 217 Dialectic of Sex, The, 245 Dignitas Personae (The Dignity of the Person) (2008), 121 Diminished ovarian reserve (DOR), 206, 225n13 Disciplines, role of diversity in development of AR, 84 Discrimination, reproductive, 76 Donors and donation donation and selling of eggs, 12 donation and selling of sperm, 122, 173, 213 donation, use of term, 118 donor anonymity, 113, 114, 131, 134–135 donor-conceived persons/people (DCPs), 134, 135, 205

donors to early programs, 173, 209, 221 sperm donation, 13, 17n12, 76, 120, 122, 124, 164, 203, 205, 216 Donor Sibling Registry, 135 Donum Vitae (The Gift of Life) (1987), 121 Dubai (UAE), 4, 85, 178 Due, Clemence, 184 E

Ectogenesis, 31, 33, 240, 241, 245, 250–251, 255 Ecuador, 122–123 Edinburgh (Scotland), 50 Edinburgh University, 30, 47, 79, 104n88 Edwards, Robert, 1, 2, 11, 16n5, 27, 29, 30, 33–37, 39, 41–50, 52, 53, 71–73, 75, 77, 79–83, 85, 91, 114, 124, 132, 139, 213, 241, 242, 249, 257 Egg(s), 2, 3, 5, 8, 13, 17n14, 23n51, 31, 35, 36, 40, 41, 44, 74–76, 81, 83, 88, 92, 116, 121, 124, 131, 154n133, 159–184, 185n6, 204, 208–210, 212, 215, 216, 218, 221, 223, 244–249, 251, 265n33 difficulty working with, 34 donation, 12, 13, 45, 76, 160–161, 163, 165, 209, 210 elective (social) freezing, 203, 209 in vitro maturation (IVM) used in AR, 161 medical freezing, 208, 209

 Index 

numbers used in early IVF research, 100n26 provision, 4, 162, 164, 169, 178, 180, 181, 208, 251 selling, 8, 12, 162–163, 166, 170, 181 sharing, 161–162 Egypt, 113, 114, 116, 120, 122, 214 See also Cairo (Egypt) Elder, Kay, 44 Elective single embryo transfer (eSET), 133, 172 Embryo(s) donation, 76, 117, 160–161, 241, 243–245 flushing (see Lavage, embryo) fourteen-day research rule, 250 freezing, 37, 47, 75, 76, 82, 108n145, 128, 130, 161 gene ‘editing,’ 9, 241, 243 genetic screening in public health, 178 ‘glue’ (see Adjuvant treatments) role in current reproduction research, 241 Embryo Research Licensing Committee (Australia), 119 Embryology, 6, 29–31, 33, 58n35, 114 Embryonic stem cells, 246, 247, 249 Endocrinology, 6, 29, 31, 47, 58n35, 79 Enzmann, Ernst, 35 Ethics Advisory Board (US), 115 Ethics, debates on IVF research, 161 Ethnicity, importance of gamete provision, 164 Eugenics

347

liberal, 93, 164 positive, 38, 93 twentieth-century, 108n149 Eugenics Society, 32 Europe, 41, 214 European Court of Human Rights (ECtHR), 130, 173 European Society of Human Reproduction and Embryology (ESHRE), 3, 80, 83, 84, 87, 88, 90, 138, 166, 179, 181, 184, 219 Exploitation, risk of, 8, 136, 167, 168, 176, 179, 184 F

Facebook, 209 Fallopian tubes obstruction as medical indication for IVF, 44, 49 flushing as non-AR fertility treatment, 73 Family creation through AR gay men, 203 heterosexual people, 112, 120, 124, 167 lesbians, 203 marriage laws, 172 single people, 128, 167, 203 Family, notions of, 203, 210 Farquhar, Cindy, 150n99 Feminism views on AR within, 7, 123, 180, 181 views on regulation, 127–128 See also Feminist scholarship Feminist fiction, 32, 245

