Fertility

The New York Times posted an article today on the complications that often result from fertility treatments.  Under current fertility treatment practices, patients are likely to implant multiple embryos, which leads to an increased risk of twins, premature babies, and other serious complications.  The estimated expense of caring for premature babies that were conceived through IVF was $1 billion last year, with the bulk of that expense being passed on to businesses and other consumers.  In cases where children suffer disability, society pays further costs in the form of services like special education.

This problem poses a number of difficult ethical questions about our reproductive rights and the costs of healthcare, but what interests me that most is that the article doesn’t seem to address at least one obvious way of reducing this problem.  While some couples need fertility treatments, and surely they offer wonderful benefits to those who do, other women need fertility treatments because they feel a need to postpone pregnancy.  This post is not designed to be critical of anyones choices, but given the immense cost associated with fertility treatments that we are all indirectly paying, can we make an argument that perhaps economically we would be better off creating a society where young women lucky enough to be in the position to have children could do so at a biologically optimal time without fear of derailing their professional pursuits?

Comments

  1. If fertility itself were the only issue, then surely a 15 year old girl is at a ripe age. But emotionally she may just not be ready to provide a stable life for her child.

    On the other hand, fertility doesn’t seem to be a problem in poor nations around the world. At what age do girls/women begin giving birth, in say, Bangladesh or Nigeria?

  2. young women lucky enough to be in the position to have children could do so at a biologically optimal time without fear of derailing their professional pursuits
    I think the best way to do this would be to engineer it so that men (fathers really) take hits to their careers for having kids the same way women do. Have mandatory paternity leave, prevent businesses from paying part-time workers less, etc. This one sounds the most draconian, but I think it best addresses the fact that our society is still structured around male oriented career paths meaning that women have to work in their careers as if they were men (more specifically as if they were men who have wives.)

    When men (and women) stop being so heavily rewarded for following those family-un-friendly sorts of career paths then it will start to be worth it for men to take some time off work and do more at home with the kids. This means that hiring women won’t be more risky or costly than hiring men. And since no one gets a leg up just because they don’t have to deal with childcare then women won’t take such a big hit for having kids and will likely want to do it sooner when it would be physically easiest.

  3. Starfoxy, can I live in the world you describe? I’m really hating the fact that science isn’t something one can do part time, even for the few short years that kids need a full-time parent.

    Natalie–I think one o the best suggestions for decreasing the number of IVF twins was given in that article. I think it’s a bit of a crock that infertile couples pay the same amount for every cycle of IVF (or so it sounded from the article–feel free to correct me if I’m wrong). I think subsequent rounds of IVF following an unsuccessful cycle should be at the least heavily discounted, if not free, or a certain number included in the initial price. The success rate per cycle isn’t that high–I’m really surprised it’s not just routine to expect to do several cycles and have that expectation reflected in the price.

  4. Have mandatory paternity leave, prevent businesses from paying part-time workers less, etc.

    Better also make it illegal to hire a consulting company to perform some of your company’s labor (using either onshore or offshore staff), hire new college graduates or interns, allow legal immigration/H1Bs, etc. Need to also prevent a business from engaging in any business model that is family-neutral.

  5. Good point, Natalie. If I remember right, in The Price of Motherhood, Ann Crittenden suggest something like a stipend paid directly to mothers of young children, paid for by the rest of us? It seems like that might make it easier for women to have children when they’re younger and fertility is less of an issue.

    The problem is that our fertility peaks at a very young age relative to when our earning power does. (Or at least that’s a large problem.) So if not something as potentially heavy handed as a tax and stipend approach, what about a similar approach that we use to allow people to get expensive educations when they’re young and haven’t made much money yet? If we can have government subsidized student loans, why not government subsidized young parent loans?

  6. Even if we did as a society make it easier for women to have children at an optimal child bearing age, it is unlikely they would do it. Look at Europe. Despite lots of family friendly policies (and then some) Russia’s (and in other countries) population is dropping fast.
    Family friendly policies (or lack there of) don’t necessarily make up for personal choice.

  7. Peter LLC says:

    Correlation, mmiles, not causation. It may be that family friendly polcies simply aren’t friendly enough in countries with high taxes and costs of living. Or imagine what birth rates would look like if some personal choice crusader substituted stern lectures on the importance of taking a hit for the team for family-related benefits and job protection.

