Parenthood at Any Price

Liza Mundy’s harrowing new book, Everything Conceivable, has the air of an exposé. Forget all those pink-and-blue fertility clinic brochures with their pictures of hunky donors, cuddly babies, and beaming families. Mundy, a Washington Post reporter, uncovers the real stories behind the fertility industry’s public relations façade.

Consider the case of Tammy and Steve LaMantia. Married young, the couple began trying for a baby almost immediately. When they failed to conceive, they visited a fertility specialist who diagnosed Tammy with polycystic ovarian syndrome, a hormonal disorder that can render patients infertile. In 1999, they began in vitro fertilization (IVF) treatment. Their doctors implanted three embryos, and Tammy became pregnant with triplets. But the couple’s joy was short-lived. At 21 weeks, Tammy went into labor. One boy was stillborn, the two other children, both girls, died an hour later.

Although Tammy and Steve tried to reconcile themselves to the prospect of adopting a child, just two weeks after the triplets’ funeral Tammy found herself once more saying, “I want to have a baby.” She waited four months — against the advice of doctors who wanted her to wait at least a year — and began IVF again. In 2001, she became pregnant. Tammy had another difficult pregnancy, developing placenta previa, a sometimes-fatal condition in which the placenta grows over the opening of the cervix. She spent more than three months in the hospital on bed rest, finally giving birth to twins.

The LaMantias’ tale is neither an uncommon nor an extreme example of the travails couples with fertility problems face when they resort to assisted reproductive technologies (ART). For many couples, it is a costly process fraught with uncertainty and pain, often culminating in disappointment. Not that any of this dissuades fertility patients. As one doctor tells Mundy, fertility patients are more motivated than cancer patients. Indeed, sometimes the only thing scarier than the medical procedures Mundy describes is the fierce determination of the patients themselves to have a child, no matter the cost.

There are women injecting themselves with their daily dose of hormone shots, their thighs bruised from previous jabbings. There are still more women lying on examining tables, feet in stirrups, getting ready to undergo a hysterosalpingogram, “a terrifically painful procedure in which dye is forcibly injected into the Fallopian tubes to see if they are open.” (Even when infertility is due to male factors, Mundy notes, it’s usually the woman who gets treated. As one nurse tells a patient, “Guys are the fragile sex.”) Mundy gives all the grisly details of scientists’ many attempts to get at the female germ line. In the 1970s, doctors would inflate the woman’s abdomen with carbon dioxide gas to get at the ovaries. Others used a spring-loaded gun to fire a needle into the ovary — anything for a pregnancy.

Today, fertility treatment has become a “consumption specialty,” often thought of as just another lifestyle option. Doctors frequently downplay the risks of procedures, especially when it comes to transferring multiple embryos, if they discuss them at all. Patients expect the impossible, like the woman in her forties who erupted in anger at her doctor when he told her she would need to use an egg donor. Fertility treatment, Mundy stresses, is a medical procedure, and like all medical procedures it’s uncomfortable and sometimes painful. It often fails (only a third of IVF attempts succeed) and it’s expensive — anywhere from $8,000 to $12,000 a pop. Yet clinics remain eager to cater to what Mundy describes as “our widespread expectation that events, including childbirth, should happen as soon as we are ready.” IVF patients request twins because they think (mistakenly, as Mundy shows) that having two children at once will be more convenient. Career women have their eggs frozen and stored, waiting for the day when they feel “ready” for children.

What of the babies who are the goal of these new reproductive technologies? The procedures of ART can harm the very children they help to create. Infertile fathers often pass their infertility down to their sons. Prematurity is now the leading cause of infant mortality in the United States, in part due to the “epidemic” of multiple births to IVF patients. Multiples are twenty times more likely to die in the first month of their lives than singletons; those multiples that survive are more likely to have respiratory difficulties, learning disabilities, and other problems. Cerebral palsy, for instance, has become more common in the United States, even as its major cause, jaundice, has been all but eliminated. And even IVF singletons are less healthy than non-IVF children: they tend to be smaller and are more likely to be born with birth defects, including bowel and genital deformations and eye cancer.

And yet press reports abound with stories of “designer babies.” Would-be parents relying on sperm or egg donations try to micromanage every part of the donor selection process — eye color, height, musical or athletic ability, even political leanings — in part, no doubt, because they desperately want to exert some control over a process in which they are largely powerless. Mundy tries, at times, to play this tendency down, arguing that most fertility patients don’t want to design a perfect baby; they’re grateful to have any baby. She quotes a nurse who tells her, “I’ve never come across a patient who wants to design their baby.”