348 Index

Feminist International Network of Resistance to Reproductive and Genetic Engineering (FINRRAGE), 127 Feminist scholarship, 8, 127, 128 Fertility agencies and intermediaries, 15 blogs, 5, 7 financing schemes, 3 ‘hyper-fertility,’ 39 professional societies’ role in expansion of AR, 82–84 See also Fertility drugs; Infertility Fertility and Sterility, 82, 83, 88, 136, 137 Fertility Clinic Success Rate and Certification Act (1992), 136 Fertility drugs, 31, 33, 37, 39–41, 56n22, 80, 81, 129, 165–166, 190n46, 204 clomiphene citrate, 74 follicle stimulating hormone (FSH), 206 gonadotrophin-releasing hormone (GnRH) analogues, 190n46 human chorionic gonadotrophin (hCG), 74 human menopausal gonadotrophin (hMG), 41, 42, 74 luteinizing hormone (LH), 206, 225n13 See also Ovarian hyperstimulation syndrome Fertility Society of Australia (FSA), 83, 84, 90, 162 Finland, 83 Firestone, Shulamith, 245, 257 See also Dialectic of Sex, The

First IVF births (1978) contingency of achievement, 1, 27–53 scepticism about, 2, 16n7, 48 France, 29, 30, 41, 43, 44, 75, 78, 79, 85, 88, 93, 114, 115, 120, 125, 166, 169, 173, 211, 212 Franco, Francisco, 123 Frangenheim, Hans, 33 Frankenstein; or, the Modern Prometheus (Mary Shelley), 211 Franklin, Sarah, 4, 20n31, 28, 29, 39, 42, 43, 77, 114, 139, 180, 221, 222 Freezing egg, 94, 203, 207–213 embryo, 47, 75, 76, 82, 108n145, 128, 130, 161 gamete, 3, 30, 94, 125, 161, 167, 205, 207–210 See also Cryobiology ‘French champagne,’ see Ménézo’s B2 medium Frydman, René, 29, 41, 43–45, 50, 79, 88, 132, 253 Funding of early IVF benefactors, 86 commercial sponsors, 96 doctors, 86 Ford Foundation, 39, 47 patients, 86 G

Gabon, 105n96 Gamete(s) donation, 114, 117, 121, 126, 134, 135, 256

 Index 

laboratory-made (see In vitro gametogenesis (IVG)) mammalian use of in research, 35 provision, 12, 119, 128, 134, 166, 167, 175, 251 sale, 8, 180 See also Egg(s); Oocytes; Sperm Gamete intra-fallopian transfer (GIFT), 123 Gay parenting, see Family creation through AR Gayovych, Olga, 172 Gametogenesis, 248 G (gonadotrophin) Club, The, 83 Gender, 2, 5, 9, 32, 122, 128, 141, 178–179, 197n126, 202, 203, 209, 214, 222, 224n2, 239 Gender relations, 122, 128, 239 Gender roles in parenting, 203, 209, 214 Gene editing, 9, 242–244, 247 See also Genetic modification; Mosaicism Genes, 118, 163, 241–243, 248, 254, 255 Genetic engineering, see Genetic modification Genetic modification, 240, 243 See also Gene editing Genetics, 3, 30, 31, 43, 44, 73, 76, 93, 111, 112, 116, 118, 121, 128, 130, 145n37, 164, 167, 169, 178, 184, 203, 205, 212, 216, 218, 223, 240–244, 251–255 Georgia (country), 169 Germany, 32, 41, 75, 78, 124, 166, 210

349

See also Roman Law, application of in Germany; West Berlin (Germany) Ghana, 105n99 Girault, Louis, 30 Glasgow (Scotland), 43, 50 Gonadotrophin(s), 64n110 early use in humans, 31, 41, 42 Gonadotropin(s), see Gonadotrophin(s) Grand Shaykh of Al-Azhar University (Cairo), 116 Greece, 77, 170 See also Thessaloniki (Greece) Groupe Inter-africain d’Etude de Recherche et d’Application sur la Fertilité (GIERAF), 85 Guinness Book of Records, 210 Gunning, Jennifer, 130 Gürtin, Zeynep, 93, 167 Gynaecologists, 1, 34, 50, 73, 77–79, 88 Gynaecology, see Obstetrics and gynaecology H

Haldane, Charlotte, 32, 57n25 Haldane, John Burdon Sanderson (J. B. S.), 31, 32, 57n26, 245, 257 Hammersmith Hospital (London), 77, 79, 118 Hampshire, Kate, 19n31 He Jiankui and first claim of gene editing, 242–243 Health, Education, and Welfare (HEW), Department of (US), 115, 142n9, 143n13