  8. It will never happen. The latest “green” propaganda is that the single greatest thing a family can do to lower their carbon footprint is to have fewer children. Given that, it’s not a long stretch to see governments (and not just the US) implement policies that are less family friendly, and even family hostile. Like:
    -end per-child tax credits
    -charge health insurance on a per-person basis, instead of a general “employee + spouse/partner + children” catch-all.
    -per-child public school charges
    -increased taxes on larger vehicles
    -IVF/Infertility treatment as a seperate rider on insurance.

  9. StillConfused says:

    If you want to have IVF, great, but you need to pay for it yourself. There are many other things in life that if you want you must pay for.

  10. I don’t understand why people opt for pricey and risky fertility treatments instead of adopting (which is also expensive, but has much lower health risks). Can anyone explain that?

  11. esodhiambo says:

    I agree that I wish adoption were made a more attractive option.

    I know of a fertility clinic that charges a set fee for treatments and if you don’t have a healthy baby, they return the entire fee so you can apply it towards adoption.

    In Kenya, I saw a banner advertising a health clinic meeting in a certain town for “all women of childbearing age: 14-55″–quite a different mindframe than we have! Of course, women regularly die in childbirth there, too, and in that particular community, it is taboo to discuss a child until it is a) born and b) still alive.

    In my experience, there is nothing that disturbs people more than to have their parenthood questioned, but I have serious reservations about IVF interventions. It seem at least morally questionable to pour so much money into producing a genetic heir when you could apply that money toward loving and parenting kids (who already exist) and need parents.

    It is not in any way fair that it is so easy (too easy) for some people to become pregnant and others not. But I do have reservations.

  12. I kind of agree with StillConfused.

  13. In this discussion are we not including the benefits (including $) that these otherwise unborn children will add to our economy in the future?

  14. In our secular world the only thing to me anyway that helps facilitate responsible births to married young parents is religious belief on the part of the two parents. No government policy can create this dynamic with incentives as demonstrated by attempts to do so in Japan and Germany etc.

    In order to have children young you need to simply have faith and go for it as a married couple. Most of the time you will end up fine long term. Careers can be put back on track if that is what you enventually want. But that “good child bearing time” from 20-35 or so once gone is gone forever.

  15. The simplest solution is to make it illegal to implant more than 1 embryo in women under, say, 35, and more than 2 embryos for women 36+. Either that or require insurance to cover 1 or 2 rounds of IVF as needed. Then couples wouldn’t be as financially motivated to maximize the return on their $25K investment in IVF (knowing that insurance will pay for anything that goes wrong with twins+, but won’t pay for the IVF in the first place).

    The fertility industry is less regulated and has less oversight than any other area of medicine, not least because it operates entirely outside the sphere of insurance, which functions as a kind of private-sector regulator in other areas.

  16. There are plenty of young women having babies. Most of them are not self-sufficient though and depend on the dole to help raise their kids.

    I think there should be a minimum “trying” time, say 5 years, required before fertility treatments are allowed. So many people think they should get pregnant immediately just because they have decided it is time. If they started a little younger they just might concieve naturally. Of course, folks with medical reasons that preclude ever being able to conceive naturally would be exempted.

  17. Steve Evans says:

    Michael (#8) – it’s not propoganda, it’s fact. Having fewer children has a dramatic impact on carbon footprint, trash production, etc., etc……. but nobody is presenting any serious argument that this should be a determining factor in having children.

    I believe in a free market when it comes to fertility treatments. Make couples wait FIVE YEARS? Forcibly limit the number of implantable embryos to one? Please stop.

    Provide monetary incentives for couples to have children at a younger age, if you like. Ziff’s on the right track.

    Melissa (#10), the desire to propogate your own genetics is undeniable. Perhaps only those who are faced with the impossibility of doing so can understand it. Adoption was not really on the radar for us, for example.

  18. BTW, I know of very few people who don’t have to pay for their IVF, whether through their health insurance or out-of-pocket. There’s no public option for in vitro.

  19. Also, what Peter LLC said (#7).

  20. Cynthia L. says:

    #17–The problem with free market managing fertility treatments is that the benefits are internalized and the costs are externalized. Couples pay out of pocket for IVF, but not for the months of NICU (assuming they have insurance). So unless you want to take maternity and newborn care out of all insurance plans so that those are out of pocket and under “free market” as well….

