assisted reproductive technology research topics

Articles on Assisted reproduction technology

Displaying 1 - 20 of 49 articles.

What is IVF? A nurse explains the evolving science and legality of in vitro fertilization

Heidi Collins Fantasia , UMass Lowell

Eggs from men, sperm from women: how stem cell science may change how we reproduce

Julian Koplin , Monash University and Neera Bhatia , Deakin University

Promising assisted reproductive technologies come with ethical, legal and social challenges – a developmental biologist and a bioethicist discuss IVF, abortion and the mice with two dads

Keith Latham , Michigan State University and Mary Faith Marshall , University of Virginia

Qld agrees to allow donor-conceived people the right to know the identity of their donor. Here’s why it’s important

Giselle Newton , The University of Queensland ; Caitlin Macmillan , Deakin University , and Katharine Gelber , The University of Queensland

Fertility treatment use is on the rise – new legislation could increase protections for donors and families in an industry shrouded in secrecy

Naomi Cahn , University of Virginia and Sonia Suter , George Washington University

‘Maeve’s law’ would let IVF parents access technology to prevent mitochondrial disease. Here’s what the Senate is debating

David Thorburn , Murdoch Children's Research Institute and Megan Munsie , The University of Melbourne

Sperm donation is largely unregulated, but that could soon change as lawsuits multiply

The fertility industry is poorly regulated – and would-be parents can lose out on having children as a result

Naomi Cahn , University of Virginia and Dena Sharp , University of California College of the Law, San Francisco

People are using their super to pay for IVF, with their fertility clinic’s blessing. That’s a conflict of interest

Neera Bhatia , Deakin University

Are chemicals shrinking your penis and depleting your sperm? Here’s what the evidence really says

Tim Moss , Monash University

Disputes over when life begins may block cutting-edge reproductive technologies like mitochondrial replacement therapies

Walter G. Johnson , Arizona State University and Diana Bowman , Arizona State University

Only two northern white rhinos remain, and they’re both female – here’s how we could make more

Ruth Appeltant , University of Oxford and Suzannah Williams , University of Oxford

New technologies mean states must reconsider what ‘reproductive rights’ are

Bonginkosi Shozi , University of KwaZulu-Natal

5 things not to say to someone struggling with infertility

Jennifer L. Gordon , University of Regina

Genetic testing IVF embryos doesn’t improve the chance of a baby

Karin Hammarberg , Monash University and David Amor , Murdoch Children's Research Institute

We may one day grow babies outside the womb, but there are many things to consider first

Neera Bhatia , Deakin University and Evie Kendal , Deakin University

IVF changes babies’ genes but these differences disappear by adulthood

Jane Halliday , Murdoch Children's Research Institute ; Boris Novakovic , Murdoch Children's Research Institute , and Richard Saffery , Murdoch Children's Research Institute

Who’s your daddy? Don’t ask a DNA test

Nara Milanich , Barnard College

A new procedure may preserve fertility in kids with cancer after chemo or radiation

Kyle Orwig , University of Pittsburgh

Researcher claims CRISPR-edited twins are born. How will science respond?

Dimitri Perrin , Queensland University of Technology and Gaetan Burgio , Australian National University

Related Topics

• Assisted reproduction
• Donor conception
• Infertility
• In vitro fertilization
• Reproduction

Top contributors

Associate Professor in Law, Deakin University

Professor and Group Leader, Reproductive Epidemiology, Murdoch Children's Research Institute

Assistant Professor and Canada Research Chair in the Politics of Reproduction, University of Waterloo

Professor of Law, University of Virginia

Senior Research Fellow, Global and Women's Health, School of Public Health & Preventive Medicine, Monash University

Professor of Law & Adjunct Professor, Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne

Distinguished Research Professor, Emerita, Dalhousie University

Monash University

Dean and Professor, Law School, La Trobe University

Associate Professor in Sociology, Swinburne University of Technology

Professor of Law, George Washington University

Lorenzo and Pamela Galli Chair in Developmental Medicine, Murdoch Children's Research Institute

Adjunct Associate Professor, Department of Obstetrics and Gynaecology, Monash University

Professor in psychology, Australian Research Council Future Fellow, Flinders University

Clinical Geneticist, SA Clinical Genetics Service, SA Pathology & Clinical Affiliate Professor, University of Adelaide

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Research Article

Main topics in assisted reproductive market: A scoping review

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Software, Visualization, Writing – original draft

Affiliations Applied Molecular Biology Lab (LAPLIC), Biochemistry Department, Federal University of Rio Grande do Norte (UFRN), Natal, Rio Grande do Norte, Brazil, Januário Cicco´s University Hospital (MEJC), Federal University of Rio Grande do Norte (UFRN), Natal, Rio Grande do Norte, Brazil

Roles Data curation

Affiliation Applied Molecular Biology Lab (LAPLIC), Biochemistry Department, Federal University of Rio Grande do Norte (UFRN), Natal, Rio Grande do Norte, Brazil

Roles Conceptualization, Formal analysis, Funding acquisition, Investigation, Project administration, Supervision, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

• Janaina Ferreira Aderaldo, 
• Beatriz Helena Dantas Rodrigues de Albuquerque, 
• Maryana Thalyta Ferreira Câmara de Oliveira, 
• Mychelle de Medeiros Garcia Torres, 
• Daniel Carlos Ferreira Lanza

• Published: August 1, 2023
• https://doi.org/10.1371/journal.pone.0284099
• Reader Comments

Infertility affects around 12% of couples, and this proportion has been gradually increasing. In this context, the global assisted reproductive technologies (ART) market shows significant expansion, hovering around USD 26 billion in 2019 and is expected to reach USD 45 billion by 2025.

We realized a scoping review of the ART market from academic publications, market reports, and specialized media news, to identify the main terms and characterize them into the main topics in the area.

We apply an LDA topic modeling process to identify the main terms, and clustered them into semantic synonymous topics. We extracted the patterns and information to these topics and purposed a factor/consequence correlation to them.

We found 2,232 academic papers and selected 632 to include in the automatic term detection. We also included 34 market reports and seven notices produced by specialized enterprises. Were identified 121 most relevant cited terms covering 7,806 citations. These terms were manually aggregated into 10 topics based on semantic similarity: neutral terms (37.2%), economic aspects (17.6%), in vitro fertilization ( IVF) commodities & cross-border reproductive care (CBRC) (10.6%), geographic distribution (9.5%), social aspects (7%), regulation (6%), trends & concerns (3.9%), accessibility (3.4%), internet influence (2.9%), and fertility preservation for non-medical reasons (2%).

The analysis indicates a market with expressive complexity. Most terms were associated with more than one topic, indicating the synergism of this market’s behavior. Only seven terms related to economic aspects, surrogacy and donation represent around 50% of the citations. Except for the topic formed by generic terms, the topic of the economic aspects was the most represented, reflecting macro perspectives such as a-la-carte standard of treatments, many clinics operating on a small/medium scale, and the recent formation of conglomerates. The IVF commodities & CBRC topic brings an overview of gametes pricing and transnational surrogacy, and its regulation. The topic of geographic distribution indicates that that the Asia-Pacific (APAC) market has the most significant growth potential in all fields. Despite the increase in supply and demand for infertility treatments and technological advances in recent decades, the success rate of IVF cycles remains at around 30%. Terms referring to research and development or technical improvement were not identified in a significant way in this review.

Conclusions

The formation of topics by semantic similarity proved to be an initial path for the elaboration of in-depth studies on the dynamics between several factors, for this, we present the panel classifying main terms into factors (demand, pent-up demand, or distributive) or ART market consequences. Through this approach, it was possible to observe that most of the works addresses economic aspects, regulation and geographic aspects and that topics related to research and improvement have not been addressed. In this way, we highlight the need to deepen the analysis of market elements that may be related to increased efficiency of IVF in the technical field.

Citation: Aderaldo JF, Rodrigues de Albuquerque BHD, Câmara de Oliveira MTF, de Medeiros Garcia Torres M, Lanza DCF (2023) Main topics in assisted reproductive market: A scoping review. PLoS ONE 18(8): e0284099. https://doi.org/10.1371/journal.pone.0284099

Editor: Meijia Zhang, China Agricultural University, CHINA

Received: June 28, 2022; Accepted: March 19, 2023; Published: August 1, 2023

Copyright: © 2023 Aderaldo et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: This study was funded by Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript

Competing interests: The authors declare that they have no competing interests.

Introduction

Infertility is currently defined as a failure to achieve a clinical pregnancy after at least one year of regular attempts [ 1 ], which was later updated to include physiological or psychological conditions incompatible with natural meeting of gametes [ 2 ]. It affects between 8% and 12% of couples globally [ 3 ], and this proportion is gradually increasing [ 1 , 4 ] because of multiple causes, such as the modern lifestyle, diseases, and the postponement of parenthood [ 5 – 7 ].

In that context, it is estimated that half of the infertile couples never seek fertility [ 8 ], and the investigation of the reasons reveals a complex product of the national public and private health policies and economic, political, and cultural factors [ 9 – 11 ].

However, the global assisted reproductive technology (ART) market expanded in clinic numbers and procedures [ 9 ], The ART market services were around USD 26 billion in 2019 [ 12 ] and are expected to reach USD 45 billion by 2025 [ 5 ]. Between 1997 and 2016, ART treatments have increased more than five-fold in Europe, 4.6-fold in North America, and three-fold in Australia and New Zealand [ 13 , 14 ].

The distribution of this billionaire market is heterogeneous due to complex clustering factors like unequal regulatory restrictions, local procedures practices, and socio-cultural differences associated with disposable income [ 7 , 15 – 18 ]. Despite the volume of information about several factors that compose this market, there is no structured analysis of these factors in clusters.

For this reason, we produce this scoping review for the identification of the main terms and topics cited in ART market texts. This is an appropriate tool for examining emerging evidence that has not been comprehensively reviewed or of a complex and heterogeneous nature, mapping the available evidence for clarifying definitions and conceptual boundaries [ 19 , 20 ].