350 Index

Hertig, Arthur, 34 Heteronormativity, 48 Heterosexuality, 3, 112, 120, 124, 167, 173, 175, 202, 205–207, 213, 223, 248, 258 See also Family creation through AR Hinduism, 122 Homophobia, 224n2, 257 Homosexuality, 175, 176, 183 Hormonal stimulation, see Fertility drugs Howell, Lillian Lincoln, 42, 86 ‘How to Buy a Baby’ (film), 13 Hudson, Nicky, 227n26, 231n59 Human–animal hybrid, 250 Hukou, household registration, China, 174 Human Fertilisation and Embryology Act (1990), 117 Human Fertilisation and Embryology Authority (HFEA), 117, 119, 125, 133, 134, 138, 145n36, 162, 210, 212, 213, 220, 231n55 Human Reproduction, 83, 99n23, 101n38, 135, 154n138, 155n149, 156n161, 190n46, 190n51, 199n147, 224n3, 263n21, 265n32 Human rights commentary, 179–184 Hunan Province (China), 120 Hungary, 94 Huxley, Aldous, 6, 31, 32, 240, 245, 257 See also Brave New World Huxley, Julian, 31, 32, 57n25 Hybrid, see Human-animal hybrid

I

Iceland, 83 Incest, 116, 124 Incest, genetic, 121 India, 2–4, 19n28, 28, 29, 37, 42, 47, 48, 50–52, 54n4, 78, 92, 95, 104n93, 164–166, 197n126, 210, 212 international surrogacy, 159, 168–170, 175, 176 law, 122, 179, 182, 183, 241 See also Agarwal, Kanupriya; Deomampo, Daisy; Mukerji, Subhas; Union Cabinet of India; West Bengal (India) Indian Council of Medical Research, 52 Indian Journal of Cryogenics, 50, 68n149 Induced pluripotent stem cells, 246, 247, 266n35 Infertility changing definitions, 138 endometriosis, 81 experienced as loss, 256 in the female, 3, 75, 213–215 grief reaction, 206 idiopathic, 3, 75 in the male (‘male factor’), 203, 213–216 primary, 3 secondary, 3 social, 3 tubal, 73, 74, 77 tubal repair as treatment response to, 81 unexplained, 75, 81 See also Fertility drugs

 Index 

Infertility (Medical Procedures) Act (1984), 117 Inhorn, Marcia, 4, 20n33, 122, 167, 185n4, 214, 222, 252, 270n64 Institute for Research in Reproduction (Bombay), now National Institute for Research in Reproductive Health, (Mumbai), 50 Institut national de la recherche agronomique, France (INRA), 30, 36 Intermediate Court of Wuxi (China), 212 International Committee for Monitoring Assisted Reproductive Technology (ICMART), 184, 201, 224n2, 224n3 International Federation of Fertility Societies (IFFS), 2, 112, 131, 133, 134, 141n3, 154n144, 178, 184, 191n58, 197n127, 221, 252 Internet, 7, 91, 120, 163, 204, 257 Intracytoplasmic sperm injection (ICSI) male infertility, 216, 217 overtaking use of IVF in non-­ male factor, 216, 217 Intrauterine insemination (IUI), 24n52, 133, 154n133 In vitro fertilisation (IVF), and passim compared to ICSI, 217 development towards in twentieth century, 28, 29, 31 early controversy and media relations, 243

351

importance of diverse disciplines, 33 In vitro gametogenesis (IVG), 246–247 In vitro maturation (IVM) of eggs, 161, 265n33 INVOcell, 253 Iran, 214 Ireland, 125 Irish Fertility Society, 125 Islam, 121, 124 Islam, Shi’ite, 121, 143n23 Islam, Sunni, 116, 121, 122, 143n23 Israel, 2, 4, 17n12, 41, 42, 83, 92, 95, 121, 164, 165, 168, 172, 189n46, 207, 212, 254, 257 High Court, 207 Ministry of Health (MOH), 95 See also Sheba Medical Center at Tel Hashomer (Tel Aviv, Israel) Italy, 41, 128, 129, 142n11, 174 See also Bologna (Italy), Milan (Italy) Italy, Law 40/2004, 128–130 feminist perspectives, 129 IVF Australia (1985–1992, later, IVF America), 90 IVF Friends, 86 IVF imaginary, 31–33, 257 IVF, see In vitro fertilisation J

