Lab-made gametes in the clinic: Who would benefit? Who should decide?

^{Photo by Louis Reed on Unsplash}

This blog post is adapted and expanded from comments Alana Cattapan delivered on the panel “Social, Ethical, and Legal Considerations Raised by IVG” at the workshop “In Vitro Derived Gametes as a Reproductive Technology,” organized by the National Academies of Science, Engineering, and Medicine (April 19-21, 2023). Read more about the workshop here and here. Alana Cattapan is Canada Research Chair in the Politics of Reproduction and an Assistant Professor in the Department of Political Science at the University of Waterloo and a participant in CGS’ Missing Voices Initiative.

My work has largely focused on feminist approaches to the governance of reproductive and genetic technologies, and how we can involve often-excluded communities in those conversations. At the heart of this research are concerns about reproductive autonomy and justice, and how to engage in the governance of reproduction in ways that are not only ethical, but also address our responsibilities to future generations.

These concerns ought to be at the forefront of any discussion of reproductive technologies, including in vitro gametogenesis (IVG). But considering the sessions at this workshop on the implications of IVG in clinical practice and “imagining a potential clinical pathway,” there seems to be an operating assumption that IVG is destined for the clinic and that we are here to chart the course. Scientists, clinicians, and corporate leaders have presented IVG as aspirational, but not too far off. They have claimed that it will provide a “solution” for those seeking a genetic relationship with children outside of coital reproduction, one that may also reduce the physiological burden on those undergoing conventional fertility treatments. I take issue with these claims and their underlying assumptions that IVG is both necessary and desirable for certain groups. I am also skeptical of how this technology will be deployed – likely in ways that will exacerbate longstanding and continuing inequalities for those already experiencing marginality.

To begin, IVG will not “eliminate infertility” as some industry actors have claimed. Rather, it will make it possible to circumvent inquiry into the causes of high rates of infertility, to avoid meaningful conversations about public policy that might help people have children earlier in life if they want to, or to think through what different family forms might look like. We will not eliminate infertility, we will simply (continue to) defer to technology to make the children people desire, avoiding the question of how to reduce the need for so many fertility interventions in the first place.

Further, IVG has been touted as an intervention that will enable equity for queer families who might not otherwise be able to engage in family building in the ways they desire. And while it may do so for those privileged enough to be able to access it, there is risk here too, in continuing to privilege biogenetic relationships. As Katherine Kraschel indicated in her presentation, in the absence of law and public policy that recognizes, incentivizes, and enables different family forms, IVG – rather than recognizing and protecting family diversity outside of genetic relationships –may come to serve as a response to concerns about legal protections for queer families.

Proponents of IVG have also often mentioned that the technology would eliminate the need for ovarian stimulation and egg retrievals during IVF and in egg donation. Reducing the risks these procedures pose for women would indeed be an important contribution. But I’m skeptical of the suggestion that the motivation for developing IVG is to reduce the risks of IVF for women, and particularly for egg donors. For decades, social scientists and advocates have been calling for longitudinal research with egg donors to identify the long-term risks of egg donation, to no avail. The fertility industry has not been particularly interested in women’s health, or even in infertility prevention. The singular goal of fertility clinics has largely been creating babies for those who want them. IVG will allow them to do so in ways that largely sidestep the costly inconvenience of women’s reproductive tracts.

The consequences for people with disabilities are critical here, especially as I have heard discussion of the potential use of IVG as a means to circumvent the transmission of genetic disease. It is entirely possible that IVG will be used to create more eggs than might otherwise be available, which may then be used to create more embryos, enabling large scale genetic screening of IVF embryos. Those presenting embryo testing as a potential benefit of IVG have been careful to state that IVG-enabled screening should not be used to select for hair colour, or eye colour or height, but rather only to select out heritable genetic diseases. The lines between medicine and so-called “enhancement” are not clear, however, and I worry about what attempts to choose the “best” embryo will mean for the lives of people with disabilities. To this end, we also need to be thinking about how IVG may serve as a precursor to heritable genome editing. As the concluding statement from the organizers of the Third International Summit on Human Genome Editing stated in March, there is not, by any means, societal consensus about whether or how to proceed on these matters.

Speakers have mentioned the “shadow of Dobbs” looming over this workshop, and also the ways that talking too much about the disposition of large numbers of embryos created through IVG might draw unwanted attention from anti-abortion conservatives. We can imagine restrictive laws that limit embryo research through concerns about disposition, but Dobbs’ pronatalist logic seems the site of greater concern. IVG could be part of a growing pronatalist capitalism, in which those with financial resources are given nearly limitless reproductive options, so long as they can pay for it, while others are forced to carry pregnancies to term. In this context, the availability of IVG would strengthen contemporary commitments to fulfilling the desires of the wealthy few, as conditions worsen for others. 

This expanding economic disparity in who gets to choose their reproductive futures is particularly notable given how IVG research is occurring in the American regulatory environment. The US restriction on federal funding for embryo research has resulted in IVG research occurring almost entirely in the private sector, with Silicon Valley at the fore. Tropes of disruption, innovation, and investment here loom large, as teams of scientists work together with extraordinary funding, outside of the university/scientific pipeline and without the intervention of research ethics boards. With investors at the helm and a race underway to stake new IP claims and protect the economic spoils of their discoveries, these sites lack the oversight capacity of a self-regulating scientific community, however fraught. We need to keep thinking about who gets to decide how and when we engage with IVG. Who will determine if it is necessary? These decisions are not to be left to scientists and private capital alone. We are all affected by our collective genetic futures.

In closing, I’ll say that I have been struggling lately with the ubiquitous language of “progress,” and the assumptions that genetic interventions will make us healthier and improve the human experience. The conclusion I have come to, though, is that we need to think more carefully about who gets to make decisions about the future of these technologies, what is at stake, and to whom the benefits really accrue.