The following question guided this review: What are the aspects that compose the global ART market?

To answer the question that guided this review, we choose the scoping review approach with Latent Dirichlet Allocation (LDA) topic modeling as the method to identify this evidence.

We performed a scoping review based on guidelines proposed by the Joanna Briggs Institute (JBI) Scoping Review Methodology Group [ 21 ]. The methodology was adapted from Tricco et al . (2017) [ 22 ]: a) elaboration of the research question; b) identification of relevant studies; c) selection of relevant terms by LDA topic modeling using an automatic tool and aggregation of them by iterative team approach for studying a selection and data extraction [ 23 , 24 ]; d) chart production from the data incorporating quantitative and qualitative thematic analysis; e) summarization and report of the results ( Fig 1 ).

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This design was adapted from Page et al. (2020) and purposes to identify the studies in databases and other methods through the query elaborated from the research question. After selecting studies by eligibility criteria, the titles, keywords, and abstracts were subjected to detecting terms using the topic modeling approach [ 23 ]. Terms were aggregated by semantic similarity into clusters (topics), summarized, and presented.

https://doi.org/10.1371/journal.pone.0284099.g001

Eligibility criteria

We included the following peer-reviewed and gray literature in this review: a) academic publications; b) market reports about the ART market produced by specialized research companies; and c) selected referenced media news.

About peer-reviewed publications, the following bibliographic databases were screened from 2010 to 2022: PUBMED, MEDLINE, EMBASE and Google Scholar. We defined the query (((assisted reproductive market) OR (infertility market)) OR (fertility market)) AND (("01/01/2010"[Date—Publication]: "2022"[Date—Publication]))).

For gray literature, market reports, and media news, we searched Google using the terms ‘assisted reproductive market’, which focused on referenced economic agency websites, and specialized media websites, excluding blogs and clinic websites.

Search and selection of sources of evidence

Two independent reviewers selected pertinent literature through abstracts and titles using the Sysrev software [ 25 ]. Disagreements were resolved by consensus. After this selection, the selected studies were submitted to LDA topic modeling from the content of abstracts, title, and keywords using keywords Knime software [ 24 ], which identifies repetitive word patterns across a corpus of documents [ 26 ].

Synthesis of results

The terms detected by topic modeling were clustered by synonymous and semantic similarity into topic groups. We evaluate the content of these topics and present them in a quantitative approach by ranking the number of term citations in each topic about the recent ART, and a qualitative approach through an analytic mini review.

Methodological quality appraisal

We did not appraise methodological quality or risk of bias of the included articles, consistent with guidance on scoping review conduct [ 20 ]. We draw the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist [ 27 ] in S1 Table .

Selection of sources of evidence

We found 2,232 academic papers and selected 632 that were eligible. We also included 34 market reports and seven notices produced by specialized enterprises. In these 673 records, were identified 121 most relevant cited terms covering 7,806 citations ( Fig 2 ). The academic evidence source represents 93.9% of the total, whose proportion remained approximate in the abundance of citations for each term.

We identified 2,232 academic publications in initial search. After duplicates, and ineligible exclusions (n = 1,600), we included 41 gray literature records. In total, were selected 673 abstracts, titles, and keywords for topic modeling screening step.

https://doi.org/10.1371/journal.pone.0284099.g002

The 121 identified terms were cited 7,806 times in 673 texts used for the terms detection approach ( Fig 3A and S2 Table ). The ratios were 0.18 for terms/number of texts and 11.6 for the number of citations/number of texts. We manually aggregated by team consensus these 121 terms into 10 clusters by semantic similarity ( Fig 3B and Table 1 ). As an example, the terms `ethical`and `social`were clustered into the topic of the social aspects.

A) 30 most cited terms detected by the topic modeling automation tool and each number of citations on the database. 26.9% of citations correspond to the neutral term reproductive . This was overestimated for being present in all titles and keywords and repeated in abstracts. Disregarding this term, we identified specific terms such as industry (586 citations) and surrogacy (345 citations); B) 10 Clusters of 121 detected terms aggregated by semantic similarity. We chose to organize the clusters based on the total number of citations (orange bars). The number of topics in each cluster is available in the blue bars.

https://doi.org/10.1371/journal.pone.0284099.g003

https://doi.org/10.1371/journal.pone.0284099.t001

The neutral terms topic corresponds to 37.2% of citations (27 terms; 2,900 citations). Despite this topic presenting the majority cluster, these terms were disregarded for the content analysis because they returned practically the entire set of records used.

The economic aspects topic corresponds to 17.6% of citations (16 terms; 1,375 citations) and refers to the econometric analysis of the market. We identified two subgroups, which following: a) a group of nine generic terms (1,178 citations) that returned unspecified records, and b) a group of seven terms (197 citations) representing specific economic terms such as insurance and coverage.

The compensation for reproductive services topic corresponds to 10.6% of citations (9 terms; 829 citations) and refers to records about the pricing of reproductive services and their ramifications. We identified two subgroups: a) commercial surrogacy (4 terms; 574 citations), and b) gametes pricing (5 terms; 255 citations).

The geographic distribution topic corresponds to 9.5% of citations (12 terms; 739 citations) and refers to the global distribution of the market in terms of size, demand, characteristics, and profitability.

The social aspects topic corresponds to 7% of citations (14 terms; 546 citations). In this group, the terms can be clustered into five subgroups, which follows: a) ethical/moral discussions (4 terms, 314 citations); b) religious issues (3 terms, 84 citations); c) gender issues (3 terms, 82 citations); d) sexual preferences (2 terms, 36 citations); and e) stress that was considered an independent term (10 citations).

The regulation topic corresponds to 6% of citations (9 terms; 469 citations) and refers to legal aspects of the ART market. It includes the assessment of the impact of regulation (laws and guidelines) on market behavior and the assessment of the impact of transnational practices on national regulation.

The ART market projections topic corresponds to 3.9% of citations (13 terms; 304 citations) and refers to prognostic analyzes. The group can be divided into three subgroups: positive trends (5 terms; 115 citations), b) concerns (5 terms; 152 citations), and c) neutral comparisons (3 terms; 47 citations).

The accessibility topic corresponds to 3.4% of citations (9 terms; 264 citations) and refers to terms that returned a set of texts to evaluate the social impacts related to the ART market.

The internet influence topic corresponds to 2.9% of citations (7 terms; 224 citations) and refers to terms that returned a set of texts related to the evaluation of the internet in the ART market.

The fertility preservation for non-medical reasons topic corresponds to 2% of citations (5 terms; 156 citations) and refers to terms that returned a set of texts related to this specific theme.

Critical appraisal within sources of evidence

Although resulting from the same search terms, we have found two essential differences in the content of academic publications and market studies. Academic publications focus, in general, on only one factor as a central objective and make an in-depth analysis. In contrast, market reports focus on economic projections and, more often, present the factors in a superficial and aggregated way as an increase/decrease ART market factor.

The specialized media news provided relevant information on the formation of conglomerates and open market companies. Considering that 93.9% of used literature was composed of peer-reviewed publications, the gray literature can provide a complementary perspective to peer-review information [ 28 ].

Summary of evidence

The ratio of 0.18 between the number of terms/number of texts and 11.6 between the number of citations/number of texts inform us that the texts generally deal with specific themes, whose citations are reinforced throughout the texts. Of the 121 terms detected, 16 were identified as variations of the same lexical root, and the others were identified as synonyms. We checked the accuracy of the automated tool by comparing the articles that gave rise to the identification of each of the terms. For many of these terms, there was practically total overlap between the groups of articles that gave rise to the terms identified as synonyms.

Neutral topics.

The terms grouped in neutral topics were disregarded from the content analysis because they practically returned all the records used in the term detection approach. This result is consistent with what was expected for the technique that uses the formation of matrices to search for terms and, for this reason, unspecific terms have a larger data set.

Economic aspects.

This topic refers mainly that the macro aspects of the market such as the mostly a la carte standard of treatments [ 29 ] and a structure with many clinics operating on a small/medium scale of the market that is rivaling the recent and growing formation of conglomerates [ 30 ].

Economic aspects are hardly quantifiable in imperfect markets such as health, where there are high interference levels from variables and market regulations [ 10 ]. The high prices are only one of several factors determining the ART market, which has cultural and religious associations that cannot be easily measured or evaluated by econometry [ 31 ]. However, the data collected on the growth of the ART market size in the last decades indicates that the regional discrepancies are derived from the different attractiveness for the several capital contributions made by different public and private subjects, a phenomenon known as the ’Matthew effect’ [ 32 ].

About the stock exchange and merging & acquisitions in the ART market (MAART), a few large companies have spent millions of dollars consolidating a fragmented IVF market [ 33 , 34 ]. While the conglomerates are growing, more venture capital firms invest in startups and fertility clinics, including specific niches [ 30 ]. These expansions reach state and national borders with a more entrepreneurial and corporate bias and heavy investments in technology [ 35 ].

Among the main actions carried out by companies in the sector we can mention:

• 2013—An Australian IVF company became the first IVF company traded on a major stock exchange, and it holds about 35% of the market [ 36 , 37 ].
• 2016—Cooper Surgical acquired Wallace Pharmaceuticals (India) for approximately USD 168 million [ 38 ].
• 2017—PitchBook accounted for more than US$ 178 million invested in startups that develop fertility products [ 34 ].
• 2017—The merger of IVI-RMA made this company the largest assisted reproduction center worldwide [ 39 ].
• 2017—The Thomson Medical Group Ltd. (TMG) formalized a joint venture to expand the IVI-RMA network in APAC and Mexico markets [ 40 ].
• 2019 –An enterprise that manages fertility benefits for employees of large companies reached USD 103.4 million in the first semester and released the shares on NASDAQ [ 41 ].