Jaffe, Aaron, 115 Japan, 2, 4, 36, 39, 40, 48, 83–85, 159, 172, 210, 212, 240, 246, 247 regulation by professional body, 125, 126, 169

352 Index

Japan Society of Fertility and Sterility, 83 Japan Society of Obstetrics and Gynecology (JSOG), 125, 126, 149n89, 159 Jasanoff, Sheila, 141 Jenkins, Warren, 86, 87 Johns Hopkins University (Baltimore), 48 Johnson, Martin, 43, 44 Johnston, Ian, 29, 73, 76, 86, 90, 98n19, 222 Jones, Georgeanna Seegar, 29, 48, 78, 79, 86, 250 Jones, Howard, 29, 44, 48, 78–80, 250 Journals, 7, 11, 20n36, 50, 51, 73, 81–83, 96, 136, 139 Judaism, 95, 121, 122 K

Kennedy, Richard, 221 Kenya, 169, 176 Key performance indicators (KPIs), in AR commerce, 220 Klein, Renate, 151n105, 151n110 Kolkata (India, formerly Calcutta), 2 L

Laissez faire, policy of, 115 Lancet, The, 11, 12, 81 Language, narrative and media, importance in AR history, 9–11 Laos, 176, 212 Laparoscopy, 2, 33, 44, 47, 53

Latin America, 180 See also Brazil; Ecuador; Mexico Lavage, embryo, 161 Laws, 3, 4, 7, 8, 11, 112–117, 119, 120, 123, 125, 129–131, 135, 140, 141, 167–170, 172, 173, 175–177, 179, 180, 182, 211 See also Case law, compared to statute law; Peer regulation; Statute law Leeton, John, 29, 40, 74 Legitimacy, 130, 139, 141, 172, 173, 181, 205, 223, 258 See also Citizenship, state policies on AR births Lesbian parenting, see Family creation through AR LGBT+ family creation through AR, 206–207 LIV Fertility Center, 179 Live birth rates, see Success rates following AR Lizhu, Zhang, 41, 85, 92, 93 Lobbying, 86, 117 Lopata, Alex, 29, 49 Loraine, John, 47, 79 Loth, David, 38 Low-cost IVF, 251, 253 Low Cost IVF Foundation (LCIVF), 252, 253 Lunenfeld, Bruno, 41, 83, 100n26 Luteinizing hormone (LH), 225n13 M

Maastricht (Netherlands), 83 MacDonald, Alastair, 50, 72

 Index 

‘Mackenzie’s Mission’ (Australian genetic testing policy), 254 Malawi, 215 Mali, 85, 86 Manchester (UK), 1, 252 Mandelbaum, Jacqueline, 29 Marital status, see Marriage Marketing of AR, 88, 163, 167 Marriage, 180 gay, 112, 121, 172, 174, 202, 206, 207, 212 heterosexual, 202 lesbian, 207 Marrs, Richard, 84 Mba, Dr, 86, 105n95 McBain, John, 46 McLaren, Angus, 32 Media media/medicine nexus, 9, 89 medical press, 77 reportage, 5 Medical associations, 125 Medical autonomy, doctrine of, 184 Medical industrial complex, 88, 89 Medically assisted reproduction (MAR), see Assisted Reproduction (AR) Medical Research Council (MRC), 39, 49, 76 Medicare (Australia), 86 Meetings and conferences, as foundation of fertility industry, 78–87 Meiosis, 246, 248, 255 Melbourne (Australia), 46, 71–75, 78, 79, 84, 86, 127, 161, 221, 222 Ménézo, Yves, 36, 60n59

