Course BASIC_Graduate level learning material about the challenges of human reproductive medicine in a changing Europe

SYLLABUS

6. The interplay of reproductive technologies and social transformations

(Basic)

Technological changes and social transformation are usually deeply interconnected, shaping and influencing each other in many, complex ways. First, technological advancements often drive shifts in social behaviors and norms, as we continuously experience in e.g. smartphones influencing communication patterns and social interactions. Second, social needs and demands drive technological innovation, with inventions emerging to address societal challenges or meet evolving preferences.
Similarly, the development of ART depends on societal needs and knowledge, just as it shapes them. As Franklin (2013) put it ”As we enter the fifth decade of human IVF, this technique presents a paradox. On the one hand, IVF has become more regular and ordinary, even a new norm of social life. On the other hand, it has arguably become, as Alice might have said, ‘curiouser and curiouser’, with the development of its applications”.
In the following curriculum, we raise the question of how Assisted Reproductive Technologies (ART) interventions
a) overwrite our perceptions of fertilization, human existence, experiences of body and time, and our relationship regarding creation (topic 1.,2.);
b) align with the increasingly prevalent gender issues; changing individual lifepath  and the multicultural society (topic 3.,4.5).

1. How do reproductive technological changes continuously raise unforeseen questions?

Assisted reproduction has seen significant milestones. The groundwork for assisted reproduction was laid with early experiments in the 1950s, including in vitro fertilization (IVF) in animals (Bavister, 2002).Than Louise Brown, the first "test-tube baby," was born in 1978, marking a major breakthrough in human IVF. The 1980s saw the development of Gamete Intrafallopian Transfer (GIFT), an alternative to IVF, where both egg and sperm are placed directly into the fallopian tube. Intracytoplasmic Sperm Injection (ICSI), a technique to inject a single sperm into an egg, was introduced in 1992, revolutionizing male infertility treatment. Preimplantation Genetic Diagnosis (PGD)became available in the late 1990s, allowing for the screening of embryos for genetic disorders before implantation. The 21st century has witnessed significant advances in egg freezing technology, expanding options for fertility preservation and family building.The donation of germ cells (sperm and eggs) and embryos as well as surrogate motherhood are controversial topics.
The new and diverse treatments made possible by technological progress push the limits in different ways, expanding the possibilities of humans (we can even ask: will science and technology make us gods?), thereby raising new questions for individuals.

The goal is always intervention in natural procreation. The available methods range from spermatogenesis and ovulation stimulation to human cloning. These opportunities are very diverse not only from a medical and technical perspective but also in the questions they raise. For example, the differences in the appearance and role of a third (or fourth) participant, as well as the relationship to sperm and eggs.

In the case of drug treatment or surgeries, a third participant, the doctor, intervenes in making fertilization possible, but does not perform fertilization itself. For instance, the aspect of intimate relationships remains in the process. However, in the case of sperm injection, the doctor uses mechanical means to introduce sperm into the uterus, and the sperm becomes a laboratory product. In the case of artificial insemination by a donor, a new participant emerges: the unknown donor. This might raise questions about the meaning of the family or the moral tone of society. In the case of surrogacy the fourth person is another woman, whose role is more complex during the procedure as in the case of a male sperm donor. Moreover, in the case of surrogacy the sperm and eggs can originate from the biological parents, partly from biological parent or from donors. It makes the understanding of the whole process more complicated: whose child is born?

The above considerations have raised questions about the roles of the third and fourth participants, as well as the relationship to sperm and eggs. However, the various reproductive intervention techniques can be similarly contemplated in terms of their relation to time or the emergence of the possibility of genetic manipulation. Indeed, cryopreservation allows for the possibility of someone giving birth even posthumously, and in the case of IVF, the option of genetic manipulation comes into play. We can also examine the effects of long-term infertility on relationships, as well as the unknown effects of repetitive forced ovarian hormonal stimulations or the risk of fetal chromosomal abnormalities, and the possible challenges of parenting at an advanced age etc.