Coverage has a significant effect on use for older and more educated women, more significant than the effects found for other groups [ 42 , 43 ]. Studies report that more than half of working women consider changing jobs for better reproductive health benefits [ 44 ].

On the other hand, there is the possibility that insurance coverage laws may have adverse effects on total fertility in the medium and long term due to overly optimistic perceptions about the possibility of extending or delaying reproductive life in an induced way, which can be called ex-ante moral hazard [ 42 , 45 ], one of the alleged reasons for reducing public funding in Germany and Australia [ 46 , 47 ].

There is a growth in coverage for infertility treatment among jumbo employers, who tend to be trendsetters for smaller employers, and studies reported that more than half of working women would consider changing jobs for better reproductive health benefits [ 48 , 49 ]. On the other hand, there is the possibility that policies may have adverse effects on total fertility due to overly optimistic perceptions about the delay of reproductive life [ 42 , 45 ], one of the alleged reasons for reducing public funding in Germany and Australia [ 46 , 47 ].

Generally, economic recessions impact natural fertility in the developed world in does not leave a visible mark on the fertility levels of the global cohort [ 50 ]. The expressive increase in COVID-19 cases and massive hospitalizations has collapsed most health systems globally and caused the suspension of new fertility treatments, except for patients on cycle or who urgently require fertility preservation for oncological reasons [ 51 ].

Although the countries reacted with diverse responses in this pandemic, the ART services have been mainly responsive to public health and individual patient concerns [ 52 ]. The pandemic impact on fertility appears to have five main factors: high mortality, restricted access to family planning services, reduced work-life balance, economic recession and uncertainty, and disruptions to assisted reproduction services [ 53 ]. It is still early to assess how the pandemic caused by the Covid-19 disease has affected the ART market; however, it is expected that the economic recession and uncertainty impact assisted reproduction services.

Compensation for reproductive services.

Regarding the topic of c ompensation for reproductive services , the separation of these topics, although practical, has limitations because all of them are also strongly related to social aspects and legislation. We found two main analyses in the returned records for this topic: a) gamete pricing, and b) commercial surrogacy. Both are part of a more focused analysis on transnational markets called cross-border reproductive care (CBRC), popularly called reproductive tourism.

About 10% of IVF cycles are performed in the USA with donor eggs [ 54 ], and the results are like the use of fresh and frozen oocytes [ 55 ]. The term "donation" of gametes is considered inappropriate because they are generally sold [ 56 ]. The United Kingdom limits gamete’s values, while gamete donations are banned in Japan [ 54 ]. A complex set of stereotypes has led to the monetization of gametes and embryos and rapid response to price stratification based on donor phenotype and social characteristics as a degree or artistic achievements [ 57 – 59 ].

The CBRC is a global billionaire industry phenomenon that involves the transnational laissez-faire regulation [ 60 – 62 ], inequalities [ 63 ], and the demand for reproductive services [ 38 , 64 ]. It is a contentious and largely unregulated area [ 65 ] governed by the heterogeneity of conditions in each country [ 66 – 68 ]. At least ten motivations for CBRC have already been identified, grouped into four broad categories: legal and religious prohibitions, resource considerations; quality and safety concerns; and personal preferences [ 69 ].

Geographic distribution.

The topic of g eographic distribution comprises 9.5% of the citations (12 terms, 739 citations), the most discussed subject in the market reports. In general, the data presented addresses:

• The size of the market in billions of dollars: globally was around USD 26 billion in 2019 [ 12 ] and is expected to reach USD 45 billion by 2025 [ 5 ];
• Percentage distribution of clinics and number of procedures worldwide: Europe and North America represent ∼65% of the global ART market, followed by APAC with ∼25%; Middle East, Africa, and Latin America (also called by ’rest of the world’—RoW) representing ∼10% [ 5 ];
• Procedures and clinics per region: between 1997 and 2016, ART treatments have increased more than five-fold in Europe, 4.6-fold in North America, three-fold in Australia and New Zealand [ 13 , 14 ], with grown expectative in all scenarios and
• Factors (social/legal/economic) that impact this distribution: increasing infertility rates [ 7 , 15 , 16 , 38 , 70 , 71 ], rising disposable incomes [ 5 , 70 – 73 ], adoption of the western lifestyle [ 16 , 73 – 75 ], late family planning [ 16 , 70 , 72 ], low-cost and high-quality healthcare [ 18 , 72 , 75 ], favorable government initiatives [ 7 , 38 , 76 ], expansion of healthcare infrastructure [ 64 , 74 ], reduced socio-ethical stigma [ 15 , 77 ], and the CBRC [ 18 , 38 , 71 , 72 , 78 , 79 ].

ART market projections.

After neutral terms, the topic of ART market projections focused on more generic terms ( Table 1 ). The content mainly presents forecasts of the contents present in other topics such as social aspects, geographic distribution, accessibility, and regulation. The clustered terms comprised various database content, with analytical content as a characteristic in common. In addition to the market’s financial growth expectations, there is also an assessment of the geographic distribution, with the unanimous affirmation that the Asia-Pacific (APAC) market has the greatest compound annual growth rate (CAGR) and potential [ 5 , 7 , 15 , 16 , 38 , 70 – 75 , 77 , 78 ] ( S3 Table ).

The stock exchanges participation and mergers & acquisitions in the ART market (MAART) are a trend observed for a few large companies that have spent millions of dollars to consolidate a fragmented IVF market [ 33 , 34 ], with heavy investments in technology [ 35 ]. These companies also have been focused on specific niches considered non-traditional families [ 30 ].

The main projected concerns relate to reproductive commodification, in particular commercial surrogacy, and stereotypic gamete pricing [ 63 , 68 , 80 – 82 ]. In the same way that India regulated the issue to protect vulnerable women groups [ 65 , 83 ], there is a debate about ways of fair compensation for domestic surrogacy in Australia, the introduction of professional intermediaries, and limits on advertising to minimize risks [ 84 ]. It is an issue that is difficult to resolve and that depends on efforts and intranational agreements.

Social aspects.

The topic s ocial aspects subgroups can be clustered into five subgroups: a) ethical/moral discussions (4 terms, 314 citations); b) religious issues (3 terms, 84 citations); c) gender issues (3 terms, 82 citations); d) and sexual preferences (2 terms, 36 citations); and e) stress was considered an independent term (10 citations).

The records returned in this topic showed considerable overlap with the records returned in the accessibility topic, which is understandable because inequities are strongly associated with social and cultural characteristics [ 85 , 86 ].

It is complex to measure these social aspects’ impact on the ART market, a complex and imperfect health business where there are high interference levels [ 10 ]. The high prices are only one of several factors determining the ART market, which has cultural and religious associations that cannot be easily measured or evaluated by econometry [ 31 ].

It is estimated that a 1% increase in European national gross domestic product (GDP) would be able to increase 382 ART cycles per million women of reproductive age and, even so, it only increases 25% of this potential, concluding it is due to the social factors involved [ 87 ]. These factors also affect nations’ repayment policy (pro-natal or anti-natal) regardless of their GDPs, reflecting cultural and social priorities [ 88 ].

Many records about queer reproductive justice (QRJ) are returned on this topic. It refers to non-normative audiences who want to form a family nucleus, such as homo-affective couples, single parents, and other audiences who are discouraged when seeking reproductive services [ 89 , 90 ]. This market niche is often not directly related to accessibility and cost problems, and its acceptance has been partly driven globally by the strength of the neoliberal market [ 91 , 92 ].

Regulation.

Despite representing 6.7% of the number of citations in the detection stage, the topic of regulation represented 13% of the corresponding bibliography. Around 85 of those contributing to the IFFS triennial publication have regulated legislation or guidelines [ 65 ], generally associated with national economic and moral concerns [ 93 ].

We compared the data presented on the main modification to legislation in the last three years with the main topics presented by IFFS [ 65 ] detected, to assess whether there is synchronism in the topics assessed in legislation and academics ( Fig 4 ). We found some common points, but no direct correlation in the timing of the discussions.

The main themes of recent legislative changes stated by the IFFS (2019) coincide with the terms identified by topic modeling. In this way, we identified in which topics the similar terms were inserted and prepared this graph to illustrate the location of the main themes of legislative changes in relation to the main topics in assisted reproduction. Note that each topic may be included in more than one topic due to the complexity of the market.

https://doi.org/10.1371/journal.pone.0284099.g004

There is a recent debate on global policy and systematic regulatory forecasts to guide government responses to the existing market, preferably including a discussion open to all interested parties [ 94 , 95 ]. Most of the articles cited, regardless of the central focus, conclude with the statement of the need for consensual regulation at a global level to regulate the market and the public, thus avoiding most ethical conflicts [ 61 , 63 , 68 , 96 , 97 ].

Based on this lack of regulation, incoherent or fragmented regulation, the ART market worldwide is provided by free-market initiatives [ 63 ] and is associated with themes such as CBRC [ 98 ] and embryo gender selection [ 79 , 99 ]. Although it is a consensus that current regulations do not guarantee the exercise of reproductive rights and equal opportunities [ 100 , 101 ].

Accessibility.

The topic of accessibility has the same number of terms as the regulation topic but almost half the number of citations (9 terms, 264 citations). It is a topic strongly associated with economic aspects and regulation, as noted in the definition itself, which is the level of access to medical treatments necessary for infertility care through vantage/disadvantage in other aspects such as financial/social, race, class, gender, culture, and legal status played out on a social field [ 67 , 86 ].

Two terms that compile the dynamic and synergistic balance in the ART market, both domestic and transnational, are reproductive governance and stratified reproduction. Reproductive governance defines how different social actors use their powers to produce reproductive behaviors, such as legislative controls or permissions, economic incentives or disincentives, ethical and moral injunctions, or inductions [ 102 ]. Stratified reproduction refers to the inequity in reproductive rights by race, class, gender, culture, and legal status played out on a social field [ 67 ] that generates the accessibility and treatment offered to people into separate groups [ 85 , 86 ].

