Indian Journal of Medical Ethics Vol III No 2 April-June 2018 [ 95 ] Author: Rakhi Ghoshal (rakhi.ghoshal@gmail.com), Independent Consultant-Researcher, B-3, Spandan Apts, Kalikapur, Kolkata 700 078, INDIA To cite: Ghoshal R. Assisted reproductive technologies: Conundrums and challenges. Indian J Med Ethics. 2018 Apr-Jun;3(2) NS: 95-8. DOI: 10.20529/IJME.2018.030 © Indian Journal of Medical Ethics 2018 Infertility: Blame it on women A few weeks ago, a leading multi-city IVF clinic published an advertisement in a leading news daily. The advertisement sounded ominous, “The longer you wait, the lower your chances” – it referred to one’s chances of getting pregnant. The subtext was far too easy to decipher: the content was thoroughly gendered and directed solely at women, particularly at career-oriented women who delay their marriages and childbearing plans far too long, supposedly lowering their fertility in the process. It also sounded benevolent in its attempt to warn these “erring” women. It is socially accepted that women are responsible for increasing the infertility rates in the country by their “poor, untimely, and problematic prioritisation of life choices” . While men produce sperm that are regenerative, a woman’s reproductive potential is perpetually on a decline; born with a fixed number of egg cells, she never produces any more in her lifetime. However, male infertility is an interesting area to delve into; 40–50% of total infertility is male factor infertility (MFI) (1). MFI is significantly on the rise (2), so much so that a team of researchers thought it prudent enough to invest their energies and funds in developing a technology that would allow the layman to screen semen for potency. This smartphone-based semen analyser is said to give results “with nearly 98% accuracy” (3). MFI is not a miniscule issue if we really want to engage with infertility per se, and the factors that doctors attribute to the spurt in MFI are “stress, pesticides, pollution, altered lifestyle” (2). The point here is that these factors are exactly the same as those used to analyse rising infertility among women. And yet, the infertility spotlight continues to glare disproportionately on women—and if the woman is one holding a white-collar job and living life on her own terms, people instantly jump in to chastise her and to save her, both at the same time. Four pointers followed the warning in the advertisement: (a) the more years that pass, the fewer the eggs a woman has left, (b) the older one is at childbirth, the more difficult it is to carry a baby to term, (c) ovarian reserve starts to decline in the 30s, and (d) if one has tried for a year to conceive without success, it is time to seek fertility treatment 1 . Men were not implicated at all. Infertility was all about eggs and child delivery; the sperm was forgiven. Seeing how the ad was designed—large font size and all in bright, blood red—I wondered if women would have the courage to wait even six months after marriage. In-vitro fertilisation (IVF) is a fascinating, paradoxical space: commonly treated synonymously with assisted reproductive technologies (ART), this market sustains itself not just on the conditions of primary or acquired infertility, but significantly, on the “irresponsibility” of women who delay their childbearing plans. It is a market that thrives by criticising the very constituency that helps sustain it. The paradoxes go back a long way: Sarojini N and Vrinda Marwah point out how the Indian state, in a rather counterintuitive way, welcomed the advent of technologies that facilitate reproduction, viz the ARTs, in order to help the state achieve its earlier set target of stemming population growth (4). The Indian state was married to the idea of family planning right from 1951, and of the various methods it promoted and implemented, controversial and otherwise, tubal ligation was—and remains—a top choice. However, India also had a high neonatal and infant mortality rate 2 , and women were known to resist tubal ligation. Against this backdrop, the promise of the ARTs showed the state a wonderful way out of the impasse. A 1984 Indian Council of Medical Research (ICMR) document observed, If a couple is convinced that pregnancy could be achieved with certainty by the IVF-Embryo Transfer technique, in the event of their losing the existing children, they might readily accept tubal sterilization as a method of family planning. Thus, in vitro fertilization could be of great relevance to our national welfare programme. (As quoted in 4, p. 4; emphasis added) It is indeed telling that right from its days of infancy in India, ARTs never had a linear relationship with the state-market. The state advocated for the acceptance of these technologies because of their indirect ability to make people accept sterilisation. But soon the state took a backseat, allowing the private sector to come to the fore, set prices, function without regulatory mechanisms, and make promises of high success rates for IVF. The ART market promised women they could “enjoy” life and only when they would THEME EDITORIAL Assisted reproductive technologies: Conundrums and challenges RAKHI GHOSHAL