  21. I really think that the growth in fertility treatments have come in part from our “I want it now” culture. Maybe 5 years is a bit long, but certainly no less than three.

  22. living in zion says:

    I read the NY Times article and thought it brought up interesting points. The leading story was about an LDS couple who were told they needed to consider selective reduction or none of their multiple children would survive. They prayed and consulted with their spiritual leaders and decided to “leave it in God’s hands”. The outcome has not been what they’d hoped.

    Being LDS myself, I don’t see any problems with selective reduction. By the time a couple is considering artificial anything, God’s will is not the question anymore. If it were up to God, they wouldn’t have any natural born children. I think it makes sense to reduce the odds of problems by returning the womb to a logical number – one or two babies. In my mind, the line of God’s will has already been crossed.

    Of course the whole process costs an insane amount of money. That is our American free market economy at work.

    I am an adopted kid and have been blessed to have my own children, so I can’t imagine the pain of being childless. But I can speak to the pain of being a 7 yr. child in foster care through no fault of my own. Adoption is a blessing for everyone.

  23. nr,

    5 years? Even 3? That is incredibly risky when playing the fertility game. I understand wanting to limit embryo implants, but one? That’s just not reality.

    Adoption is great, however I think people are being a bit unrealistic when they just say, “Adopt.” It really is not that simple. Adoption can be just as expensive, and have bad and not so happy outcomes that are expensive to boot. With in-vitro and surrogacy the chance of getting a baby are higher.

    I’m all for family friendly policies. I’m just not convinced they’d make a big difference, some difference yes–but small ones.
    They do pay families in Russia to have children, with lots of other perks. It isn’t helping.

  24. No less than three! You should run for office on that platform, [nr].

    Seriously, your view is ridiculous. Fertility treatments have risen in frequency because they have become more medically possible and less expensive, not out of some notion of selfishness or lack of long-term view.

    For every Octomom or 40-year old couple who put off kids to get another Saab, there are dozens of ‘regular age’ couples who just couldn’t have kids without medical assistance. Views like yours or Cynthia’s would basically be punishing the garden-variety user of fertility treatments in order to prevent the outliers from occurring. This strikes me as neither efficient nor moral.

  25. personally I am of the opinion that couples should be free to use whatever fertility treatments they need in order to conceive and bear kiddos.

    God is pleased I am confident with the birth of each child conceived thru medical assistance and tears of joy are shed by the parents as they at they marvel the bundle of joy that medical advances have brought in to their lives.

    I think the rational moral view is to see medical advances in regards to fertility as a blessing from God.

  26. living in zion says:

    mmiles #23-

    So when you are saying adoption is a simplistic answer to a complicated problem, are you meaning that adoption is something you would never consider because it might be hard? Or too messy? After reading the NY Times article, the same exact problems exist with fertility treatments.

    This is a problem with multiple outcomes, all which require money, emotion and risk. Adoption is no better or worse than fertility treatments.

  27. Meredith C says:

    I too read the NYT article the morning and my heart broke for the LDS family in Texas who had lost all but two of their six babies. I don’t presume to criticize them, since I wasn’t privy to their decision making process – but in general I agree with #22 above that selective reduction isn’t something that LDS should be loath to consider in the face of such clear risks to mother and children. Letting nature take its course after hijacking it so spectacularly with IVF is maybe not the best idea.

    This is not to say that I am against IVF in any way – I have friends that just welcomed a healthy boy that was conceived through IVF and I’m overjoyed for them. But this article definitely raises some complex ethical issues.

  28. Most women have upwards of 30 childbearing years. 3 years is too long to try?

  29. Nick Literski says:

    #22:
    The leading story was about an LDS couple who were told they needed to consider selective reduction or none of their multiple children would survive. They prayed and consulted with their spiritual leaders and decided to “leave it in God’s hands”. The outcome has not been what they’d hoped.

    Had they “left it in God’s hands,” they wouldn’t have conceived. Where was their “leave it in God’s hands” faith back then?

  30. Perhaps we should stick to the point of the OP, which is not about the ethics of IVF, but how society can offset the disadvantages of women having children when they are younger and less likely to have difficulty conceiving.