Accessibility, the ratio of the cost of IVF treatment to annual income [ 88 ], affects not only who can have access to ART treatment but also a) which treatments are used, as cheaper techniques are generally more likely to be covered by health insurance 100, and b) how ART is practiced, such as the association between accessibility and the number of embryos transferred [ 46 ]. This cascade of decisions impacts the results [ 10 ], and, still, most patients bear partial costs [ 103 ].

In IFFS 2019 Vigilance, 62% of the countries reported no existing family concept ART requirements; however, 50% reported limiting access to diagnostic or treatments mainly to single women or same-sex couples, excluding single men and intersex or transgender subjects [ 65 ]. This market niche is often not directly related to cost, and its acceptance has been partly driven globally by the strength of the neoliberal market [ 91 , 92 ].

Internet influence.

The topics of Internet influence and fertility preservation for non-medical reasons or social egg freezing (SEF) comprise less than 3% of the citations each. However, both are frequently cited in the texts included in the topic trends & concerns , where both growing trends and sources of concern and attention are pointed out. It is common sense that the internet and social media are powerful tools of massive influence, used by most patients during their infertility journey [ 104 , 105 ]. The content of these sites influences consumers’ selection process of both the chosen clinic and the doubts and desires for treatment and the possibility of high expectations [ 106 ]. The Society for Assisted Reproductive Technology (SART) updated your policy in 2018 to reduce public misunderstandings caused by different interpretations of data provided by clinics [ 105 ].

In addition to the search for information, the internet and social media have become spaces for selling surrogacy services in countries with legal permission or omission. This happens through forums for possible substitutes and customers [ 63 ] and a rapidly growing market for SEF and human commodities. While the benefit of dissemination and information is clear, it is essential to ensure that there is no misrepresentation and distribution of misleading information [ 107 ].

Fertility preservation for non-medical reasons.

Despite being the least represented among the topics (5 terms, 156 citations), s ocial freezing is one of the main trends [ 108 ]. Some jumbo enterprises announced the social freezing as a workplace benefit [ 48 , 49 ], although the American Society for Reproductive Medicine (ASRM) guideline includes a caution to avoid false hopes about delaying procreation [ 104 ]. The main reasons are not having a committed [ 109 , 110 ] , searching for financial security via career, or completing studies [ 111 , 112 ].

The possibility of preserving fertility in healthy women as a precaution for future infertility has gained strength in recent years [ 108 ] and the case of reproductive preservation in trans individuals who intend to alter their hormonal system and reproductive organs [ 113 ].

The emergence of egg banking can be considered a different sector in the infertility industry [ 114 ]. The influence of media and the desire for women’s autonomy contributed to the market growth [ 5 , 48 , 49 , 114 – 116 ]; this focuses on the public after 30, a suboptimal age from a clinical point of view, because the quantity and quality of eggs have already decreased considerably [ 108 ].

The ASRM guideline on ART marketing includes a caution to avoid false hopes about delaying procreation, which falls short of what is requested regarding the type and quality of information on most affiliated clinic sites [ 48 , 104 , 117 ].

In parallel, in several situations, the comparative analysis of cost-effectiveness based on direct medical costs demonstrates that the SEF can be financially advantageous in comparison to IVF in older women [ 118 , 119 ]. However, the most efficient/economic strategy for women planning to postpone pregnancy remains uncertain [ 117 ].

The division into clusters was helpful for the identification of topics and do not limit the evaluation of the behavior of the global market, as is the case of the notorious association between moral concerns and national legislation [ 121 ]. Topic modeling proved to be an appropriate tool for detecting terms that allowed us to cluster relevant aspects of this growing market. We were able to identify the size and distribution of this market, as well as list legal, social, and economic aspects, as well as trends and concerns.

Analyzing the ART market is a challengesince many isolated, interdependent, and feedback factors compose it, with cultural and religious associations that cannot be easily evaluated by econometry [ 31 ]. We note that most studies conclude on the need for transnational regulations to solve different issues. We also highlight, the need of more actions in terms of Corporate Social Responsibility, in which the commitment of companies to society occurs based on the practices carried out, going beyond the concept of profits [ 120 ].

We found that, most of the works addresses economic, regulatory, and geographic aspects, and that these topics covered have a synergistic relationship with each other. Two findings gained special attention: a) the potential impact of the formation of conglomerates and mergers on a transnational scale (MAART), considering the certainty about the growing search for reproductive treatments even with legal/social/financial barriers for the final consumer, this has a potential impact on the fragmented pattern of small/medium scale operation, as well as on the CBRC; and b) the lack of health technology assessment (HTA) in reproductive add-ons. Despite technological advances and the insertion of many add-ons over two decades, the success rate remains at around 30% of IVF cycles [ 14 ], especially considering that the ART market devices & consumables were valued at USD 13.75 Billion in 2020 and projected to double by 2028 [ 121 ].

From these findings, it will be possible to establish dynamic and synergistic relationships between the identified topics. This can be used to generate predictive models about the ART market and to point out situations that need to be better understood, such as the low efficiency of IVF cycles. This information can help identify new market niches and increase the availability of technologies and actions for the treatment of infertility.

Limitations of the study

The most significant limitation of this study is the impossibility of exhausting each identified aspect. Also, the generalization of accumulated data causes the loss of local nuances. We would like to create correlation cascades, but we chose not to do so at the risk of creating spurious contexts and escaping the intended purpose of the scoping review.

Supporting information

S1 table. preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (prisma-scr) checklist..

The elaboration of reviews from the checklist is mandatory for quality studies. We used the specific model for scope reviews according to the model published by Tricco et al . (2018).

https://doi.org/10.1371/journal.pone.0284099.s001

S2 Table. Topics detected by automation tool.

Complete list of terms mined by topic modeling (LDA protocol by Knime). We identified 121 terms covering 7,806 citations.

https://doi.org/10.1371/journal.pone.0284099.s002

S3 Table. The CAGR of the global ART market, according to market reports.

Survey of compound annual growth rate (CAGR) presented in market reports on the subject studied. Note the market growth forecast in all scenarios.

https://doi.org/10.1371/journal.pone.0284099.s003

Acknowledgments

We want to thank the Januário Cicco Maternity Hospital School of the Federal University of Rio Grande do Norte–MEJC/UFRN.

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Assisted Reproductive Technology: Clinical Aspects

• First Online: 18 June 2022

Cite this chapter

• Pardis Hosseinzadeh 3 ,
• M. Blake Evans 3 &
• Karl R. Hansen 3  

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Assisted reproductive technologies (ARTs) involve all fertility treatments that include the handling of oocytes and/or embryos outside of the body. In vitro fertilization (IVF) is the most common and efficacious ART treatment used today. Recent advancements in the science and technology have revolutionized IVF success rates, and today, IVF accounts for over 1% of all children born in the USA each year. The process of IVF is highly coordinated and involves weeks of preparation beginning with ovarian stimulation with exogenous gonadotropins, followed by retrieval of oocytes from the ovaries, fertilization and embryo culture in the laboratory, and transfer of the embryo into the recipient’s uterus. Special considerations include how to fertilize the oocytes (intracytoplasmic sperm injection or conventional insemination), fresh versus frozen embryo transfer, whether to perform preimplantation genetic testing on the derived embryos, and management of premature progesterone rise in IVF cycles. Many controversies exist, which we will address in this chapter.

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Pardis Hosseinzadeh, M. Blake Evans & Karl R. Hansen

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Hosseinzadeh, P., Evans, M.B., Hansen, K.R. (2022). Assisted Reproductive Technology: Clinical Aspects. In: Falcone, T., Hurd, W.W. (eds) Clinical Reproductive Medicine and Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-99596-6_17

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Bibliometric analysis and visualization of literature on assisted reproduction technology

Affiliations.

• 1 Urology Surgery, The Third Affiliated Hospital of Beijing University of Chinese Medicine, Beijing, China.
• 2 Department of Andrology, Shunyi Hospital, Beijing Hospital of Traditional Chinese Medicine, Beijing, China.
• 3 Department of Surgery, Beijing Xuanwu Traditional Chinese Medicine Hospital, Beijing, China.
• 4 Department of Gynaecology, The Third Affiliated Hospital of Beijing University of Chinese Medicine, Beijing, China.
• 5 Department of Andrology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China.
• PMID: 36530896
• PMCID: PMC9751384
• DOI: 10.3389/fmed.2022.1063040

Introduction: Assisted reproductive technology (ART) is a method that uses various techniques to process sperm or ova. Assisted reproductive technology involves removing ova from a woman's ovaries, combining them with sperm in the laboratory, and returning them to the woman's body or donating them to another woman.

Methods: Based on the web of science core collection database, we firstly analyzed the quantity and quality of publications in the field of ART, secondly profiled the publishing groups in terms of country, institution, author's publication and cooperation network, and finally sorted out and summarized the hot topics of research.

Results: In total, 6,288 articles on ART were published between 2001 and 2022 in 1,013 journals. Most of these published articles represent the global research status, potential hotspots and future research directions. Publications and citations of research on assisted reproductive technology have steadily increased over the past few decades. Academic institutions in Europe and the United States have been leading in assisted reproductive technology research. The countries, institutions, journals, and authors with the most published articles were the United States (1864), Harvard Univ (108), Fertility and Sterility (819), and Stern, Judy E. (64). The most commonly used keywords are Assisted reproductive technology (3303) and in-vitro Fertilization (2139), Ivf (1140), Pregnancy (1140), Women (769), Intracytoplasmic Sperm injection (644), In Fertilization (632), Risk (545), and Outcome (423).

Conclusion: Frozen embryo transfer, intracytoplasmic sperm injection, and in vitro fertilization are the main research topics and hotspots in the field of assisted reproductive technology.

Keywords: CiteSpace; VOSviewer; assisted reproduction technology; bibliometric analysis; visualization.

Copyright © 2022 Meng, Deng, Wang, Zhou, Zhao, Li, Liu, Gao, Liao and Wang.