This seems willfully naïve, even unbelievable. As much as Mundy wants to get past the stereotype of the super-picky fertility patient practicing “yuppie eugenics,” the stories she tells reinforce it. One couple fights over how tall their egg donor should be; another, to head off such squabbles, creates a mathematical formula for potential egg donors: “health plus education times looks, add back social sports.” “What are you going to do, get someone with [an SAT score of] 1550, or are you going to cheat your child and get them a mom with a 1210?” asks the parent who devised that “unofficial algorithm.” Such sentiments might strike the reader as shallow and laughable, but underneath these attitudes lie some unsavory (and decidedly illiberal) assumptions about human equality. One self-described “ardent social liberal” explains her feelings about donating her excess embryos (created using both an egg and sperm donor) thus: “These could be superstar embryos. I didn’t want to put them with high school graduates; you have the product of a doctor and a lawyer, and I wanted them to have the benefit of being around people like them.”

For all the time fertility patients spend ensuring their future children’s genetic superiority, they rarely ask what those genes might mean to the child outside of a talent for math or a love of music. Might not these children someday want to “have the benefit of being around people like them” — their genetic parent(s)? We’re told that love, not blood, makes a family, and yet parents turn to ART precisely because they desperately want a child genetically related to at least one of them. Mundy phrases this paradox quite nicely: “In the age of the genome, the message is that genetics are paramount in the formation of your child — and yet at the same time genetics are nothing in the formation of your relationship with your child.”

Mundy asserts that in writing her book she did not mean to take sides — to judge what procedures are or are not acceptable — but she is a partisan nonetheless. In interviews, she explains that Everything Conceivable grew out of her interest in the political battle over abortion. “Choice” meant one thing when she began her career in the 1980s. But now, she warns, the fertility industry has co-opted the ideology of “choice” to justify an ever-expanding array of reproductive technologies, from sex selection to genetic diagnosis of embryos (in which those found less fit are discarded). Meanwhile, the feminist movement has remained myopically focused on “a woman’s right to choose.” As one feminist activist tells Mundy after reading a Newsweek cover story on fetal rights, “Oh my God, our movement’s messages suck.”

Mundy concurs. “In the twenty-first century,” she writes, “the radical thing may not be to end a pregnancy, but to begin one.” Feminists must find a way to integrate ART into a new understanding of reproductive liberty, and show women how “the movement can help them face new concerns and challenges.” They must ask themselves “whether every choice made possible by science is a choice pro-choicers should welcome into the broad philosophical tent of choice…. Abortion rights should not be the precedent determining every reproductive issue.”

Choice, she argues, does not always serve feminist goals. She points to the most obvious example: sex selection. True, parents in the United States and first-world countries tend to use sex selection to achieve a desired mix of boys and girls, not to get rid of babies of one undesired sex as is the practice in China and India. Even so, Mundy argues, sex selection is still based on gender stereotyping — the idea that parents have different kinds of relationships with their sons and daughters — which should be anathema to feminists. She questions the wisdom of National Organization of Women president Kim Gandy’s attack on the American Society for Reproductive Medicine for its infertility awareness campaign. Mundy asks who really benefits from encouraging women to delay childbearing. Might not the beneficiary be an “unforgiving work culture that doesn’t really ever see childbearing for female employees as convenient?”

She asks too whether feminists’ commitment to equality and “social justice” is compatible with the eugenic possibilities of ART, particularly the way clinics divide women into the different “categories” of donors and surrogates. “Most surrogates I come across are not typical donor caliber as far as looks, physical features, or education,” one doctor explains. “Most egg donors are smart young girls doing it for the money to pay for college. Most surrogates are — you know, they need the money; they’re at home with four kids — of a lower socioeconomic class.” Or as another physician more succinctly explains the value of this “breeder class” of women: “Moo.”

Fertility clinics may encourage would-be parents to give their surrogate the “princess treatment” (one advises couples never to meet their surrogate without bringing a gift) but the surrogate is a servant nonetheless. Mundy adroitly describes the mixture of motives at work for both parents and surrogates: the real altruism that drives many surrogates, the gratitude parents feel toward this beneficent stranger, their concerns for her health (and that of their future child), and, of course, the money. One couple sent their surrogate, Ann Nelson, “surprise packages” with gifts for her kids, and later brought her and her family to Los Angeles for a month-long vacation. When the couple asked her to gestate a sibling, Ann readily agreed. But when the first embryo transfer was cancelled due to health complications, the couple went with another donor. Ann, who felt a connection with the couple (and was no doubt disappointed there would be no more paid vacations), was hurt.