  31. living in zion says:

    Nick #29 –

    Agreed. When we take on artificial means to do anything – create life, prolong life, etc. we are taking God’s will out of the equation. God spoke and we didn’t care for the answer, so we changed it. The freedom to choose outcomes includes the responsibility to do the hard things, even deciding which embryos live and which won’t. No different than bringing an oxygen starved brain back through heroic measures and then taking care of that disabled person for the rest of their lives.

  32. Good call, madhousewife.

  33. I don’t know if society really can or should offset the disadvantages of women having children when they are younger. The disadvantages to my mind are:

    1. Lack of education (Education trumps experience)
    2. Lack of maturity (Self-control, problem-solving skills, patience, etc.)
    3. Increased chance of divorce/father abandonment (The Younger you are when you marry, the higher chance of divorce. Supposedly 25 is the ideal age to marry for least risk (don’t recall my source))

  34. merritt b says:

    “the desire to propogate your own genetics is undeniable. Perhaps only those who are faced with the impossibility of doing so can understand it.”

    thanks steve (for saying what i was thinking).

  35. “When we take on artificial means to do anything – create life, prolong life, etc. we are taking God’s will out of the equation. God spoke and we didn’t care for the answer, so we changed it.”

    Living in Zion,
    What are you talking about? Are you saying that it is God’s will that I get a headache and by taking a Tylenol I am changing God’s will? That the consequences of such a choice are somehow morally inferior to the consequences of avoiding the drug (because God “wills” that I suffer a headache)? We make a thousand choices a day that, according to your logic, “take God’s will out of the equation.”

  36. #35.

    In addition to this we leave out the idea that advances in medicine are made possible by a just God.

  37. Everyone, please listen to madhousewife in #30. Thanks.

  38. I’m surprised that no one has brought in our prophet’s counsel on this matter. For the sake of argument, the Church’s recommended solution is to accept things as they are:

    “By divine design, fathers are to preside over their families in love and righteousness and are responsible to provide the necessities of life and protection for their families. Mothers are primarily responsible for the nurture of their children. In these sacred responsibilities, fathers and mothers are obligated to help one another as equal partners.”

    How do you reconcile this with the comments about women and “professional pursuits”?

  39. Oh Mike.

  40. Natalie B. says:

    30, 37: Great idea. It’s very remarkable that we are developing the technology for people to have children who might not be otherwise able to, and it seems like the best conversation we can have here is not one about critiquing choices, but rather one about how we can minimize risks so that we can more readily benefit from technology. Or, perhaps we can have a conversation more directed about what new technologies for reproduction mean for Mormon theology. How do they complicate how we understand our responsibilities/roles?

  41. #39: Steve

    I agree with your comment, and wished typing could express emotion and how I meant the comment. I agree with the sentiments on here, and think women have been relegated to a second-class role throughout the majority of recorded history.

    My question at the end is truly for my own enlightenment on how a “TBM-type” or “literalist” (I hate those terms, actually) reconciles the Proclamation with the issue raised here?

  42. I wonder what we have done to our environment that has so many couples infertile…it seems like a disproportionate amount of people struggle with this.

    Do you think it is that there is now technology to do something about it and it’s not really worse?

    I hardly see how relying on medicine cuts God out of any equation…or even that the outcome they hadn’t wanted is one from which they can’t learn what God would like them to learn.

  43. Kristine, I am, in theory, willing to agree that society should try to structure itself to encourage childbearing at the optimal biological time (in the woman’s 20’s). But the whole “without fear of derailing their professional pursuits” just seems so unrealistic. Children are such a huge, huge amount of work. Someone has to take care of them 24/7. To me, this idea that women get derailed in their career pusuits because of the way work is structured just doesn’t make sense to me. No matter how you structure workplaces, taking care of children is still a huge amount of work. The need to do that work will compete with career work, no matter how much flexibility is in the system. Parents who need to attend to their children will always have a huge, huge amount of “family work” competing with career work that non-parents will not have.

    I’m fine with arguing that fathers should take equal responsibility and make equal sacrifices to raise children. That’s more or less how we do it in my family. There are a lot of couples that decide to do it more traditionally and I think that is fine. Regardless, the basic problem remains the same and I don’t think it’s going away regardless of what type of scheduling or technology is employed to try and change it.