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Research in Assisted Reproductive Technologies

Various techniques have been developed and refined to obtain a large number of offspring from genetically superior animals or obtain offspring from infertile (or subfertile) animals. 

These techniques include: artificial insemination, cryopreservation (freezing) of gametes or embryos, induction of multiple ovulations, embryo transfer, in vitro fertilization, sex determination of sperm or embryos, nuclear transfer, cloning, etc.

Artificial Insemination and Cryopreservation

Artificial insemination (AI) has been used to obtain offspring from genetically superior males for more than 200 years. Improvements in methods to cryopreserve (freeze) and store semen have made AI accessible to more livestock producers. In the same manner as cryopreservation of semen, embryo freezing allowed for the global commercialization of animals with high genetic qualities. Semen from bulls is especially amenable to freezing and long-term storage. In the dairy industry, where large numbers of dairy cows are managed intensely, AI is simple, economical, and successful. More than 60 percent of dairy cows in the United States are bred by AI. However, the situation is different for beef cattle, where breeding populations are usually maintained on range or pasture conditions. In the United States beef industry, AI accounts for less than 5 percent of inseminations. For reasons that are not yet well understood, it is more difficult to freeze and store semen from other livestock species, including horses, pigs, and poultry, than it is to freeze cattle semen. NIFA has supported  research projects  to understand the physiological processes associated with cryopreservation of semen or embryos and to develop improved methods of cryopreservation for gametes (eggs and sperm) and embryos from several livestock species.

Multiple Ovulation and Embryo Transfer

Development of embryo transfer technology allows producers to obtain multiple progeny from genetically superior females. Depending on the species, fertilized embryos can be recovered from females (also called embryo donors) of superior genetic merit by surgical or nonsurgical techniques. The genetically superior embryos are then transferred to females (also called embryo recipients) of lesser genetic merit. In cattle and horses, efficient techniques recover fertilized embryos without surgery, but only one or sometimes two embryos are produced during each normal reproductive cycle. In swine and sheep, embryos must be recovered by surgical techniques. To increase the number of embryos that can be recovered from genetically superior females, the embryo donor is treated with a hormone regimen to induce multiple ovulations, or superovulation. NIFA has supported  basic and applied research  to enhance the efficiency of superovulation and embryo transfer in livestock species.

In Vitro Fertilization

As an alternative to collecting embryos from donor animals, methods have been developed recently to produce embryos  in vitro  (in the laboratory). The methods are also called  in vitro embryo production. Immature oocytes (female eggs) can be obtained from ovaries of infertile or aged females, or from regular embryo donors (described above). Ovum (egg) pick up is a nonsurgical technique that uses ultrasound and a guided needle to aspirate immature oocytes from the ovaries. Once the immature oocytes have been removed from the ovary, they are matured, fertilized, and cultured  in vitro  for up to seven days until they develop to a stage that is suitable for transfer or freezing. NIFA has supported a number of  basic research projects  to understand the physiological mechanisms associated with production of embryos  in vitro .

Sex Determination of Sperm or Embryos

The beef industry in the United States prefers male calves, which tend to have higher body weights and higher feed efficiency (compared to female or heifer calves) when placed in feedlots for the growing and finishing stages of meat production. In contrast, the dairy industry prefers heifer calves, which will ultimately produce offspring and milk for human consumption. Thus, methods are needed to determine the sex of sperm or embryos so producers can control the sex of the offspring of their livestock. Using a specific dye that binds to DNA (the Hoechst 33342 stain) and a flow cytometer/cell sorter, the DNA content of individual sperm is measured. In cattle, the X-bearing sperm contain 3.8 percent more DNA than the Y-bearing sperm. In mammals, the presence of a Y chromosome (and one X chromosome) determines that the individual will be a male. Female mammals contain 2 X chromosomes. Although the process to sort the X and Y bearing sperm is slow (approximately 10 million live sperm of each sex can be obtained per hour—this is about the number of live sperm required for one conventional dose of frozen semen for artificial insemination), this procedure determines the sex with higher than 95 percent accuracy.

Nuclear Transfer or Cloning

Since the mid 1980s, technology has been developed to transfer the nucleus from either a blastomere (cells from early, and presumably undifferentiated cleavage stage embryos) or a somatic cell (fibroblast, skin, heart, nerve, or other body cell) to an enucleated oocyte (unfertilized female egg cell with the nucleus removed). This “nuclear transfer” produces multiple copies of animals that are themselves nearly identical copies of other animals (transgenic animals, genetically superior animals, or animals that produce high quantities of milk or have some other desirable trait, etc.). This process is also referred to as cloning. To date, somatic cell nuclear transfer has been used to clone cattle, sheep, pigs, goats, horses, mules, cats, rabbits, rats, and mice.

The technique involves culturing somatic cells from an appropriate tissue (fibroblasts) from the animal to be cloned. Nuclei from the cultured somatic cells are then microinjected into an enucleated oocyte obtained from another individual of the same or a closely related species. Through a process that is not yet understood, the nucleus from the somatic cell is reprogrammed to a pattern of gene expression suitable for directing normal development of the embryo. After further culture and development in vitro, the embryos are transferred to a recipient female and ultimately result in the birth of live offspring. The success rate for propagating animals by nuclear transfer is often less than 10 percent and depends on many factors, including the species, source of the recipient ova, cell type of the donor nuclei, treatment of donor cells prior to nuclear transfer, the techniques used for nuclear transfer, etc. NIFA has supported  research projects  to obtain a better understanding of the basic cellular mechanisms associated with nuclear reprogramming.

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Safety and Child Health of Assisted Reproduction Technology (ART)

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Assisted reproductive technology (ART) provides an opportunity for couples suffering infertility to obtain a baby. However, with the increasing occurrence of complications on infertile women in the ART process, there is a corresponding interest in the safety of ART on women. Meanwhile, the effect of ART on ...

Keywords : ART, safety, complications, offspring health, genetics

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Hamdan, Mukhri. "Endometriosis and assisted reproduction technology." Thesis, University of Southampton, 2016. https://eprints.soton.ac.uk/416621/.

Morgan, Jonathan J. "State Regulation of Assisted Reproductive Technology." BYU ScholarsArchive, 2010. https://scholarsarchive.byu.edu/etd/2206.

Hui, Pui-wah. "Nuchal translucency in pregnancies conceived after assisted reproduction technology." Click to view the E-thesis via HKUTO, 2003. http://sunzi.lib.hku.hk/hkuto/record/B31971040.

Hui, Pui-wah, and 許佩華. "Nuchal translucency in pregnancies conceived after assisted reproduction technology." Thesis, The University of Hong Kong (Pokfulam, Hong Kong), 2003. http://hub.hku.hk/bib/B31971040.

Brodin, Thomas. "Ovarian Reserve and Assisted Reproduction." Doctoral thesis, Uppsala universitet, Obstetrik & gynekologi, 2013. http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-192998.

Wilson, Poe Emma. "Vitrification of day 5/6 human morulas/blastocysts: A 10 year retrospective study in a private assisted reproductive techniques [ART] clinic." Thesis, Stellenbosch : Stellenbosch University, 2015. http://hdl.handle.net/10019.1/96876.

Batty, Lynne Patricia. "Assisted Reproductive Technology: The Aotearoa/New Zealand Policy Context: A thesis submitted in fulfilment of the requirements for the degree of Master of Arts in Sociology in the University of Canterbury." Thesis, University of Canterbury. Sociology, 2002. http://hdl.handle.net/10092/912.

Ellender, Stacey. "Assisted reproduction defining and evaluating the multiple outcomes of technologically advanced interventions /." online access from Digital Dissertation Consortium, 2005. http://libweb.cityu.edu.hk/cgi-bin/er/db/ddcdiss.pl?3193097.

Sengupta, Anindita. "The Desired Baby: Assisted Reproductive Technology, Secrecy, and a Cultural Account of Family Building in India." The Ohio State University, 2017. http://rave.ohiolink.edu/etdc/view?acc_num=osu1483451149153858.

Kruger, Theunis Frans. "The role of sperm morphology in assisted reproduction (ART)." Thesis, Stellenbosch : Stellenbosch University, 2012. http://hdl.handle.net/10019.1/71682.

Fasano, Giovanna. "Contribution of vitrification to human assisted reproduction." Doctoral thesis, Universite Libre de Bruxelles, 2013. http://hdl.handle.net/2013/ULB-DIPOT:oai:dipot.ulb.ac.be:2013/209484.

Cornet, Bartolomé David. "Molecular determinants of human oocyte quality in assisted reproduction." Doctoral thesis, Universitat de Barcelona, 2019. http://hdl.handle.net/10803/667566.

Hultling, Claes. "Assisted reproduction technology in men with ejaculatory dysfunction with special reference to spinal cord injury /." Stockholm, 1998. http://diss.kib.ki.se/1998/91-628-2806-1/.

Mumford, Karen Rose. "The Stress Response, Psychoeducational Interventions and Assisted Reproduction Technology Treatment Outcomes: A Meta-Analytic Review." [Tampa, Fla.] : University of South Florida, 2004. http://purl.fcla.edu/fcla/etd/SFE0000495.

Uner, Ozge. "A Study On Social And Affective Dimensions Of The Use Of Assisted Reproduction Technology (art) By Women In Turkey." Master's thesis, METU, 2004. http://etd.lib.metu.edu.tr/upload/12605229/index.pdf.

Boshoff, Gerhardus Marthinus. "Investigating a novel in vitro embryo culture system – The Walking Egg Affordable Assisted Reproductive Technology." Diss., University of Pretoria, 2017. http://hdl.handle.net/2263/63049.

Traça, Ana Bárbara Batista de Abel. "Evolução do controlo reprodutivo equino em Portugal e as suas repercussões na produtividade." Bachelor's thesis, Universidade Técnica de Lisboa. Faculdade de Medicina Veterinária, 2010. http://hdl.handle.net/10400.5/2556.