For thousands of years, questions about existence, our being, such as creation, our relationship with nature, the nature of time, and the purpose of our existence on Earth, have captivated humankind. How we contemplate these questions is closely tied to our spiritual, cultural, religious, epistemological, and philosophical perspectives. Regardless of our interpretations of these issues, it is evident that the advancement of ART prompts us to reconsider these philosophical questions in new ways.
Below, we articulate some of these fundamental philosophical issues and provide examples of how they can be reframed in the light of ART:
a) issues about human being
When does life begin? Is there an exact point that defines it?
In the light of ART, this question can be formulated as follows: What is the sperm and the egg? At what point can we speak of life? Does the stimulation of the ovulation, for example, still fall outside the realm of intervention in life, but IVF does not?
Is the human made up of cells, or is it perhaps an aggregation of organs or body parts, or is there something else? What is the relationship of the constituent parts to the human, and what is their status in the world?
In the context of ART, we can ask whether the embryos formed during in vitro fertilization are considered part of the parent, regardless of fertilization occurring outside their bodies.
b)humankind and nature
How do we coexist with nature? What does the "order" of nature signify? What does intervention in the order of nature, shaping nature, mean? Is intervening in the order of nature against the natural order itself? What are the consequences of creation? Can, should, or do we want to control evolution?
In the context of ART, questions emerge such as who decides the criteria for genetic selection during ART? Even in selections deemed ethical, there is intervention in evolutionary processes. To what extent, and how does this alter evolution?
c)humankind and time
What does time mean in general and in human life? Is it an independent entity or a societal construct that we can control?
How should we reinterpret our understanding of human generations or the synchronicity of time, given the fact that a child from a donor who may have passed away decades ago can still come into existence? How should the stages of human life be reconsidered when women, even after menopause, are capable of giving birth with the assistance of ART?

3. How does the focus on gender issues align with the possibilities of new reproductive technologies?

Gender studies emerged in the second half of the 20th century, examining issues related to gender identity, gender roles, and gender discrimination. One fundamental premise of gender studies is that gender identity is not solely based on biological sex but is also influenced by social and cultural factors.
Robert Stoller, from whom the concept of gender is derived, discussed the concept of gender identity in his 1968 work Sex and Gender. He describes it as a "fundamental sense of belonging to one sex. [The core gender identity is]  produced by the infant-parents relationship, by the child's perception of its external genitalia, and by a biologic force that springs from the biologic variables of sex.” (Stoller, 1984, 29.)
In other words, gender identity does not necessarily follow from biological sex, just as societal roles don't, given that they are social constructs (parenthood).
New reproductive technologies, such as IVF and sperm donation, allow individuals to become parents even in cases where there is a discrepancy between their born biological sex and gender identity, or when there are challenges with biological reproductive conditions and unconventional partner choices. In essence, these technologies assist same-sex couples, couples facing fertility issues, and transgender individuals in becoming parents:

Gender issues in society and the advancement of new reproductive technologies are emerging in parallel. Both contribute to making society more open and accepting of gender diversity, and they also contribute to the transformation of concepts such as the notion of family.

4. How can individual and family lifepaths change in relation to reproductive technologies?

A concept of the "biological clock" describes the conflict between the biological temporality of declining fertility and the social temporality of family planning. While the biological timeline steadily diminishes the possibility of childbearing from a woman's age of 20, societal changes point towards increasingly delayed parenthood. While the biological framework (of capabilities) remains constant, the concept of the biological clock becomes more clearly defined. Biotechnological advancements, on the other hand, extend fertility. It emerges the question, that “what happens when the biology at the core of temporal regulation of reproductive lives becomes instable?” (Bühler 2022). If one of the stable frameworks regulating the temporal boundaries of childbirth ceases to exist, meaning that biotechnological timing takes control, fundamental moral decisions fall upon women, couples, and physicians. These decisions have not arisen before and there is no comprehensive established societal consensus on them. In certain contexts, legal regulation can indeed assist in decision-making, but it cannot eliminate the individual and moral-philosophical dilemmas; at most, it may alleviate the decision burden on the individual in specific cases.

Questions directly influencing the quality of life and life path arise from medical, psychological, and social perspectives. Besides optional health challenges, it's crucial to consider challenges in the mother-child relationship due to age differences and societal implications of late parenthood. Older women face a higher risk of hypertension and pregnancy complications, diabetes, chromosomal abnormalities (such as Down syndrome), and an increased likelihood of needing a Cesarean section. Additionally, there is a greater chance of pregnancy complications for older mothers, including issues like fetal size, preterm birth, or miscarriage. From the perspective of the mother-child relationship, questions arise about generational differences, differences in energy and activity between the mother and child, and potential earlier health deterioration. In the social context, issues include the child's integration into the parental community, the distinct generational differences compared to the peer group, and the resulting socialization questions.