  44. Oops, not Kristine. I meant Natalie B.

  45. Stephanie says:

    Re comment 14 In our secular world the only thing to me anyway that helps facilitate responsible births to married young parents is religious belief on the part of the two parents. No government policy can create this dynamic with incentives as demonstrated by attempts to do so in Japan and Germany etc.

    In order to have children young you need to simply have faith and go for it as a married couple.

    This reminds me of something I’ve heard before, something like “Soceities are run by either government or God”. Elder Christofferson hinted at this idea in his talk when he said

    The lack of internal control by individuals breeds external control by governments.

    Not that we are talking about lack of control here, but your comment reminded me of this because several of the comments are related to how government can encourage women to have children when they are younger. As you pointed out, religious belief encourages couples to have children when they are young. The benefits to society of that are measurable (hence the need to encourage it). So, in the absence of God, government needs to step in (which, as you pointed out, doesn’t really seem to work in this case anyways). I find this interesting.

  46. Stephanie says:

    Pardon me – I misspelled “Societies”. (that’s what happens with a baby on you lap)

  47. That’s ok, E. All feminists kind of look alike.

  48. I think America needs to adopt more socialist policies we see in the Scandinavian countries where mothers get paid maternity leave of like 18 months, and fathers are given some time off too. Their rationale is to incentivize child birth, so that working professionals are not overwhelmed with taking care of children as well as being professional workers. I think those are very family oriented policies that could benefit our society too.

  49. “But the whole “without fear of derailing their professional pursuits” just seems so unrealistic. Children are such a huge, huge amount of work. Someone has to take care of them 24/7.”

    Agreed, but why is it that more part time careers aren’t available? Or careers that allow for a few years of part-time work with later resumption of full-time? I’m a grad student right now, which theoretically means I am a part-time worker (if you look at my paycheck, anyway). It’s been made pretty clear to me, though, that a 60 hour work week is still expected, even with my kid and with a husband who is simultaneously finishing his degree. Personally, I feel like more work is expected of me now that I have a child–like I have to prove that I really want this. I’ve heard from other women who found their bosses expected more *after* a kid than was expected before. I feel penalized for having had a child at the young age of 30.

    Productivity arguments don’t really cut it with me, either. Sure, kids are a lot of work and they take away from the “real” work someone is capable of doing. But really, that’s not a permanent situation. Kids get older and need less supervision. They enter school and someone else is taking care of them most of the day. Eventually they leave the next altogether and typically a woman still has a few productive year left after that. Why is it so difficult for them to re-enter the workplace at that point, or stay in part time while child rearing–enough to stay current in your field–making the transition back to full-time employment easier?

  50. What’s “unrealistic” is to think that we can solve the world’s problems with only half of the available talent.

  51. #49: Kristine, I have nothing against part time work, temporary leaves from work, or other arrangements that facilitate childcare. I think a lot of people do those things. But devoting less time to work means that down the road you will have had less experience in your field. You will have less seniority, will have made less money, and have earned less for retirement. These are real costs that you will have incured because of your (very real) decreased productivity.

    Kristine #50: I’m not sure what in my comment should be construed as advocating that half the world’s talent should be buried. I don’t really even understand what you are suggesting. All women should work full time because if they don’t, they’re wasting their talent? But wouldn’t they then have to hire someone to take care of their children? And wouldn’t it be sad for all those child-care workers to be wasting their talent when they could be solving all the world’s problems?

  52. E, mothers who get paid only part-time are NOT devoting less time to work. They’re working more, so that men (mostly) don’t have to be encumbered by childcare responsibilities and are free to earn more money, etc. Their productivity is not decreased, it’s just that the system only counts very limited kinds of production.

    Q.E.D.

  53. #49: Kristine, I can definitely sympathize with where you’re at. I have been in the same situation. It doesn’t last forever, and hopefully once you have reached the light at the end of that tunnel, you’ll look back and feel the satisfaction of having survived and gained a lot in the way of personal growth. That’s how it’s been for me.

  54. #52: Kristine, I guess I must not be communicating very well. I was not saying that parents who work part-time at their careers work less over all. I was pointing out that parenting is A LOT of work and that work competes with career-related work.