Williams, Nicola Jane. "Pre-implantation and pre-natal selection of offspring : can there be a duty to select against disability?" Thesis, University of Manchester, 2015. https://www.research.manchester.ac.uk/portal/en/theses/preimplantation-and-prenatal-selection-of-offspring-can-there-be-a-duty-to-select-against-disability(00aa8d13-c161-46cc-a338-9cf49106dacc).html.

Pangestu, Mulyoto 1963. "Drying biological material for use in assisted reproductive technology." Monash University, Institute of Reproduction and Development, 2002. http://arrow.monash.edu.au/hdl/1959.1/7879.

Chang, Jeani. "Relationship Between Assisted Reproductive Technology and Risk of Stillbirth." ScholarWorks, 2017. https://scholarworks.waldenu.edu/dissertations/4508.

McComiskey, Mark Henry. "Unrecognised healthcare consequences of children born following assisted reproductive technology." Thesis, Queen's University Belfast, 2014. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.675460.

Smith, Heather K. "The impact of framing on policy passage: the case of assisted reproductive technology." Thesis, Georgia Institute of Technology, 2011. http://hdl.handle.net/1853/42774.

Hoogendijk, Christiaan F. (Christiaan Frederik). "Sperm DNA fragmentation : implications in assisted reproductive technologies." Thesis, Stellenbosch : Stellenbosch University, 2007. http://hdl.handle.net/10019.1/21626.

Evbuomwan, I. O. "Osmoregulation in ovarian hyperstimulation syndrome (OHSS)." Thesis, University of Newcastle upon Tyne, 2001. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.246609.

Gibson, Andrew Robert. "The impact of the child welfare principle on access to assisted reproductive technology." Thesis, University of Glasgow, 2015. http://theses.gla.ac.uk/6716/.

Couture, Vincent. "Les vases communicants : une ethnographie des services reproductifs transfrontaliers au Canada." Thèse, Université de Sherbrooke, 2018. http://hdl.handle.net/11143/11862.

Morris, Akilah. "KNOWLEDGE, INTENTIONS, AND BELIEFS ABOUT FERTILITY AND ASSISTED REPRODUCTIVE TECHNOLOGY AMONG ILLINOIS COLLEGE STUDENTS." OpenSIUC, 2018. https://opensiuc.lib.siu.edu/dissertations/1595.

Davidson, Lien M. "Infra-red laser applications in the reproductive sciences : improving safety for assisted reproductive technology and developing novel research tools." Thesis, University of Oxford, 2017. http://ora.ox.ac.uk/objects/uuid:7472f917-7bf2-4a5d-81e1-16b179cfd0f6.

Wong, Yim-kuk Aileen. "Stress and coping for women from infertility to assisted reproductive treatments /." Hong Kong : University of Hong Kong, 2000. http://sunzi.lib.hku.hk/hkuto/record.jsp?B22331529.

Yelumalai, Suseela. "Potential effects of assisted reproductive technology upon the abundance and localisation of two vital sperm proteins." Thesis, University of Oxford, 2015. http://ora.ox.ac.uk/objects/uuid:be57f123-c6dc-4cc8-ae53-1f32716cc1e5.

Santos, Gomes Barbara Micaela. "Development of novel tools for assisted reproductive technologies based on electrically switchable surfaces." Thesis, University of Birmingham, 2018. http://etheses.bham.ac.uk//id/eprint/8690/.

Dooley, Brigitte A. "ATTITUDES TOWARD ASSISTED REPRODUCTIVE TECHNOLOGY: THE EFFECTS OF GENDER, RELATIONSHIP STATUS, AGE, AND SEXUAL ORIENTATION." UKnowledge, 2014. http://uknowledge.uky.edu/hes_etds/11.

Bailey, Vicki E. "Ethical considerations for Christian couples facing infertility and weighing the possibilities offered by assisted reproductive technology." Online full text .pdf document, available to Fuller patrons only, 1999. http://www.tren.com.

Sigala, Julien. "Qualité du protéome du spermatozoïde humain et infertilité." Thesis, Lille 2, 2016. http://www.theses.fr/2016LIL2S039/document.

Sakian, Sina. "Investigation of methylation and gene expression in placenta of pregnancies conceived by assisted reproductive technology (ART)." Thesis, University of British Columbia, 2011. http://hdl.handle.net/2429/31191.

Peters, Kathleen, and k. peters@uws edu au. "Misguided hope: a narrative analysis of couples' stories of childlessness despite treatment with assisted reproductive technology." Flinders University. School of Nursing and Midwifery, 2006. http://catalogue.flinders.edu.au./local/adt/public/adt-SFU20061011.123633.

Wong, Yim-kuk Aileen, and 黃艷菊. "Stress and coping for women from infertility to assisted reproductive treatments." Thesis, The University of Hong Kong (Pokfulam, Hong Kong), 2000. http://hub.hku.hk/bib/B31250907.

Souza, Camila Vitule Brito de. "Casais de mesmo sexo, parentalidade e novas tecnologias reprodutivas." Universidade de São Paulo, 2014. http://www.teses.usp.br/teses/disponiveis/5/5137/tde-14112014-154413/.

Valenzuela, Alcaraz Brenda I. "Cardiovascular assessment in fetuses and children conceived by assisted reproductive technologies." Doctoral thesis, Universitat de Barcelona, 2016. http://hdl.handle.net/10803/401805.

Schwarz, Lukas [Verfasser], Oliver G. [Akademischer Betreuer] Schmidt, Oliver G. [Gutachter] Schmidt, and Benjamin [Gutachter] Friedrich. "Magnetic Micromotors in Assisted Reproductive Technology / Lukas Schwarz ; Gutachter: Oliver G. Schmidt, Benjamin Friedrich ; Betreuer: Oliver G. Schmidt." Chemnitz : Technische Universität Chemnitz, 2020. http://d-nb.info/1220943169/34.

Wunderlin, Beverly J. "The Regulation of Medically Assisted Procreation in Europe and Related Nations and the Influence of National Identity, Social Cultural, and Demographic Differences." Thesis, University of North Texas, 2002. https://digital.library.unt.edu/ark:/67531/metadc3192/.

Senaya, Charles M. "Outcome of assisted reproductive technology in women with poor ovarian response undergoing infertility treatment in the reproductive medicine unit of Groote Schuur hospital: a five-year review." Master's thesis, Faculty of Health Sciences, 2021. http://hdl.handle.net/11427/34032.

Kavaliauskienė, Birutė. "Dirbtinio apvaisinimo finansavimo iš Privalomojo sveikatos draudimo fondo biudžeto teisiniai aspektai." Master's thesis, Lithuanian Academic Libraries Network (LABT), 2006. http://vddb.library.lt/obj/LT-eLABa-0001:E.02~2005~D_20060314_101027-28072.

Ben, Messaoud Khaoula. "Etude du recours, de l’accès et de l’abandon des traitements de l’infertilité à partir des données du Système National des Données de Santé Infertility Treatment in France, 2008–2017: A Challenge of Growing Treatment Needs at Older Ages." Thesis, université Paris-Saclay, 2020. http://www.theses.fr/2020UPASR014.

Nuojua-Huttunen, S. (Sinikka). "Intrauterine insemination (IUI) treatment in subfertility." Doctoral thesis, University of Oulu, 1999. http://urn.fi/urn:isbn:9514251717.

Dedrick, Elizabeth A. "The politics of being an egg "donor" and shifting notions of reproductive freedom." [Tampa, Fla.] : University of South Florida, 2004. http://purl.fcla.edu/fcla/etd/SFE0000286.

Kirsch, Juliane Katharina [Verfasser]. "Bedeutung von AMH in Follikelflüssigkeit und Serum bei Behandlung von Patientinnen im Rahmen eines ART-Programmes (Assisted Reproductive Technology) / Juliane Katharina Kirsch." Kiel : Universitätsbibliothek Kiel, 2018. http://d-nb.info/1161729496/34.

Corrêa, Maria Eduarda Cavadinha. "Duas mães? Mulheres lésbicas e maternidade." Universidade de São Paulo, 2012. http://www.teses.usp.br/teses/disponiveis/6/6136/tde-29042012-124625/.

Franco, Joana Sofia. "Vivências psicológicas de um casal homossexual feminino na transição para a homoparentalidade." Master's thesis, ISPA - Instituto Universitário, 2013. http://hdl.handle.net/10400.12/2760.

Burger, Riana. "Evaluation of spermatozoa DNA tests for an assisted reproductive techniques (ART) program : correlation with semen parameters and ART outcome." Thesis, Stellenbosch : Stellenbosch University, 2013. http://hdl.handle.net/10019.1/80343.

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ART: assisted reproductive technology. This report includes 413,776 ART cycles performed in 2021 by the 453 clinics that reported their data as required.

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• v.2012; 2012

The Ethical, Legal, and Social Issues Impacted by Modern Assisted Reproductive Technologies

Background . While assisted reproductive technology (ART), including in vitro fertilization has given hope to millions of couples suffering from infertility, it has also introduced countless ethical, legal, and social challenges. The objective of this paper is to identify the aspects of ART that are most relevant to present-day society and discuss the multiple ethical, legal, and social challenges inherent to this technology. Scope of Review . This paper evaluates some of the most visible and challenging topics in the field of ART and outlines the ethical, legal, and social challenges they introduce. Major Conclusions . ART has resulted in a tectonic shift in the way physicians and the general population perceive infertility and ethics. In the coming years, advancing technology is likely to exacerbate ethical, legal, and social concerns associated with ART. ART is directly challenging society to reevaluate the way in which human life, social justice and equality, and claims to genetic offspring are viewed. Furthermore, these issues will force legal systems to modify existing laws to accommodate the unique challenges created by ART. Society has a responsibility to ensure that the advances achieved through ART are implemented in a socially responsible manner.

