Sex Selection: Patient Choice or Misguided Use of Fertility Treatment?

Pros, cons & our basic principle that the sex of a child isn’t a medical condition in need of correction

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A recent Denver channel 7 report on utilizing the services of infertility clinics for sex selection (previously also known as gender selection) begs the question: If the technology exists then why not use it? With many recent advances in the field of in vitro fertilization (IVF), it appears that the technology has outpaced the ethical aspects raised by these advancements.

This is particularly relevant in human genetics where we have witnessed exponentially improved identification of obscure genetic disorders via high resolution genetic sequencing. Accompanying these many advances are couples requesting that fertility doctors utilize sophisticated reproductive services to select the sex of their next child.

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So, what is the harm in offering these services to the general public? After all, in a consumer driven market why not offer the most current medical advances, assuming we can guarantee patient safety? The answer to this question is convoluted as evidenced by recent policy statements by the American Society of Reproductive Medicine (ASRM) and the American College of Obstetrics and Gynecology (ACOG).

An ASRM committee opinion as early as 1999 supported preimplantation genetic screening (PGS) for sex selection to avoid the birth of a child with a sex-linked disorder. In short, couples would seek either a boy or a girl to avoid the gender more prone to a certain genetic disease. However, the committee voiced concern over couples who medically required IVF and also included genetic testing for sex selection. Further, ASRM discouraged couples from requesting IVF for the sole purpose of sex selection. ACOG uniformly opposed sex selection for nonmedical reasons in their 2007 committee opinion and 2011 update citing a predilection for prejudice against female children.

The most recent ASRM policy statement on gender selection for nonmedical reasons surfaced in 2015. In a departure from ACOG, the 2015 update presented both pro and con arguments while ultimately avoiding any definitive consensus statement. In short, each center offering assisted reproductive technology (ART) services was encouraged to develop clinic-specific guidelines while allowing employees to either participate in or refrain from engaging in sex selection for nonmedical reasons.

Arguments in support of sex selection for nonmedical reasons

Patient autonomy

Couples requesting elective sex selection often justify their choice using concepts such as reproductive liberty and patient autonomy. They believe they should be allowed to experience rearing a child of their desired gender and are simply exercising their procreative rights without any undue outside influence.

Family balancing

Other couples seek to balance their families by selecting the very sex that they currently lack in their children.

Reduce twins & unwanted pregnancies

Based in some scientific validation, genetic assessment of embryos to orchestrate delivery of a desired sex may actually reduce the number of elective terminations. It can also be argued that sex selection lowers the risk of multiple gestations (by limiting the number of usable embryos), and decreases the number of unwanted pregnancies.

Avoid cultural abuse

In some cultures, women perceive this reproductive choice as a means to reduce any self-directed familial and cultural abuse that may accompany the birth of a child viewed as the “undesired gender.” This particular point speaks to the abuse directed against women in some developing countries after delivery of a female child.

Arguments against sex selection for nonmedical reasons

Bias leading to sex imbalance

Critics of sex selection for nonmedical reasons are quick to cite a prevailing assumption of bias against female offspring. While this may be true in India and China (males exceed females by 34 million in those two nations), surprisingly, requests for sex selection in the United States have not tipped the scales with an unequal number of requests for male and female children. This negates any predilection that sex selection leads to “sex imbalance.” However, there may be an unmeasured harm to other children in these families if they perceive their parent’s action of sex selection as being biased against a particular gender.

Waste of medical resources

One may view use of these expensive technologies for the purpose of sex selection as a wasteful redirection of medical resources. Sex selection is accomplished via biopsy of pre-implantation embryos, necessitating use of IVF with the resultant price tag of at least $20,000 once genetic costs are factored in to the equation.

Only for the wealthy

In short, this may restrict availability of gender selection to only those wealthy enough to afford these services. In states without mandated infertility coverage, a large segment of the population will lack the financial resources to engage in sex selection or in any advanced reproductive services for basic infertility treatment.

Needless increase in medical harm

In a profession that pledges to, above all, do no harm to patients who entrust us with their care, some opponents suggest that gender selection for nonmedical reasons needlessly increases medical harm to both mother and the intended child. The IVF process requires the patient to undergo a medical procedure under anesthesia to extract human eggs. This transvaginal approach is routinely performed on a daily basis in our country and only rarely associated with complications, which may include bleeding and post procedure infections requiring protracted care and/or surgery.

To be clear, these untoward events are extremely rare but occasionally occur, and the patient needs detailed informed consent indicating their understanding and acceptance of these rare risks. Imagine the attention garnered if a perfectly healthy young fertile women were to suffer a complication from a procedure solely performed for sex selection and not required for infertility.

Decrease miscarriages

Couples typically use genetic screening in conjunction with IVF to maximize their reproductive potential by assuring transfer of only genetically normal embryos. This process increases the likelihood of a live born child per each transfer, mainly by decreasing the incidence of miscarriages since only genetically normal embryos are transferred in to the uterus.

Our approach to sex selection

The Denver channel 7 report featured a fertility doctor from Beverly Hills, California, who routinely performs sex selection for nonmedical reasons, basically at the patient’s request. This policy certainly supports the principles of patient autonomy while advocating for reproductive liberty, yet simultaneously results in an unfair allocation of expensive health resources to the advantaged few who can afford such care.

The doctor’s claim that 90 percent of his patients want these services seems widely disparate from reports from other infertility centers. Perhaps this merely reflects a more affluent clientele frequenting his center but does not necessarily reflect patient demographics of many infertility centers across the country.

Some view indiscriminate use of advanced reproductive services for nonmedical sex selection as leading us down the “slippery slope” toward genetically engineered children. Is this simply the initial modifiable trait that fertility doctors can offer to their patients?

Medical ethicists and many physicians fear that parents will request reproductive services to select other traits, such as eye color, height and even heightened intelligence. In fact, the Beverly Hills physician quoted in the original news feature admitted that he already offered eye color, although as an investigational service only. But not all medical tests offer 100 percent accuracy, and some patients may pay a high price without obtaining the desired result.

University of Colorado Advanced Reproductive Medicine in Denver offers sex selection only to those patients who undergo medically necessary IVF and, in particular, those clients who require genetic screening for other reasons. Granted, this includes patients who choose IVF over other fertility treatment options and then request sex selection, but it particularly excludes fertile individuals who seek to use high-tech reproductive services only for sex selection. After all, we do not view the sex of a child as a medical condition that needs correcting.