353

Ménézo’s B2 medium, 36, 60n59 Menkin, Miriam, 29, 31, 34, 35, 57n23, 89 Metzler, Ingrid, 141 Mexico, 41, 95, 120, 169, 175, 176, 179, 182, 243, 244 See also Mexico City, Puerto Vallarta (Mexico), Quintana Roo (Mexico); Tabasco (Mexico) Mexico City, 175 Mice bimaternal, 248 bipaternal, 248 Middle East, 3, 214 See also Cyprus; Egypt; Iran; Israel; Jordan; Lebanon; Saudi Arabia; Turkey; United Arab Emirates (UAE) Middle East Fertility Society, 83 Milan (Italy), 83 Miracles, IVF births as, 9, 10, 50, 256 Mishtal, Joanna, 141 Mitchison, Naomi, 32 Mitochondria, 244, 245, 255, 263n21 Mitochondrial deoxyribonucleic acid, see Mitochondrial DNA Mitochondrial DNA, 243–245, 263n21 Mitochondrial donation, 241, 243–245, 251, 255, 263n21 Mitterrand, François, 115 Modernity, 73 Moffett, Ashley, 218, 219 Monash University (Melbourne), 72, 84

354 Index

Morgan, Lyn, 123 Mosaicism, 243 Moscow (Russia), 83 MtDNA, see Mitochondrial DNA Mukerji, Subhas, 1, 2, 16n3, 28, 29, 36, 37, 42, 47, 48, 50–53, 54n4, 78, 79, 104n88 Mukherjee, Sunit, 1, 16n3, 28, 29, 48, 50–52 Multiple birth risks to children, 131 risks to mother, 133 Mumbai (India, formerly Bombay), 50 Mutlu, Burcu, 175 N

Nahman, Michal, 94, 109n152, 164, 166, 181 ‘Narelle’s law’ (Victoria) (2017), 135 Narrative, 5, 9–14, 110n165, 203, 222 Natalism, 91–96 Nation, 4, 5, 7, 15, 38, 91–97, 120, 167, 168, 204, 205 National Health Service (NHS), 38, 79, 86, 102n58, 202 National Institutes of Health (NIH), 40, 51 Nationality, see Citizenship National regulations, 119, 120 Natural cycle (IVF), 37, 46, 52, 53, 77 Natural Killer (NK) cells, see Adjuvant treatments Natural ovulatory cycle, 1–2 See also Natural cycle Nature, 49, 72, 81, 99n24, 243

Neo-liberal economic policies, 257 Neonatal care, 240, 253 Nepal, 168, 169, 176 Netherlands, 170, 249 See also Maastricht (Netherlands) New Caledonia, 93, 108n146 New South Wales (Australia) See also Supreme Court (New South Wales); Westmead Hospital (Sydney, New South Wales) New York (US), 121, 209, 243, 249 New Zealand, 83, 86, 125, 214 Niger, 105n96 Nobel Prize, 53, 70n189 Nordic Fertility Society, 83 Norfolk Hospital (Virginia, US), 80 Norman, Rob, 138, 220 North Africa, 3 Norway, 83, 166 O

Obstetricians, concerned about AR, 1, 29, 30, 73, 77–79, 83–85 Obstetrics, see Obstetrics and gynaecology Obstetrics and gynaecology, 6, 82, 172, 253 See also Gynaecologists; Obstetricians, concerned about AR Oldham (UK), 1 Oldham District and General Hospital, 47 Oligospermia, 75, 81 Ombelet, William, 253 Oocyte provision, see Egg(s), provision

 Index 

Oocytes, see Egg(s) Oocyte spindle transfer, see Mitochondrial donation Orbán, Viktor, 94 Organon, 33, 87 Oudshoorn, Nelly, 31 Ovarian hyperstimulation syndrome (OHSS), 8, 42, 99n26, 131, 165, 184, 189n46, 253 Ovulation, 30, 31, 37, 41, 42, 44, 47, 53, 72, 74, 75, 84, 87, 99n26, 160, 185n6 Ovum/ova, see Egg(s) P

Palmer, Raoul, 33 Parenthood, 13, 14, 76, 81, 95, 170–171, 173, 182, 206, 214, 223 Parkes, Alan, 49 Patrizio, Pasquale, 94, 252 Paul, John, 43 Peek, John, 125 Peer regulation, 7, 114, 125–126, 131, 135, 140 Pentagon, The US Department of Defense, 209 People’s Republic of China, see China Pergonal (hMG), see Fertility drugs Perth (Australia), 132, 211 Piercy, Marge, 257 See also Woman on the Edge of Time Pincus, Gregory, 31, 34, 35, 57n23, 57n25 Pioneers, IVF use of the term ‘pioneer,’ 10 women pioneers, 43–47