1. Introduction

ART is currently a commonplace technology that has successfully treated millions of infertile couples the world over. However, the explosion of this technology has introduced a myriad of new social, ethical, and legal challenges. This paper evaluates some of the most visible and challenging topics in the field of ART and outlines the ethical, legal and social challenges they introduce.

2. Scope of ART Utilization

Infertility has traditionally been an area of medicine in which physicians had limited means to help their patients. The landscape of this field changed dramatically with the announcement of the birth of Louise Brown in 1978 through in vitro fertilization (IVF). This historic moment was eloquently encapsulated by Howard Jones who observed “Eleven forty-seven p.m. Tuesday, July 25, 1978, was surely a unique moment in the life of Patrick Steptoe. This was the hour and minute he delivered Louise Brown, the world's first baby, meticulously, lovingly, and aseptically conceived in the laboratory, but popularly referred to as the world's first test tube baby” [ 1 ]. The importance of this birth to scientists, clinicians, and most particularly infertile patients throughout the world cannot be overstated. In several short decades, IVF has exploded in availability and use throughout the world.

Worldwide, more than 70 million couples are afflicted with infertility [ 2 ]. Since the first successful IVF procedure in 1978 [ 3 ], the use of this and related technologies has expanded to become commonplace around the globe. Over the past decade, the use of ART services has increased at a rate of 5–10% annually [ 4 , 5 ].

In 1996, approximately 60,000 IVF cycles were initiated in the United States with approximately 17,000 clinical pregnancies and 14,000 live births [ 6 ]. Currently, IVF accounts for approximately 1% of all live births in the United States [ 6 ]. As of 2009, 3.4 million children have been born worldwide after ART treatment, and ART utilization is currently increasing at a rate of 5–10% annually in developed countries [ 4 ].

3. Reporting Regulations

The widespread use of this technology throughout the world has prompted a desire by the public, governmental bodies, and professional organizations to create mechanisms that evaluate the utilization of ART. Advances in the arena of assisted reproductive technologies (ART) are accompanied by ethical and societal concerns. Legislation and professional societies have attempted to address these concerns for some time. For example, in 1986, the American Fertility Society first published guidelines for the ethical implementation of ART in the United States [ 7 ]. The dynamic nature of ART and the rapid evolution of the field result in constant paradigm shifts that require frequent and comprehensive evaluation by professional organizations and society alike.

In the 1980's, concerns surrounding ART focused on the safe administration of gonadotropins, transparency of pregnancy data from clinics, and addressing economic barriers to ART access. Some of these issues, such as reporting requirements for ART pregnancy results, have also been mandated with legislation in many nations [ 8 ]. Furthermore, ART reporting requirements generally include the number of embryos transferred. This measure has been extremely important in correlating the risk of multiple gestations with the transfer of 2 or more embryos. However, in many nations, reporting regulations are not accompanied by legislation defining practice patterns. For example, in the United States, while physicians are required to report the number of embryos transferred in an IVF cycle, there are no laws that state the allowed number of embryos transferred [ 8 ].

Through centralized mandatory reporting registries, general estimates of IVF activity are available in many nations. In an effort to define current IVF statistics and to make this information more transparent and available to patients, the Fertility Clinic Success Rate and Certification Act of 1992 was created in the United States [ 8 ]. This law requires clinics providing IVF in the United States to report specific information regarding IVF cycles, including pregnancy rates [ 6 ]. This reporting data is only reported on IVF cycle outcomes and does not include detailed information regarding the maternal or paternal medical history [ 6 ]. In other countries, similar national registries exist [ 5 ], making it possible to evaluate data from IVF cycles on both a national and international scale. A detailed accounting for ART reporting and regulations across the globe is available from the International Federation of Fertility Societies (IFFS) [ 5 ]. In their 2010 report, the IFFS reported ART outcomes data from 59 countries [ 5 ].

Such laws were implemented in an attempt to ensure that patients may be informed as to which clinics have superior ART pregnancy results. In some instances, however, this has led to some clinics “cherry picking” patients to improve their overall pregnancy results. This has actually become a barrier to receiving ART for many patients with a relatively poor pregnancy prognosis.

4. Practice Regulations and Multiple Gestation Pregnancies

Federally mandated regulations, however, are not limited to registries. Increasingly, nations have enacted legislation that defines the parameters for acceptable practice of ART. The transfer of multiple embryos in a single cycle increases the rates of multiple births [ 9 ]. Because of the increased social costs and health risks associated with multiple births, legislation or guidelines from professional societies have been introduced in many countries restricting the number of embryos that may be transferred per IVF cycle in an effort to limit the incidence of multiple gestations [ 9 – 11 ]. Indeed, a study in the United Kingdom found that the total health care system costs following a singleton birth were £ 3313, £ 9122 following a twin birth and £ 32,354 following a triplet birth [ 9 ]. Additionally, the health risks, both to the mother and the infant, increase dramatically with increasing number of infants [ 9 ]. In the United States in 2007, the number of embryos transferred per cycle ranged from 2.2 in women under 35 to 3.1 in women over 40 years of age (CDC). Multiple birth rates in the United States in 2007 ranged from approximately 35% in women under 35 to 15% in women over the age of 40 [ 12 ]. In Europe, the approximate number of embryos transferred in the year 2006 was one (22%), two (57%), three (19%), or four (1.6%) [ 13 ]. In 2007, 79.2% of European births were singletons, with a twin rate of 19.9% and a triplet rate of 0.9% [ 5 ].

Pregnancy rates associated with IVF are high compared to those seen in the early days of the procedure. The current efficiency of IVF is more cost effective and efficacious in achieving pregnancy than other modalities, such as injectable gonadotropins coupled with intra uterine insemination (IUI), which traditionally some have preferred [ 14 ]. The increased efficiency of IVF has also resulted in an increased rate of multiple gestations. Recent data suggests that single embryo transfer, coupled with subsequent frozen embryo transfer, results in equivalent pregnancy rates compared with the transfer of multiple embryos, without an increase in multiple pregnancy rates [ 11 ]. Additionally, single embryo transfer would inherently decrease maternal and infant health risks associated with multiple gestation pregnancies [ 9 ]. Therefore, a trend toward single embryo transfer is likely to increase in the future.

Variability of legislation regulating IVF exists in different countries and even states/provinces within a single nation [ 6 ]. For example, in an effort to minimize multiple gestation pregnancies resulting from ART, some laws place limits on the number of embryos that may be transferred, cryopreserved, or fertilized per IVF cycle [ 5 , 6 , 15 , 16 ]. In some cases, these regulations or fiscal pressures result in couples traveling across international border to obtain treatments that are unavailable in their native country [ 17 ]. This practice, known as cross-border reproductive care (CBRC), is thought to account for as much as 10% of the total IVF cycles performed worldwide [ 17 , 18 ].

5. Financial Aspect for IVF Treatment

Perhaps one of the most obvious ethical challenges surrounding ART is the inequitable distribution of access to care. The fact that significant economic barriers to IVF exist in many countries results in the preferential availability of these technologies to couples in a position of financial strength [ 19 ]. The cost of performing ART per live birth varies among countries [ 4 ]. The average cost per IVF cycle in the United States is USD 9,266 [ 20 ]. However, the cost per live birth for autologous ART treatment cycles in the United States, Canada, and the United Kingdom ranged from approximately USD 33,000 to 41,000 compared to USD 24,000 to 25,000 in Scandinavia, Japan, and Australia [ 14 ]. The total ART treatment costs as a percentage of total healthcare expenditures in 2003 were 0.06% in the United States, 0.09% in Japan, and 0.25% in Australia [ 4 ]. Some have maintained that the cost for these cycles pales in comparison to the social advantages yielded by the addition of productive members of society [ 21 ]. This is especially true in societies that have a negative or flat population growth rate coupled with an aging population [ 21 ].

The funding structure for IVF/ART is highly variable among different nations. For example, no federal government reimbursement exists for IVF in the United States, although certain states have insurance mandates for ART [ 4 , 19 , 22 ]. Many other countries provide full or partial coverage through governmental insurance [ 4 , 9 ]. In many instances, long waiting times for IVF through these government programs encourage couples to seek treatment in private fertility centers that accept remuneration directly from the patients [ 4 , 23 , 24 ]. In the United Kingdom, for example, only approximately 25% of all IVF cycles performed are funded by the National Health Service [ 9 ].

6. Preimplantation Genetic Testing

Preimplantation genetic screening (PGS) and diagnosis (PGD) offer the unique ability to characterize the genetic composition of embryos prior to embryo transfer. Given the recent successes of these technologies, the broader implementation of this technology in the future is likely. Although controversial, using PGD to choose embryos solely on the basis of gender is currently being practiced [ 25 , 26 ]. Sex selection in the proper setting may offer a substantial health benefit. For example, choosing to transfer only embryos of a certain sex may confer a therapeutic benefit if used to avoid a known sex linked disorder. However, sex selection PGD purely for the preference of the parents could conceivably, if practiced on a large scale, skew the gender proportions in certain nations where one gender is culturally preferred.

In the near future, with refinements in microarray technology and the defining of genetic sequences associated with certain physical characteristics, it is conceivable that specific physical or mental characteristics may be evaluated to guide the decision as to which embryos to transfer. This possibility raises concerns on both ethical and practical levels. Of more concern is the possibility that in the future, technology will permit the manipulation of genetic material within an embryo. Rigorous public and scientific oversight of these technologies is vital to ensure that scientific advances are tempered with the best interests of society in mind.

