Charles Coddington, MD, loves it when people ask him what he does for a living. “I get people pregnant,” he says with an impish chuckle. Recently, in one of the Mayo Clinic’s operating rooms in Rochester, Minnesota, Coddington delicately scooped up a human embryo and implanted it in the lining of a womb, providing a good chance at conception for a woman who otherwise would be infertile. That’s all in a day’s work for a fertility doctor. “It’s just about the neatest thing in the world,” he says.

Th e science of fertility has improved by leaps and bounds over the past two decades. It involves some of the most intricate workings of the endocrine system, development, cell biology, and, increasingly, genetics. And yet, the collective field of assisted reproduction technology has struggled with a bad public image and a polarizing public debate. At the heart of it is a nagging question: Is reproduction a right or a privilege? It may seem like an abstract philosophical question, but it has very real consequences for people struggling to conceive a child. A typical round of in vitro fertilization (IVF) costs between $10,000 and $15,000, and it is not unusual for women in their 30s and 40s—the demographic most likely to seek fertility treatment—to go through as many as four or five rounds of IVF. If donated eggs or a surrogate womb are required, the costs skyrocket above $100,000. Medical insurance companies in the United States will not cover those costs, and will cover only a portion of IVF, if at all.

So the cold reality for infertile Americans is that their condition is not considered a disease, says Ann Kiessling, a fertility expert in Boston. “Certainly not like cancer or other life-threatening diseases.” And yet, especially for women, the deep-rooted urge to reproduce is inescapable. Critics charge the fertility industry with exploiting their desperation.

Growing Issue

The more you learn about human reproduction, the more surprising it is that anyone manages to make babies at all. Rather than getting delivered right to the waiting egg, sperm arrives somewhere between the vagina and the cervix. Scaling for their size, that means the sperm must swim for miles. And usually there is no egg even waiting for them, because unlike many mammal species, human women do not constantly ovulate.

Instead, the pituitary gland deep within the brain must send out hormonal orders in the form of folliclestimulating hormone (FSH). Down in the ovaries, a batch of eggs starts maturing within the new follicles, which themselves broadcast estrogen. Once a mature egg has been produced, the pituitary gland releases luteinizing hormone, triggering the follicle to burst and release the egg. Only then does the journey down the fallopian tubes begin. If a sperm is lucky and strong enough to reach the egg, it gets one shot at fusing with the egg and donating its complement of DNA. But the fertilized egg still has to tumble on down to the uterus and successfully implant itself in the uterine lining. Only then does the even more complex process of development begin.

Considering that arrangement, it’s less surprising that a large portion of couples have fertility problems. “Ten percent to 15 percent is a very fair estimate,” says Coddington. And that proportion is on the rise. Both men and women are waiting longer to have children. The chances of conceiving and giving birth to a healthy baby decrease with age. Also, gay and lesbian couples are increasingly seeking assistance with conception. So the technological approach to making babies will only become more common. Luckily, new techniques have vastly improved people’s chances of success.

“Let’s look at a typical case,” says Coddington. “A 32-year-old woman walks in and says she is having trouble conceiving.” Before diagnosing her, he gathers some basic but crucial information. Has she had a regular menstruation cycle? Are there complicating health factors? He also confirms that the woman and her partner are having sexual intercourse that can result in pregnancy. “That may sound crazy, but you’d be surprised,” he says.

“The typical situation is that she has an irregular cycle, perhaps only four times in the past year; ultrasound reveals polycystic ovarian syndrome; and she is overweight. She may be experiencing androgenrelated problems, such as acne and stray hairs appearing on her face. This all points to an endocrine imbalance, and it’s very common,” says Coddington.

The first step is to boost the chances of normal conception with drugs that stimulate ovulation. If that doesn’t work, the next step could be a round of IVF. In normal ovulation, only one or two follicles fully mature and release eggs while the others recede and disappear. IVF begins with drugs that trigger all those extra follicles to mature, releasing as many as 20 eggs at once for harvesting.

It is now possible to directly inject sperm into the egg, boosting the chances of fertilization. Another significant advance is keeping embryos alive with better growth media. “In just the last eight to 10 years,” says Coddington, “we have figured out how to grow embryos in vitro up to five days of development.” Rather than just a cluster of eight identical cells, the embryo diff erentiates into the cells that will become the baby and those that form the placenta. By then, many of the defects that cause a pregnancy to fail can be spotted. That means fewer embryos need be implanted in the first place, lowering the risk of triplets and even higher multiples.

Big Business

But with higher success rates comes higher demand, and making babies has become big business. “We’re talking about tens, if not hundreds of millions of dollars here,” says Robert Klitzman, a fertility doctor and bioethicist at Columbia University in New York City. He and others are casting a wary eye on the industry that has sprouted up around their profession.

“What is the success rate for IVF?” asks Klitzman. “It can vary, with lower success rates for older women. But older women may not fully realize that.”

Over the past few years, Klitzman has surveyed the websites of U.S. fertility clinics to see how many uphold the recommendations of the American Society for Reproductive Medicine. The results are grim. At least half were noncompliant, not providing risks along with benefi ts. One-third of sites varied payment based on a donor’s traits, and 41% allowed women younger than 21 to donate.

“What if a woman donates her eggs six times? What impact does that have on her own chances at pregnancy? We don’t fully know,” he says. And who gets access to all those donated eggs, rentable wombs, and high-tech IVF techniques?

“For the most part, it comes down to money,” says Kiessling, because insurance companies are rarely mandated to cover it. “I think society owes couples with infertility appropriate medical treatment for a condition not of their doing,” she says. In her view, that should include most biological causes. Kiessling started the first IVF clinic in Oregon 30 years ago, and then helped Harvard University develop its renowned IVF clinic at Brigham and Women’s Hospital. Her focus has been on HIVinfected couples, carefully separating out uninfected sperm and egg for IVF so that babies are born HIV-free.

But convincing both her peers and society at large to see reproduction as a right has not been easy. She sees this as a peculiarly American problem. “[U.S.] fertility treatment centers need to be brought back into mainstream medical practice,” says Kiessling. The science of making babies needs “the same type of scrutiny as cancer treatments and organ transplants. ‘Success rates’ should be replaced by ‘good medical care,’ which would eliminate rushing couples into high-tech treatments too soon and putting women at risk of multiple births. It would also allow more universal access to fertility care—as it is in Canada and parts of Europe—by holding down costs and limiting risks of multiple births.”

For his part, Coddington is optimistic that some of the American conundrum in assisted reproduction will work itself out. “The costs will go down as the success rates increase,” he says. And he has a theory that applies especially to Americans. “Couples with better health have a better chance to conceive. As we reduce obesity, and blood pressure, and live healthier lives, fewer people will need help.” If he’s right, that would be two birds with one stone.

—Bohannon is a freelance writer in Boston and a regular contributor to Endocrine News.

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