355

Plachot, Michelle, 29 Planned Parenthood Federation of America (PPFA), 38 Pluripotent stem cells, 246, 247, 249 Poland, 123, 180 restrictive laws on single women, 207 Population control, 39, 50, 95 contraception research funding overlap with fertility, 39 idea of population ‘replacement’ rate, 94, 173 perceived overpopulation, 28, 38 policy, 73 Population Council, 39 Porter, Ric, 90 Posthumous assisted reproduction, 130, 203, 211–213 ‘Pre-embryo,’ 10, 118 Pregnancy definitions of, 138 spontaneous after unsuccessful AR, 220 Preimplantation genetic diagnosis of embryos (PGD), see Preimplantation genetic testing for monogenic/single gene defects (PGT-M) Preimplantation genetic screening of embryos (PGS), see Preimplantation genetic testing for aneuploidy/-ies (PGT-A) Preimplantation genetic testing for aneuploidy/-ies (PGT-A), 145n37, 178, 179, 219–221 Preimplantation genetic testing for monogenic/single gene defects (PGT-M), 118

356 Index

Pronuclear transfer, see Mitochondrial donation Public interest, 72, 119, 139, 258 Public relations, 7, 89–91, 96, 97 Puerto Vallarta (Mexico), 179 Purdy, Jean, 1, 27, 33, 34, 37, 44, 47–49, 52, 54n3, 70n189, 71 Q

Quebec (Canada), 133 Queensland (Australia), 211 Quintana Roo (Mexico), 175 Queen Victoria Hospital (Melbourne), 78 R

Race, significance in gamete provision, 163–165 Rapp, Rayna, 46 Reed, Candice, 46, 71, 86, 98n19 Regenerative medicine, use of embryos, 114 Regional Institute of Ophthalmology (West Bengal), 51 Regulation peer/medical self, 7, 125–126, 131, 135, 140 ‘soft,’ 130–139 statutory, 247 See also Laws Religion, role in AR debate, 140 Religions, religious groups Anglicanism, 116, 123 Buddhism, 94, 124 Catholicism, 38, 113, 122, 123, 127

Christianity, 121 Confucianism, 121 Coptic Christianity, 116 Hinduism, 122 Islam, Shi’ite, 121 Islam, Sunni, 116, 121, 122 Judaism, 95, 121, 122, 258 Serbian Orthodox, 124 Reproduction studies, 1–15, 27, 71–97, 111, 159–184, 202, 239–259 Reproductive cloning, 114 Reproductive imaginary, 9, 48 Reproductive physiology, 29 Reproductive studies, see Reproduction studies Reproductive Technology Accreditation Committee (RTAC), 138 Reproscape, global, 4, 5, 96 Republic of China, see Taiwan Resolve (New Zealand), 86 Resolve (USA), 86 Reuters, 89 Rhetoric, 12, 95, 133, 256 Riggs, Damien, 184 Rights children’s, 182, 183 discourse of, 182 patients, 7, 219, 257 reproductive, 95, 164, 180, 205 women’s, 38, 257 Risks, 3, 7, 8, 12, 13, 48, 76, 82, 88, 90, 95, 99n26, 111–141, 165, 168, 171–173, 176, 184, 190n46, 208, 209, 211, 214, 219, 242, 251 Risks of AR, legal

 Index 

to children, 173 in cross-border reproductive treatment (CBRT), 167 to intended parents, 169 parents, 173, 180 Risks of AR, medical, 131 to egg donor-providers, 160, 161 to providers of children through surrogacy, 8, 13 Roberts, Elizabeth, 123 Rock, John, 29, 31, 32, 34, 35, 38, 45, 56n22, 89 Rockefeller Foundation, 39 Romania, 4, 94, 180, 181 Roman law, application of in Germany, 124 Roma women (Romania), 94 Rongieres, Catherine, 125 Rose, Molly, 34 Rosenblatt, Roger, 14 Rowland, Robyn, 127, 161 Royal College of Obstetrics and Gynaecology, 82 Royal Free Hospital (London), 79 Royal Women’s Hospital (Melbourne), 71, 73, 75, 78, 86, 222 Rudrappa, Sharmila, 182, 183 Russia, 169, 181, 195n95 See also Moscow (Russia) S

Sacks, Gavin, 218 Sacoto, Sonia Merlyn, 181 Same-sex couples, 9, 130, 204, 247, 251, 255 Same-sex reproduction

