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Choosing Sex, Compensating Donors and Egg Banks: The NHMRC is calling for our thoughts on IVF

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Australia is reviewing its policy on IVF sex selection, compensating egg donors and egg banks. They have asked for submissions with our thoughts on this. My submission is below. The Working Committee has developed a range of case studies that illustrate the issues that arise. You can read more about each of these case studies here:
http://consultations.nhmrc.gov.au/files/consultations/drafts/artdraftethicalguidelines150722.pdf

You can also make your own submission here:

http://consultations.nhmrc.gov.au/public_consultations/assisted-reproductive-tech

Also, I invite you to read this illuminating article by Tereza  Hendl on the topic of sex selection in The Conversation:

https://theconversation.com/choosing-childrens-sex-is-an-exercise-in-sexism-45836

Appendix 3a Sex selection for non-medical purposes

I am heavily in favour of the existing laws remaining as they currently are. This is largely due to the inherently forceful application of gender norms upon children whose sex has been chosen. I wholeheartedly agree with the 2007 guidelines which state that admission to life should not be conditional upon being a particular sex. I address the case studies in the following ways:

Family Balancing: none of the four scenarios in this case study present a strong enough argument for sex selection, in my opinion. Rather, all four of the scenarios demonstrate an assumption that gender is tied to sex, and expectation that an child of a particular sex will display particular gender characteristics. This is a problem because it reinforces gender norms.

Replacement of a Child: While this case carries much more sympathy that the scenarios in the Family Balancing case, they essentially come back to the same problem – that there is an assumption that a child of one sex with ascribe to a particular gender, and will be somehow similar to the previous child who was or was not of that gender. I cannot support sex selection in this case.

Travelling Overseas for Sex Selection: In these scenarios we are presented with good evidence for why IVF in Australia should be more readily available and cost effective, but not good evidence for why sex selection should be allowed. While some patients will continue to travel overseas for treatment, in order to gain sex selection, it is my opinion that Australian clinics should counsel patients as to WHY they wanted sex selection, and continue to offer them safe and regulated treatment NOT including sex selection. This would mean that more parents might be encouraged to stay in Australia for their treatment, and have the opportunity to address any assumptions they have about gender and their future child.

Respecting Parental Autonomy: These scenarios present exactly the problems I have been outlining in the previous three case studies. Parents should be counselled to realise that their happiness does not depend on their child fulfilling certain gender expectations, and to try and do so is potentially detrimental to the child’s own mental health.

Other potential Uses: The is an obvious flaw here in that sex selection will not determine whether the child will or will not inherit the condition that the parents do not desire. However, there is a more significant problem, in that parents and society more generally are not able to value individuals who are seen as ‘disabled’ in some way. We must work against this assumption, just as we are with gender norms, to realise that those who have been diagnosed with some form of ‘disorder’ are not limited, or lacking potential. Rather, these people possess incredibly valuable personal qualities that can make them hugely significant contributors to our communities.

Appendix 3b Compensation of Australian women for the reproductive effort and risks associated with donating their eggs

It seems that the important distinction to be made is how much egg donors are compensated and what constitutes the difference between compensation and inducement. I would suggest that it is currently common practice for donor-recipients to compensate their egg donors all the costs referred to as ‘reasonable out-of-pocket’ expenses, including medical, counselling, loss of earnings, travel, accommodation, insurance and legal advice. It may be useful then, to have some kind of regulation around these costs, to make the line between ‘reasonable’ and ‘unreasonable’ costs clearer for all parties. So long as the egg-donor was only reimbursed, and not able to actually make a profit from donating, I see no reason why these regulations should not be brought into place. This would increase options for donor-recipients greatly, as more women might be willing to donate, particularly to not-previously-known donor recipients. However, I suspect that the numbers of voluntary donors might still remain low, since this system would not essentially be any different from the current system based on altruism, just more regulated.

Appendix 3c 3c Establishment of an Australian donor egg bank

An egg bank would have the benefit of regulating how children may continue to access their donors, and information about them throughout their lives. Donors would also be able to continue to access information about any children that were born as a result of their donation. However, donors should not be able to contact children unless parents and children have specifically requested this.

I am in support of the establishment of an Australian donor egg bank, under certain conditions. Eggs which have been frozen, but unused, by women who undertook their own IVF cycles, should be available for donation, but not for any compensation. This should only be the case once that woman has completed her own family, to reduce the risk of her regretting the decision to donate. Since the woman’s costs involved in the procedure have already been covered by herself, she should not incur any further costs in choosing to donate the eggs that she no longer wants to use. This would essentially mean that she would not be compensated more than other egg donors, who would be provided with nothing beyond ‘reasonable out-of-pocket’ expenses.