  55. Melissa (#10) — I believe your question was genuine, and raised in light of a very focused and analytical discussion. In a less scholastic setting, one of of primarily women, I do hope that your remarks would be suited to the audience and show greater sensitivity.

    Such a determination to continue with artificial reporoductive treatments (ART) might not be easy for everyone to understand, but it is a highly personal, highly emotional decision. Strangers who question such a difficult, prayerful decision can leave profound wounds and scars, albeit unintentionally. The isolation resulting from all of it can be overpowering.

  56. But wouldn’t they then have to hire someone to take care of their children? And wouldn’t it be sad for all those child-care workers to be wasting their talent when they could be solving all the world’s problems?

    This is a good point. Ultimately, someone needs to watch the children. Is it really that demeaning of a job?

  57. esodhiambo says:

    I am guessing that, for some people, child-care IS there talent. In fact, I feel quite confident in that.

    I saw a 60 Minutes piece about female Ivy League graduates who “gave it up” to do motherhood. A significant portion of them had fertility issues, largely because they waited until they were close to 40 to do so. The piece made the point that these very smart women had ignored the very real data showing that 40 is not the best time to conceive because they believed, and had been expressly taught, that they could “have it all.”

    I suppose they can, but maybe not on their timetable.

  58. A large part of the question is how important is it to nurture children…is paying someone minimum wage recognizing how important the job really is?

    Holding a baby, rocking a baby, kissing a baby…these simple “mindless” tasks have long lasting effects on a baby http://www.evalillian.com/Attachment%20Parenting%20Spoiling.aspx

    highlights from the article…Infants separated from their primary caregiver showed increased likelihood of heartbeat irregularity and trouble maintaining their body temperature.

    ‘The child’s first relationship, the one with the mother, acts as a template, as it permanently molds the individual’s capacities to enter into all later emotional relationships.’ Others agree. The first months of an infant’s life constitute what is known as a critical period – a time when events are imprinted in the nervous system.

    Is this really a job worth paying minimum wage? Even if their talent is taking care of children? Isn’t the problem that we don’t value the effect of small and simple things?

    Why do people look beyond the cradle when they want to make an impact on the world. It is easier to love a baby and nurture them into a loving adult, then save a teenager or adult who has never felt that. It is easier to discipline a toddler than to deal with a teenager who has never been disciplined consistently. Why not put the focus and energy into loving the baby and call that what it is…changing the world. It doesn’t look impressive, it deals with a whole lot of bodily fluids, it’s repetitive and mind numbing…yet it changes the world.

  59. “Why do people look beyond the cradle when they want to make an impact on the world.”

    Because babies don’t negotiate multilateral disarmament treaty.

  60. StillConfused says:

    #48… Who pays for that?

  61. E, I got it. I’m just saying that the problem is in thinking that only “career-related” work counts. As others have pointed out, caregiving work is important and valuable to society, and yet we’ve chosen not to count it as “productive.” We could make a different choice (as, for instance, Scandinavian countries do, in paying for that work through taxation and government subsidies).

  62. #60, StillConfused

    Taxpayers who think it is a good idea to invest in families ie. allowing children to have time to bond with their parents in the year or so after birth pay for it. Many of them are actually happy to pay for it.

  63. MrsPeacock says:

    #10 Melissa, because my insurance pays for IVF and gives me 3 months of short-term disability if I give birth to a child. Insurance pays nothing for adoption and I do not get short-term disability if I adopt a child, even if the child is a newborn. I could take 12 weeks of unpaid time off, though. Which I could certainly afford after an adoption that would cost $10k-$20k.

    I am 29 and have been married for 4 years. I would like to have a child, but I still owe $25500 on my student loans, so I have to work, and childcare in this is $1200-$1500 a month for a newborn. It is a real pickle.

  64. #60,

    Taxpayers of course. Unless private businesses and corporations wish to dole out such a plan of their own for their professional workers, which I highly doubt. Corporations are not family-friendly, at least not in the current form that we see today.

  65. Required reading for anyone thinking about alternative maternity models patterned after those in Europe: http://themamabee.wordpress.com/2009/09/22/more-working-mothers-better-birthrates/

  66. #58: Britt, I love your comment and I agree.

  67. Stephanie says:

    Just have to say that I love the picture at the top of that link in #65

  68. #59 …yet

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