Mundy pushes her arguments in directions sure to make her feminist readers squirm: asking how we should characterize surplus embryos — as nascent human life or mere tissue — and examining the social science research on the differences between heterosexual and homosexual households. She discusses the new advances scientists have made in charting the development of the embryo, and asserts that it is no longer possible “to argue, as pro-choice leaders once did, that abortion is not taking some form of human life.”

Yet even as she urges feminists to look beyond the abortion debate, Mundy can’t do the same when it comes to conservative critics of ART. While sympathetic to many of their arguments, Mundy nonetheless characterizes the views of conservative critics as merely an extension of their opposition to abortion. To be sure, this is true for many, like the columnist who calls embryos “microscopic Americans.” But Mundy also includes in this group Leon Kass and the President’s Council on Bioethics (or, as she calls them, “Kass and company”), dismissing the Council’s 2004 report on ART as “a backdoor anti-abortion sally” and yet “another pro-life push to enhance the moral status of the embryo.” She offers no examples of Kass making anti-abortion arguments, since there are none.

In one of the book’s more hysterical moments, she blames “pro-life opposition to embryo research” for causing “the most loving, most ordinary, most salt-of-the-earth-type couples” to feel “the most overwhelming grief imaginable.” The ban on federal funding for research involving the destruction of human embryos, she explains, has hindered scientists’ understanding of embryo viability, forcing doctors to transfer multiple embryos despite the dangers such pregnancies pose. Yet almost immediately after making this overheated accusation, Mundy explains that doctors often transfer multiple embryos to inflate their success rate, and many are now transferring fewer embryos after seeing the problems associated with high-order multiple births. Just last year, the American Society for Reproductive Medicine issued guidelines suggesting that no more than two embryos at a time be transferred into women under age thirty-five; clinics that have adopted the new guidelines have maintained their success rates.

Mundy may be suspicious of the rhetoric of pro-choicers but, in practice, she seems unwilling to curtail the exercise of choice. Instead, she confines herself to addressing mostly technical, regulatory issues. But when it comes to ART, even technical issues implicate much larger questions. Take, for example, Mundy’s argument for mandating insurance coverage for infertility. She’s right to find absurd the notion that infertility is a “self-imposed, ‘voluntary’ affliction that doesn’t deserve coverage.” But any discussion of infertility insurance inevitably leads to the question of who has the right to be a parent. As Mundy herself notes earlier in the book, a growing portion of the fertility industry’s clientele is not the “medically infertile” but the “socially infertile”: homosexual couples, single women, post-menopausal women who want to start a “second family.” Do they too have a right to treatment (as the U.K. Health Ministry has recently declared)? Mundy doesn’t say.

Mundy’s silence here is especially troubling since it relates to the most radical exercise of “choice” found in the book: the dismantling of the traditional, two-parent family structure and the move toward accepting an individual right to a child. She covers familiar cases — gay and lesbian households, single mothers by choice (so-called “maverick moms”), co-parenting arrangements in which single mothers raise their children together. But she also points to new family arrangements made possible by the intersection of digital and reproductive technologies, such as the extended family groups being formed on websites like the Donor Sibling Registry (DSR). DSR is an online database through which parents can seek out the anonymous donors who supplied half their children’s genes, children can look for information about their unknown genetic parents, and families can connect with genetic half-siblings who have a donor in common. The majority of people who post to these sites, Mundy notes, are single mothers who desperately want to give their child a family. “My daughter Kayla has wanted a sibling for so long and now she has one,” enthused one single mother. One set of families has even created a group named after their shared sperm donor, number 1476, where they can celebrate their mutual good taste in donors (such as 1476’s “trademark blue eyes”) and swap stories about their kids. Some of these people even take group vacations together.

But how far can such a “family” extend? Some donors have over thirty offspring. Can a child have a meaningful connection with such “siblings” — strangers who only have in common a fraction of DNA and a certain parental desperation? And what of the donors themselves; should they choose to meet their biological offspring? Could a sperm donor be a father figure — or even just a sort of uncle — to thirty-odd children? Many parents, once eager to reach out to new “family members,” have left the site as more and more siblings registered. And where some have too much family, others have too little. Wendy Kramer, the founder of DSR, has located two siblings of her son, but he will never be able to meet them as the family does not want to tell their daughters they were donor-conceived.