Egg sharing, where women are compensated costs for IVF in exchange for donating some of their eggs should not be allowed. Women who need IVF to conceive should have completed their own families before being able to donate to the egg bank, particularly if they have not been able to conceive easily themselves. This will reduce the likelihood of women who are currently undergoing IVF, donating their eggs, and later feeling that they ‘lost’ the ‘good’ eggs to a donor-recipient. This is a separate issue to women who wish to donate to an egg bank prior to choosing to start their own families. This should be allowed, so long as they have received significant counselling about the impact of potentially donating eggs, if natural conception does not come so easily for them later. In this case, women should be compensated, just as they would be if it were an altruistic donation to a known donor-recipient.

Egg Freezing: Helpful or Pressurising?

egg-freeze

(Please note: I use this image ironically.)

Yesterday, Professor William Ledger wrote an opinion peice in The Age on fertility and the problem of an aging population. Ledger is head of UNSW Medicine’s School of Women’s and Children’s Health and professor of obstetrics and gynaecology. You can read the opinion piece here:

http://m.theage.com.au/comment/ivf-isnt-a-fixall-for-those-choosing-to-delay-adulthood-20150531-ghddn9.html

I also attended Ledger’s lecture last night, entitled, “The Ticking Clock: Demographic Change and Future Families” presented with social researcher Mark McCrindle at UNSW. I appreciated how Ledger’s discussion of IVF in older women was preceded by McCrindle’s thoughtful analysis of demographics in Australia and how they have changed. There were moments, particularly at the end of Ledger’s question time, when he seemed to be suggesting that it was a simple thing for women to choose to have their families earlier, that they should be prioritising finding their partners and ‘settling down’ over career or other goals. I found this uncomfortable on a number of levels, not the least of which was the suggestion that women should settle with a partner they might not otherwise have wanted children with, just because they feel the pressure of their ‘ticking clock’. McCrindle’s demonstration was a welcome relief to this simplistic idea of young women’s lives. McCrindle argued that society is changing, and that the pressures of housing and income make the fairytale of ‘a house and kids’ less available to most young people.

Of course I am not ignoring the fact that while our generation can expect to have a longer lifespan than any before it, and therefore to spread out our life experiences, a woman’s window for fertility does not change. Certainly, I am taking what I consider Ledger’s most helpful piece of advice to dinner conversations with friends: if you are over 30, and not sure when you plan to have kids, get your AMH tested so that you have some idea of how many fertile years you have left. The AMH test is a simple blood test, and should cost less than $100. For giving yourself some indicator of when menopause will happen, this seems like a good investment. If you find out that you are one of the unlucky ones who will run out of eggs sooner rather than later, then you have the option to freeze some eggs, and keep them in the bank for later.

The thing that surprised me the most about sitting in this lecture was watching the audience’s reactions. I had not realised how few people understood that IVF does very little to fix the age of eggs. In fact, women in their 40s usually have the same chance of conceiving naturally as they do with IVF. So long as there are no ovulation or fertilisation issues, which there usually aren’t, IVF cannot yet do anything to solve the fundamental problem in getting pregnant at this age: that a woman’s eggs are not as chromosomally capable as they once were. This means that the egg is unable to develop an embryo, which needs all of the power of the egg to combine the DNA from egg and sperm into a new baby’s individual DNA.

Ledger mentioned some emerging research looking at how to help older eggs repair DNA more efficiently, which may reduce the aging process, but is still in the early stage of development and a long way from clinical applications. It was all too clear listening to Ledger that the research needs more funding also, and the research that is being done is primarily directed at this ‘older egg’ problem, rather than younger women’s fertility issues such as Polycystic Ovaries and Endometriosis. While I wholeheartedly agree with the fundamental premise that women and men need more education about fertility, I am also wary that pressuring young women to think about their fertility may cause unnecessary anxiety, particularly in women who are likely to have no problem conceiving once they decide that that is a life course they want to take. Ledger mentioned that, to date, the overwhelming majority of eggs frozen by young women have not been used, suggesting that these women did not need the procedure in the first place. One cannot help but be curious what advantage it is to the business model of IVF clinics to be able to extend their market into the entire demographic of women in their 20s and 30s, not just women who have been unsuccessfully trying to conceive. Perhaps I am synical, but how many more patients and cycles can be marketed and invoiced if this huge new population of women were enticed into the market?

Ledger’s one piece of advice that he would give to a woman in her 30s right now, if she wasn’t in a relationship, would be to freeze her eggs. While I think this suggestion is rather extreme, I would suggest that if you are in your 30s, and definitely know that you want a child, but don’t know how or when that will happen, at least get your AMH test done. It’s quick, it’s simple, and will more than likely let you know that you have another decade of reproductive years ahead of you. If that test tells you that you would be better off to freeze some eggs, then at least you have that option, and those frozen eggs will be ready for whenever you and your uterus are ready to use them.

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