7. Fertility Preservation

Female fertility is well documented to decrease with age [ 27 , 28 ]. Consequently, much research has been conducted aimed at preserving female fertility before advanced age is realized. Additionally, fertility preservation for individuals afflicted with cancer has important implications as often the chemotherapeutic agents used to treat cancer are toxic to the ovary and result in diminished ovarian reserve and reduced fertility. While techniques for freezing sperm and embryos are well established, techniques for freezing oocytes and ovarian tissue are still considered experimental [ 29 ]. Multiple techniques including oocyte cryopreservation and preservation of strips of ovarian cortex with subsequent reimplantation and stimulation have been described, with some pregnancy success [ 30 – 33 ]. Fertility preservation for cancer patients using in vitro maturation (IVM), oocyte vitrification and the freezing of intact human ovaries with their vascular pedicles have also been reported [ 34 ]. As of 2008, more than 5 babies had been delivered through IVF following ovarian tissue transplantation [ 35 ]. Many have suggested that, prior to being treated for cancer, women should be offered fertility preservation measures as outlined above [ 34 ].

Recently, several laboratories have demonstrated the ability to successfully cryopreserve oocytes following an IVF cycle. These developments have profound implications. As the birth control pill gave women the ability to prevent pregnancy, oocyte cryopreservation may give women the flexibility to preserve their fertility potential, starting at a young age, while postponing childbearing. However, as this technology at the present time in many countries is generally only available to those with financial means. This poses ethical and social issues that will certainly see more attention in the future.

8. Gamete Donation

The use of donor gametes, either in the form of donor sperm or donor oocytes, is commonplace in ART. The use of donor sperm can be traced to the 1800's [ 36 ]. In the mid 1980s, oocyte donation was introduced [ 36 ]. In recent years, issues surrounding the use of donor gametes have become increasingly visible [ 37 ]. Women donating oocytes must undergo IVF. Due to the inherent medical risks associated with IVF, including ovarian hyperstimulation syndrome and surgical risks, a central concern of allowing women to be oocyte donors includes adequate informed consent [ 37 ]. Consent, in addition to outlining these medical risks, should include counseling regarding the emotional benefits and risks of donation with an emphasis that long-term data regarding these risks are lacking [ 37 ]. Additionally, it is considered an ethical prerequisite that oocyte donors participate voluntarily and without coercion or undue influence [ 38 ]. Some have expressed concern that financial compensation of oocyte donors may lead to exploitation as women may proceed with oocyte donation against their own best interests, given the inherent medical risks involved [ 39 ]. The concept of commodification, that any “buying or selling” of human gametes is inherently immoral, is an additional argument used against remunerating women serving as oocyte donors [ 39 ]. Due to the substantial controversy surrounding oocyte donation, especially the amount of financial compensation may be given to an oocyte donor, federal regulations governing this practice are constantly evolving and differ substantially from country to country [ 39 ].

Another ethical and legal issue surrounding the use of donated gametes is to what extent the anonymity of the donor should be preserved. The issue of anonymity as it relates to gamete and embryo donation is emotionally charged. Indeed, the ability of human beings to know their genetic roots is universally important, at the core of self identity. Either egg and sperm donors may choose to or not to be anonymous, though the vast majority in both groups generally chooses anonymity [ 40 ]. The American Society for Reproductive Medicine has identified four levels of gamete donor information sharing depending on the wishes of the donor and recipient parties [ 37 ]. Recently, however, there is, increasing consideration of the rights of offspring as it relates to donor gametes and anonymity [ 40 ]. Advocates for allowing either gamete donors or their offspring to break anonymity cite the medical advantages of sharing medical information with their genetic offspring, in the case of the donor, or learning about their genetic history directly, in the case of offspring [ 41 , 42 ]. Others simply argue that both donors and offspring have an inherent right to meet and develop a relationship [ 43 ]. Recent court rulings suggest that these rights will become more visible in the future. For example, in the British case Rose v Secretary of State for Health [2002] EWHC 1593 , the court ruled that based on the Human Rights Act, donor offspring could obtain information about their genetic parents despite previously established anonymity [ 43 ]. The ethical and legal issues surrounding anonymity and gamete donation are sure to be a centrally debated issues within the field of ART for the foreseeable future.

9. Embryo Donation

IVF cycles often result in couples transferring several embryos and cryopreserving other embryos produced by the cycle, presumptively for the purpose future pregnancy. However, in many instances, these surplus embryos are never used by the genetic parents and therefore are stored indefinitely [ 44 ]. The number of such embryos stored internationally is surprisingly high. In the United States alone, it is estimated that over 400,000 embryos are currently cryopreserved, many of which will not be used by their genetic parents [ 44 ]. The ethical and moral issues surrounding how to deal with these surplus embryos have been the source of much debate. In general, four possible fates for these embryos exist [ 44 ]:

• thawing and discarding,
• donating to research,
• indefinite storage,
• donating the embryos to another couple for the purposes of uterine transfer.

All of these strategies have staunch supporters and detractors. Not surprisingly, there are a myriad of laws in different countries governing many aspects of how a human embryo that has been cryopreserved may be handled [ 44 , 45 ]. The use of embryos for the purpose of research, specifically as it relates to human stem cells, has also been a source of fierce debate internationally and has resulted in substantial regulation that varies substantially from nation to nation [ 46 – 49 ].

10. Surrogacy and Gestational Carriers

Another topic of ethical, social, and legal debate surrounds the use of surrogacy and gestational carriers. Surrogacy is defined as a woman who agrees to carry a pregnancy using her own oocytes but the sperm of another couple and relinquish the child to this couple upon delivery [ 50 ]. A gestational carrier, by contrast, involves a couple who undergoes IVF with their genetic gametes and then places the resultant embryo in another woman's uterus, the gestational carrier, who will carry the pregnancy and relinquish the child to this couple upon delivery [ 50 ]. Currently, the use of gestational carriers is far more common than that of surrogates [ 50 ].

As with donor gametes, surrogates and gestational carriers are subject to significant medical and emotional risks from carrying a pregnancy and undergoing a delivery [ 50 ]. As such, extensive counseling and meticulous informed consent are required [ 50 ]. Some also are concerned that the use of surrogates and gestational carriers is a form of “child selling” or the “sale of parental rights” [ 51 ]. Additionally, the rights of the surrogate or gestational carrier to not relinquish the infant following deliver are not well described [ 50 ]. In fact, legal precedent in some states within the United States has actually upheld the right of a birth mother, regardless of genetic relation to the child, to retain parental rights despite the existence of a preexisting gestational carrier contract [ 50 ].

Another central concern surrounding the use of surrogates and gestational carriers is the possibility that financial pressures could lead to exploitation and commoidification of the service [ 50 – 53 ]. The mean compensation for a gestational carrier in the United State in 2008 was estimated at approximately $20,000 [ 50 ]. In contrast, a gestational carrier in India receives an average of $4,000 for the same service [ 52 ]. Regulation of surrogates and gestational carriers varies widely from nation to nation and even within regions of individual countries [ 50 , 52 – 56 ]. Due to these financial and legal considerations, international surrogacy has emerged as an emerging industry, especially in developing nations [ 52 ]. This practice has exacerbated the already difficult ethical and legal issues surrounding gestational carriers [ 52 ]. At the present time, issues surrounding issues of individual rights, commoidification, exploitation, citizenship of the offspring of international gestational carriers, and even fair trade are largely unresolved internationally [ 52 , 55 ].

11. Possible Deleterious Effects of ART

There are questions that remain outstanding regarding the use of IVF. Conflicting data exists about the risks of IVF on the developing embryo. Multiple studies have failed to find a clinically relevant association between IVF or embryo cryopreservation and adverse maternal or fetal effects [ 57 – 59 ]. Other studies have suggested that infants of IVF pregnancies may be at a small but statistically significant increased risk for rare epigenetic and other abnormalities [ 60 – 62 ].

Despite this controversy, there is a general consensus that IVF confers a small but measurable increased risk for a variety of congenital abnormalities including anatomic abnormalities and imprinting errors as compared to the general population [ 63 ]. Some maintain, however, that this is secondary to an increased baseline risk for these problems in the population of infertile patients [ 63 ]. Regardless of the cause, this small increased risk, while statistically significant with extremely large sample sizes, will likely not be a powerful enough factor to dissuade infertile couples from pursuing parenthood through IVF.

12. Conclusion

ART has emerged as one of the most widely adopted and successful medical technologies in the last century. While giving hope to millions of couples suffering from infertility, ART also has presented new ethical, legal, and social questions that society must address. Many countries have taken steps to regulate certain aspects of ART. Specifically, what regulations and laws should be in place for ART reporting, social inequities that may arise from financial barriers to ART, genetic testing, emerging laboratory techniques that have improved embryo and gamete survival when cryopreserved, and an individual's right to their genetic offspring in the setting of gamete or embryo donation are aspects of ART which will become increasingly controversial and debated into the future.

However, the lion's share of ethical and legal questions that exist surrounding ART have yet to be resolved. Society must reconcile how to fund ART in a responsible and equitable manner to increase access to care. Additionally, the myriad of unresolved issues surrounding gamete and embryo donation must be addressed in greater detail in future social and legal dialogues.

ART is a field that is dynamic and ever changing. In areas of ART such as preimplantation genetics, new technologies continually change the capabilities of ART. Due to the rapidly evolving nature of the ART, legislation is often unable to keep pace and address all of the ethical and legal issues that are constantly emerging in the field. It is therefore incumbent upon physicians to continually monitor these issues and ensure that ART technologies are offered and delivered in a manner that balances patient care with social and moral responsibility.

Conflict of Interests

The authors declare that there is no conflict of interests.

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Gender and Law at Durham (GLAD) and Centre for Ethics and Law in the Life Sciences (CELLS) invite you to their joint event with Professor Hrefna Friðriksdóttir.

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In 2019 Iceland passed the Act on Gender Autonomy. The aim of the Act is to provide the rights of persons to define their gender and obtain the recognition of their gender identity. A person can register their gender as man, woman or neutral (non-binary) and shall enjoy the legal rights of the registered gender. In 2021 Iceland made important changes to the Act on Children, redefining the terms mother, father and parent, taking into account both children conceived without and with the use of Assisted Reproductive Technologies. The outcome is an attempt to navigate tensions between status, biological facts and agreements as the preferred legal basis for determining parenthoods. The aim of the talk is to give an overview of these changes and the underlying rationale.

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