Mundy, for her part, is disturbed (though she can’t explain her discomfort) by the family-diversity activists who want to separate parenthood from genetics — yet she largely approves of the social changes moving us in that direction. She finds “persuasive” the “attachment model of parenting” — the theory that children will thrive so long as they have a fully bonded relationship with an adult, be it with “six loving adults, or one, or two, male or female.” Fatherhood and motherhood are merely roles which anyone can take on, regardless of sex or genetic relationship: “Being a father,” she writes, is “a right you earn, by doing what fathers do — taking out rats, fixing bike seats — and those are things that anyone can do, including a woman.”

Again, she gives the conservative critics who question these trends short shrift. She notes briefly the invaluable work being done by Elizabeth Marquardt of the Institute for American Values on how states and other countries are granting parental status to an ever-expanding group of people — in part to handle the novel arrangements now made possible by ART. Mundy concedes the obvious dangers of redefining parenthood but then tartly dismisses the argument: “On the other hand, thirty years ago, conservative judges removing children from the custody of lesbian mothers weren’t all that respectful of biology, either.”

The book’s biggest weakness is in its treatment of children. Outside her chapters on the physical health of IVF children, Mundy gives very little attention to the quality of their lives. Their stories tend to stay on the periphery, like that of Megan, whose family is shattered by her parents’ quest to have a biological child. Mundy focuses on Megan’s adoptive mother, Kristina, who became determined to have a new baby through IVF when Megan was two. After a complicated pregnancy, Kristina gave birth to triplets, each of whom had serious developmental problems. Mundy describes, with great sensitivity, the challenges of caring for three special-needs children. Kristina suffered from post-partum depression and later went on antidepressants. Her marriage fell apart. A year later, when Mundy contacted them, Kristina happily reported that the triplets were much healthier — though Megan was still in therapy, trying to cope with the loss of her old home and family life.

Megan’s story is a perfect example of the ways in which ART brings children’s needs into conflict with their parents’ desires. Yet Mundy seems uncomfortable grappling with these questions, and so for the most part avoids them. She has one brief chapter on children’s rights but she soon concludes that there is no need to get worked up about it since (as one social scientist puts it) “it is insufficient to consider only the welfare of the child, which cannot, in any case, be isolated from that of the parent. Thus the primary concern should be for the welfare of the family as a whole.”

This lack of concern for the best interests of children is nowhere more striking than in Mundy’s treatment of the debate over donor anonymity — whether donor-conceived children should have the right to know the identity of their donor. Mundy describes without comment the search of one lesbian couple for an anonymous sperm donor. The couple already had a daughter, Chloe, who had been conceived with the help of a male relative. Originally, the women had planned for the man to be a kind of uncle to their child, but after Chloe was born, they felt “he was beginning to regard himself as a father.” The women told the relative to back off, and went on to conceive a second daughter with an anonymous donor. Chloe is still young, but Mundy never asks what her feelings might be in the future (and naturally never examines the plight of Chloe’s father, either).

The story is disturbing especially when juxtaposed with another later in the book. Dakota, a man now in his twenties, grew up in San Francisco in a lesbian household. Like Chloe’s parents, his mothers asked a friend to be their donor with the understanding that he would be involved in Dakota’s life. But when Dakota’s non-biological mother became jealous of his relationship with his father, she cut off contact between the two. Dakota occasionally sees his father and his half-siblings in the neighborhood, but he has no relationship with them. “We live parallel lives,” he explains. “I’m angry that so much time has passed and every day I lose more time not knowing these people. I’m never going to get it back.” Might this be Chloe’s future too? And what of her younger sister?

Too often, the story of ART is a story of parents, in which children are prized and desired possessions. Mundy makes an effort to avoid the worst of this distortion of priorities, but her book — sometimes intentionally, sometimes inadvertently — offers a host of disturbing examples of the dangers of treating parenting as all about parents. She offers a telling and at times insightful glimpse of the unexpected consequences of these profoundly transformative technologies. But again and again she turns away from the consequences of her own insights, and avoids asking the deepest questions about what the picture she paints can tell us about ourselves and our times.

Mundy also doesn’t delve deeply into the mystery of the intense, overpowering, savage desire for children — the great force that drives everything she describes, and that runs against every premise of the progressive, individualistic, liberal ethic of our times. ART may give expression to a radical form of personal choice and individual control, but it is moved in turn by a very old-fashioned desire for procreation and attachment. To think through that mystery, and what it might tell us about the depth and intransigence of human nature, would be truly to reach down to the roots of the peculiar social quandaries Mundy describes.

Even if Mundy refuses to see them, however, her book brings us to notice these questions and helps us to contemplate them. It lays open the promise and the peril of new routes to parenting and childhood that will only grow more complex, and more common, with time. For all its many flaws, it is easily the best available guide to the still-burgeoning world of ART and its implications.