Current reproductive technologies: increased access and choice?

In this issue we define reproductive technologies as the drugs, medical and surgical procedures, and devices that facilitate conception, prevent or terminate pregnancy, and prevent the acquisition and transmission of sexually transmitted infections (STIs). It is important to note that these techniques separate sex from reproduction (Tangri & Kahn, 1993). Therefore, these technologies allow individuals to engage in sexual intercourse for purposes other than procreation and facilitate procreation without engaging in sexual intercourse.

Our approach to this issue is grounded in our belief that for women to gain equality with men, nationally and internationally, requires that they have control over their bodies and are able to choose whether or not and when to have children. Reproductive health is defined by the World Health Organization (1998) as "complete physical, mental, and social well being in all matters related to the reproductive system" (p. 1). One important strategy for increasing reproductive health is to provide needed services and tools to women to help them overcome infertility; carry wanted pregnancies to term; avoid STIs and prevent unintended pregnancies; when desired, terminate a pregnancy; and enjoy physical and psychological health during and beyond the childbearing years. Our distinctive approach leads to a comprehensive analysis of issues involving reproduction with the goal of promoting more integrated reproductive health services for all women.

Over the last 25 years new reproductive technologies have emerged and extant techniques have been improved or rediscovered. Many new procedures that increase individuals' ability to build a family have led to scenarios previously only visualized in novels such as Huxley's (1998) Brave New World. The event that initially galvanized the field of infertility treatment in 1978 was the birth of the first child resulting from in vitro fertilization (IVF), the most popular of the assisted reproductive technologies (ARTs). ARTs are non-coital methods of conception that involve manipulation of both eggs and sperm. The most popular ART is IVF, used in over 70% of all ART procedures (Resolve of Minnesota, n.d.). IVF is a process that uses drugs to stimulate egg production in a woman. The ripened eggs from the ovary are then retrieved, in the laboratory, and fertilized with semen. The resulting embryo or embryos are then transferred back into the uterus for implantation (Centers for Disease Control, 2003; Resolve of Minnesota, n.d.). ARTs are expensive, (averaging $8,000-10,000 per approximately two-week egg retrieval cycle [Resolve of Minnesota, n.d.] and ranging from $60,000 to over $150,000 per successful delivery [Neumann, Gharib, & Weinstein, 1994]). In addition, they are time consuming, involve multiple injections of drugs, and have a modest success rate. Less than 25% of cycles involving fresh, non-donor eggs result in a live birth (American Society for Reproductive Medicine, 2000; Centers for Disease Control, 2003).

Procedures that involve only the use of fertility drugs or intrauterine insemination (IUI), commonly known as artificial insemination (AI), typically are not considered ART. However, for purposes of this issue they are included as reproductive technologies. Both IUI and IVF allow a couple to contract with a third-party woman who carries a child that is genetically linked to one or both members of the couple and who relinquishes that child to the couple after birth. Third party contractual parenting (commonly know as surrogacy) challenges traditional views of what constitutes a family and the relative importance of social versus genetic ties to a child. As discussed in this issue, use of methods such as surrogacy raises profound ethical and legal issues and varies in acceptability by culture. Moreover, because of high costs and lack of insurance coverage, many individuals have limited access to these methods.

In addition to technologies to overcome infertility problems, a host of technological advances are now available to prevent unintended pregnancies and limit unwanted births (Harvey, Sherman, Bird, & Warren, 2002; Schwartz & Gabelnick, 2002; Severy & Newcomer, this issue). Methods to prevent or terminate unwanted pregnancy include female hormones delivered via injection, implant, or pill; mechanical devices placed in the uterus; devices that alert women about their fertile period; and surgical procedures. Moreover, not all methods must be used prior to or during sexual intercourse. Emergency contraception involves the use of hormones up to three to five days after unprotected intercourse to prevent conception. Voluntary termination of pregnancy may involve simple surgical techniques (e.g., electric vacuum aspiration, manual vacuum aspiration) or drug-induced techniques. Some drugs, such as mifepristone (also known as the abortion pill, Mifeprex, or RU 486), have been tested extensively in other countries; others such as methotrexate were originally developed and used for other purposes. Procedures and methods to prevent conception and terminate pregnancies are not nearly as high-tech as those to overcome infertility. Yet, they raise similar types of problems and issues in terms of their acceptability to various cultural and religious groups and because of their limited accessibility. Such problems may be exacerbated by the use of technology for purposes not originally intended (e.g., the use of female hormones originally designed for contraception to control menopausal symptoms and reduce risk of disease in peri-menopausal and postmenopausal women).

Because of the world-wide AIDS pandemic (UNAIDS, 2003) and the high incidence of many other STIs such as chlamydia and gonorrhea nationally and internationally, women and men need methods to protect against Human Immunodeficiency Virus (HIV)/STIs (Eng & Butler, 1997; Rosenberg & Gollub, 1992; Stone, Timyan, & Thomas, 1999).

The male condom is widely recognized as the most effective method of protecting against HIV and some other STIs for sexually active couples (Stone, Timyan, & Thomas, 1999). Some men may, however, be unwilling to use condoms and if women desire protection, they frequently must negotiate condom use with their male partners.

Because of gender-based power inequities, some women may not be able to negotiate condom use to protect themselves against diseases (Amaro, 1995; Amaro & Raj, 2000; Blanc, 2001). There is, therefore, an urgent need for additional, preferably female controlled, methods for HIV/STI prevention. Of critical significance are devices and products still under development such as microbicides (for examples see Koo, Woodsong, Dalberth, Viswanathan, & Simons-Rudolph, this issue; Severy & Newcomer, this issue) that would protect women and their partners from HIV and other STIs. Although these devices and products are designed to prevent disease rather than to control fertility or overcome infertility, issues of acceptability are equally critical to their use.

In this issue we consider psychological, ethical, sociocultural, and political issues of selective technologies. Taken together, the technologies--some old, some new, some still on the horizon--provide more options for women and their partners, theoretically making it possible for them to have greater control over their physical health and psychological well-being. The development of better, more sophisticated scientific technologies generally is viewed by couples and medical professionals as a benefit that could potentially improve physical health and well-being (Kailasam & Jenkins, 2004; Women's Health Weekly, 2004). That said, these technologies have engendered great controversy even among feminists (Henifin, 1993; Tangri & Kahn, 1993) as has their marketing (Kolata, 2002). Feminists have failed to achieve an integrated discourse about women's reproductive decision making across the various technologies (Cannold, 2002). While they support women's right to limit or terminate pregnancy, radical feminists generally oppose assisted reproductive technology. Feminists see women as independent rational decision makers when confronted with an unwanted pregnancy. In contrast, many of them believe that women may be coerced into procedures such an IVF and surrogacy and, therefore, they cannot make unconstrained, independent decisions about these procedures (Cannold, 2002).

Certain religious and cultural groups view some or most of these technologies as unacceptable, even immoral. For instance, the Catholic Church characterizes abortion and contraception as immoral and urges women to forgo these methods (Russo & Denious, this issue; Wakin, 2003). Each of these reproductive technologies raises significant, social, ethical, and psychological issues for women and their sexual partners (e.g., Pasch & Christensen, 2000). Technologies at both ends of the fertility spectrum may be difficult to use and involve significant …