357

imprinting, 248, 255 See also Mice, ‘bimaternal’ Saudi Arabia, 214–215 ‘Saviour siblings,’ 205 Scandinavia, 75 Schenk, Leopold, 35 Schurr, Carolin, 183 Science fiction and scientific practices, 6, 31, 32, 44, 51, 57n30, 240, 258 Scotland, 36 See also Edinburgh (Scotland), Glasgow (Scotland) Self-regulation, see Peer regulation Senegal, 105n96 Serono, 41, 42, 87 See also Jenkins, Warren Sexuality, 5, 180, 202, 239 Sheba Medical Center at Tel Hashomer (Tel Aviv, Israel), 42 Shelley, Mary, 230n42 See also Frankenstein Shenzhen (China), 242, 243 See also Southern University of Science and Technology (Shenzhen) Sher, Geoffrey, 217, 225n13 Shettles, Landrum, 29, 35, 40 Shreeve, Norman, 218, 219 Simpson, Bob, 19n31, 94, 124 Singapore, 41, 83, 94, 173 Single person parenting with AR, see Family creation through AR Society for Assisted Reproductive Technology (SART), 136 Sopheap, Chak, 177 South Africa, 162, 177 South America, 39

358 Index

South Asia, 3 Southern University of Science and Technology (Shenzhen), 242 Spain, 4, 41, 123, 149n84, 166, 212, 240 Spar, Debora, 13, 167, 180 Sperm banks, 30, 122 capacitation, importance to IVF, 35–37, 40, 215 donation, 13, 76, 120, 122, 124, 164, 203, 205, 216 motility, 75 provision, 124 selling, 122, 173, 213 Spinal muscular atrophy, 254 Spindle nuclear transfer, see Mitochondrial donation Squier, Susan M., 24n57, 28, 57n25 Sri Lanka, 92, 94 Standing Review and Advisory Committee on Infertility (SRACI) (Victoria), 117 Stanley, Fiona, 126 States, regulation under federal systems, 8 Statute law, 113, 117, 130 compared to case law, 117, 130 See also Peer regulation Stem cell research, use of IVF embryos in, 43 Stem cells, 43, 240, 246, 247, 249–251, 255, 267n48 See also Embryonic stem cells; Induced pluripotent stem cells; Pluripotent stem cells; Regenerative medicine, use of embryos

Steptoe, Patrick, 1, 2, 27, 29, 33, 34, 36, 37, 39, 42–44, 46–49, 52, 53, 54n3, 62n84, 71, 72, 79, 81, 100n38 Stock market, forecast, 88, 162 Strathern, Marilyn, 11, 205 Stratified reproduction, 8, 23n44, 180 Sub-Saharan Africa, 3, 252 Success rates following AR, 133, 134, 138, 162, 217 calls for consistency from government and within industry, 88, 135 definitions of, 113 Supreme Court (New South Wales), 211 Surrogacy altruistic, 169, 170 commercial, 169–171, 175, 176, 182, 184, 191n56, 207 by family members, 210 gestational, 169, 170 See also Birth mothers in surrogacy Surrogate mother, see Surrogacy Suzuki, Masakuni, 36, 39, 60n60, 84, 103n77 Sweden, 78, 83, 133, 166 Switzerland, 78 Syndicated news, 89 Syngamy, 23n51, 118 Syria, 122 Szoke, Helen, 119, 139 T

Tabasco (Mexico), 175 Taiwan, 133, 154n136

 Index 

Take-home baby rate, see Success rates following AR ‘Technodocs’, coining of term, 88 Tel Hashomer (Israel), 42 Termination of pregnancy, see Abortion Testart, Jacques, 29, 30, 34, 41, 44, 49, 50, 60n59, 88, 242 Test-tube baby/ies, 12, 71, 72, 81, 99n24, 142n9 Thailand, 4, 91, 169, 171, 174, 176, 183 Thalidomide, 113 Thatcher, Margaret, 124, 140 Theological views of AR, see Religions, religious groups Thessaloniki (Greece), 83 Thibaud, Charles, 30 Third Congress on Human Reproduction, West Berlin 1981, 74 Thomas, Michael, 76, 268n54 Thompson, Charis, 137, 163, 182, 188n30, 199n151, 222 ‘Three-parent’ embryos, see Mitochondrial donation Times, The (London), 72, 81 Togo, 105n96 Tonti-Filippini, Nicholas, 127 Trafficking, human, 13, 177, 183 Training, importance in spread of use of AR, 73 Transgender parenting, 141 preservation of gametes, 3 Transplantation kidney, 12 uterine, 251

