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Designing Babies

Yale Medicine Magazine, 2020 - Spring

YSM alumnus Robert Klitzman confronts ethical questions around the creation of human life that technology makes increasingly possible.

The Columbia University psychiatrist and bioethicist Robert L. Klitzman, MD ’85, was in medical school when a friend from Harkness dormitory invited him to earn some easy money: a group of students were selling their sperm. “Come do it,” the friend said, “We’re going next week.”

“It was tempting,” Klitzman recalls, but “instinctively, the budding ethicist in me thought this was weird.” He didn’t go, and in retrospect he’s glad. About 30 years later, Klitzman got a more personal request to donate sperm. A friend in her late thirties asked him to be the biological father of her child. Although Klitzman declined, that request helped catalyze his new book, Designing Babies: How Technology is Changing the Ways We Create Children.

By talking to people who’d had children through assisted reproduction, Klitzman came to appreciate its benefits. Infertility affects about 20% of all heterosexual couples, and new techniques benefit not only infertile couples, but also lesbians, gay men, and would-be single mothers. Furthermore, preimplantation genetic diagnosis can prevent transmission of such devastating diseases as Huntington’s chorea: physicians implant only embryos free of the problematic gene. In 2017, medical interventions contributed to the births of 78,000 babies, or almost 2% of children born in the United States that year.

Klitzman saw that assisted reproduction can bring fulfilment and joy, but he found pervasive problems with an industry that brings in $12 billion annually but remains largely unconstrained by regulation. Even people in the field describe the United States as the “Wild West” of reproductive technologies.

For instance, Klitzman found that permitting anonymous sperm donation robs children of vital information: American children who mail in saliva for a DNA analysis may suddenly discover that their mothers used donor sperm, and that they have half-siblings. (One donor’s sperm produced 150 offspring.) Klitzman is troubled that the United States permits buying and selling eggs, a form of commerce banned everywhere else except Russia and India. No regulations limit the ages of parents using reproductive technologies, and one specialist told Klitzman he’d help a 50-year-old woman conceive with a 78-year-old partner, provided they had money to support the child over the long term. Even before conception, the prospective father had completed the average lifespan of an American male.

The industry downplays the risks of twin pregnancies. But carrying two embryos increases complications by 40% over singleton pregnancies. Problems include premature birth, low-birth-weight newborns, and increases in the incidence of preeclampsia and cesarean sections. Yet a study showed that only one in three doctors offering in-vitro fertilization (IVF) discusses these hazards with patients. These are expensive complications.

What disturbed Klitzman most is that the United States does not mandate reporting of data on practices and outcomes. In part, such information would aid research to understand the longer-term effects of these technologies. For instance, physicians are increasingly using intracytoplasmic sperm injection, in which they inject a single sperm directly into an egg rather than placing multiple sperm in a glass dish containing an egg—the usual IVF methodology. The sperm-injection technique yields rates of pregnancy and live births similar to those for IVF, at best. But it costs more, and some studies have found increased abnormalities that include birth defects, autism, and intellectual disabilities. Current and ongoing data collection would clarify whether sperm injection is an advisable technique.

Klitzman cites the story of a Spanish actress’s proposal to playwright George Bernard Shaw. The woman asked, “Wouldn’t it be wonderful if we could have a child who had your brains and my beauty?” Shaw replies, “Yes, but supposing it had your brains and my beauty?” Although some scholars dispute whether the conversation ever took place, Klitzman finds that it rings true: “Playing with Mother Nature is a tricky business, because nature is far more complicated than our understanding of it. You may not get what you want.”