These questions do not have predictable answers. The legal regulations, varying from country to country, provide some framework for this, but, in reality, it often confronts those who wish to have a child and the doctors with decisions that go beyond competence. The following illustrates the decision-making mechanism of a doctor, a Swiss example.

In Switzerland, access to reproductive technologies is only allowed for medical reasons, up to the age of 50. (Individual clinics decide where to draw the intervention limit for women between the ages of 40 and 50.) The question then becomes, what constitutes a medical reason. Bühler (2022) cites the case of a doctor who believes that if a woman at the age of 43 wants to have a child and is unable to conceive, her infertility is a social, not a medical problem. This doctor considers a woman over 43 who cannot conceive to be "normal," pathologizing those under 43 who cannot conceive.

However, regulations vary from country to country, for example, in the UK, the upper age limit is 42, while in Cyprus, it's 44, but in certain cases, it can be extended up to 55. The different regulations among countries can lead to IVF tourism. However, of course, adequate social background is required for this. The 2019 IFFS surveillance survey found that 47% of the 85 participating countries reported either insurance coverage or government funding for infertility treatment; however, less than 20% reported complete coverage, which would include diagnostic evaluation, fertility medications, IUI, and/or ART (International Federation of Fertility Societies, 2019)

In the previous part of the lecture, we discussed how technological advancements continuously raise new questions about birth, human life, time, the interpretation of generations, and the understanding of genders. In the absence of a natural framework, humans need to create one, and our perspectives on these questions are strongly influenced by our spiritual, cultural, religious, epistemological, and philosophical beliefs.

Due to globalization, these diverse value systems become visible to different people, and their customs and desires can easily be questioned by others and themselves. In multicultural societies, it is particularly important for doctors to be prepared to encounter value systems with different dispositions, worldviews, or seemingly ambivalent values.

A significant trend in European cities in recent decades, especially in the context of increasing globalization, is the growing proportion of people with a migration background. For example, in Austria in 2021, 25% of residents had a migration background, while in 2000, the same figure was 12.38%. Within Austria, in Vienna in 2019, this percentage was almost 46%. However, in multicultural societies structural racism is strongly observed within institutions.

Awareness of cultural differences is crucial because both overexoticizing and neglecting can be problematic. Furthermore, it's essential to remember that many of the challenges related to fertility and sexual health in people with a migration history are intersectional, involving factors such as social position, class, religion, cultural and ethnic background, and education level.

For instance, a Syrian woman with a university diploma might perceive her infertility differently than a Syrian woman from a working-class background with an elementary level of education. In this case, societal temporality may influence the older age at which the Syrian woman with a university diploma plans to have children, while her religious background might make her resistant to certain interventions.

Similarly, for a Muslim couple who migrated to England, it might be crucial for them to have a child, but they cannot afford the costs of the intervention. When it becomes existentially possible for them, the woman will be 45 years old, and due to her age, she may need to choose another country for the intervention to take place.

Bibliography:

American College of Obstetricians and Gynecologists Committee on Gynecologic Practice and Practice Committee. Female age-related fertility decline. Committee Opinion No. 589. Fertil Steril. 2014 Mar;101(3):633-4.

Allan, S., Balaban, B., Banker, M., Buster, J., Horton, M., Miller, K., ... & Zegers-Hochschild, F. (2019). International federation of fertility societies' surveillance (IFFS) 2019: Global trends in reproductive policy and practice. Global Reproductive Health, 1-138

Bühler, N. The ‘good’ of extending fertility: ontology and moral reasoning in a biotemporal regime of reproduction. HPLS 44, 21 (2022). https://doi.org/10.1007/s40656-022-00496-w

Franklin,Sarah. 2013. Conception through a looking glass: the paradox of IVF, Reproductive BioMedicine Online, Volume 27, Issue 6, 2013, Pages 747-755, ISSN 1472-6483, https://doi.org/10.1016/j.rbmo.2013.08.010.

Stoller, R. J. (1984). Sex and gender: The development of masculinity and femininity (Reprint). Karnac.