359

Trisomy 21 (Down Syndrome), 171 Trounson, Alan, 29, 30, 39, 43, 49, 55n10, 72–76, 78, 80, 81, 98n16, 98n18, 138, 222, 243, 253 Turkey, 21n37, 93, 107n139, 108n139, 124, 175, 195n104 TVM Capital Healthcare, 85 Tyler, John, 88 Tyrode’s solution, 36 U

Uganda, 252 Ukraine, 85, 168, 169, 171, 172, 195n95, 210 Union Cabinet of India, 241 United Arab Emirates (UAE), 4, 85, 209 See also Dubai (UAE) United Kingdom (UK), 1, 20n34, 29, 32, 34, 38, 39, 44, 45, 47–52, 71, 78, 86, 112–114, 116–120, 124, 125, 133, 138, 140, 142n7, 146n47, 166, 169, 170, 201, 210, 212, 214, 217, 220, 249, 250, 252 United Nations Special Rapporteur on the Sale and Sexual Exploitation of Children, 183 United States (US), 2, 3, 13, 29, 30, 32, 35, 37–42, 50, 60n59, 75, 78–80, 84, 86–90, 94, 112–120, 132, 133, 136–138, 162–164, 167, 169, 170, 172–174, 178–180, 184, 201, 202, 208, 209, 213, 214, 217, 240, 244, 249, 250, 252, 253

360 Index

United States Conference of Catholic Bishops, 123 University College of North Wales, Bangor, 30 University of Calcutta (Kolkata), 47 University of Cambridge, 30 University of Edinburgh, 30, 47, 79 University of Oxford, 220 University of Sydney, 30 Uterine lavage (of embryos), 161 Uterine transplant, 251 V

Vatican, see Catholic Church Venture capital, 7 Victoria (Australia) Committee to Examine In Vitro Fertilisation (1982–1984), 116, 117, 119 Infertility (Medical Procedures) Act (1984), 117 See also ‘Narelle’s law’ (Victoria) (2017); Victorian Assisted Reproductive Treatment Authority (VARTA) (Australia) Victorian Assisted Reproductive Treatment Authority (VARTA) (Australia), 24n52, 119, 220 Vitrification, 125, 208, 227n21 W

Wagner, Marsden, 90 Waldby, Catherine, 8, 162, 165, 222 Walking Egg Project, 253 Waller Committee, see Victoria (Australia), Committee to

Examine In Vitro Fertilisation (1982–1984) Waller, Louis, 116, 117, 130, 142n7 Walters, William, 239, 240, 257 Warnock, Mary, 116, 130 Warnock Committee, 116–118 Water-Babies, The (Charles Kingsley), 31 Weis, Christina, 181, 195n95 West Bengal (India), 42, 51 Department of Health Services, 51 West Berlin (Germany), 74 Western Australia, 86, 211 Westmead Hospital (Sydney, New South Wales), 90 Whittaker, Andrea, 42, 183, 198n127 Whitten, Wesley K., 40 Wilson, Duncan, 117 Winston, Robert, 77, 79, 86, 101n41, 165 Woman on the Edge of Time (Marge Piercy), 245 Women early IVF patients as ‘moral pioneers,’ 46 older, giving birth, 128, 130, 162, 203, 207–213, 223, 245, 251, 255 significance of AR for, 113, 245 See also Gender Wong, P. C., 83 Wood, Carl, 29, 36, 39, 40, 73, 74, 76, 78, 79, 81, 86, 89, 90, 93, 98n16, 99n24, 118 World Health Organization (WHO), 90, 201, 224n3

 Index 

Wu, Chia-Ling, 133 Wyden, Ron, 136, 137

Yousheng, 93, 108n149 Yugoslavia (former), 77

Y

Z

Yanagimachi, Ryuzo, 36, 40 Younger, Benjamin, 136, 162

Zhang, John, 242–245 Zimbabwe, 85, 95, 213

361