Fertility and Sterility, The Official Journal of the American Society of Reproductive Medicine

Volume 78, Issue 3, Pages 460-462 (September 2002)

Gender selection for nonmedical indications

Norbert Gleicher M.D. *a,b,c and Vishvanath Karande M.D.b,c
Received 2 January 2002;revised 29 April 2002;accepted 29 April 2002.

The issue of gender selection for nonmedical indications has recently been subject to intensive media coverage in the United States (1, 2). This coverage, which included strongly opinionated editorial comments (3, 4), was, at times, factually misleading.

Gender selection for nonmedical reasons
Gender selection for nonmedical reasons has been practiced in the United States for decades. Because the techniques used were widely perceived to be ineffective, they were offered by only a few physicians, and this treatment was largely considered peripheral to the mainstream of infertility treatment. Gender selection for nonmedical reasons, therefore, never rose to a level of relevance that would raise concern or attract scrutiny.

All of this started to change with the ascent of more modern techniques. Yet, even once it became apparent that PGD allowed the reliable determination of gender in preimplantation embryos, the uniform consensus of the profession was that the use of such technology for elective purposes was inappropriate (5).

Paradoxically, it was the significantly less reliable technology of sperm sorting by flow cytometry (6) that, for the first time, induced the Ethics Committee of the American Society for Reproductive Medicine (ASRM) to address the question of whether gender selection for nonmedical reasons could or should be considered ethically acceptable (5).

The Ethics Committee report, published in May 2001 in the official organ of the ASRM and entitled “Preconception Gender Selection for Nonmedical Reasons” (5), concluded with a recommendation that for the first time sanctioned the concept of gender selection for nonmedical reasons. It stated the following:

If … methods of preconception gender selection are found to be safe and effective, physicians should feel free to offer preconception gender selection in clinical settings to couples who are seeking gender variety in their offspring if the couple (1) are fully informed of the risks of failure, (2) affirm that they will fully accept children of the opposite sex if the preconception gender selection fails, (3) are counseled about having unrealistic expectations about the behavior of children of the preferred gender, and (4) are offered the opportunity to participate in research to track and assess the safety, efficacy and demographics of preconception selection.

This opinion of the Ethics Committee came as a surprise to most practitioners in the field, mostly because a large majority of physicians saw no obvious need to address this topic in a formal committee opinion. The profession had been almost unanimous in rejecting the concept of gender selection (5–7).

Our Center’s institutional review board (IRB), composed of scientists, lay people and clergy, with a majority of independent members and an outside physician as chairman, found fault with the fact that this Committee opinion selectively addressed preconception gender selection but did not consider preimplantation genetic diagnosis (PGD). Specifically, the IRB noted the following:

It seemed unethical to inform the public of only one and not the other methodology of gender selection.

It seemed unethical to offer the public access to only one and not the other technology, especially because preconception gender selection was diagnostically less reliable than PGD, resulting in lower pregnancy rates per treatment cycle, and therefore was also less cost effective. (Preconception gender selection is usually used in conjunction with ovulation induction cycles, followed by intrauterine inseminations, which results in pregnancy rates of approximately 14% per cycle. Without superovulation, pregnancy rates are even lower. In vitro fertilization, in contrast, achieves at least two to three times these pregnancy rates per treatment cycle and does so with much lower risk of multiple births [(8)].)

The IRB voiced the opinion that once gender selection was considered an ethically acceptable concept, patients should be informed about all the choices available and should have great discretion in their procreative decisions, as also recognized by the Ethics Committee in its opinion (5).

The IRB, therefore, instructed one of the authors (N.G.) to advise the ASRM by letter of the IRB’s concerns. The ASRM responded by return letter that the IRB’s concerns would be discussed in the Ethics Committee’s next regularly scheduled meeting in September 2001.

In a letter dated September 17, 2001, the chair of the ASRM Ethics Committee 2001 advised that the Committee had addressed the IRB’s concerns. A concluding paragraph stated the following:

In light of the Ethics Committee’s 2001 analysis of sex selection for gender variety in a family, a program might ethically offer preimplantation genetic diagnosis for that purpose when there is good reason to think that the couple is fully informed of the risks of the procedure, and are counseled about having unrealistic expectations about the behavior of children of the preferred gender.

Kolata reported on this decision in the New York Times on September 28, 2001 (1) and disclosed that this latest Committee decision was actually only reached by the Committee’s chairman and one other, anonymous Committee member. After a considerable amount of adverse publicity to this Committee decision, the ASRM, through its Executive Director, issued a press release on October 1, 2001 in which it distanced itself from the most recent opinion letter of its own Ethics Committee and described earlier Ethics Committee opinions in opposition to the use of PGD but in favor of preconception gender selection (5–7), as “endorsed” by the ASRM Board of Directors. The press release concluded in reference to those earlier Committee opinions with the following:

These reports are the current official stance of the ASRM. Obviously, individual members of the ASRM, and even the Ethics Committee and the Board of Directors may have different views, which they are free to express. We recognize that reproductive medicine sometimes raises some difficult ethical issues. Our Ethics Committee issues reports in order to provide guidance to our members as they wrestle with these issues.

A letter dated February 7, 2002, from the chairman of the Committee, further advised that the question of PGD to create gender variety in offspring in a family had been once more considered by the full Committee, which concluded the following:

The need for gender variety in a family does not at this time justify the use of IVF and PGD solely for that purpose.

In attempts to explain the change in viewpoint of the Committee, he went on to state as follows:

An important ethical issue presented by IVF and PGD for non-medical sex selection is whether the interest in choosing the gender of offspring is strong enough to justify the creation and destruction of embryos for that purpose. Given the risk of gender discrimination in any use of non-medical sex selection and the lack of social or moral consensus about the importance of selecting such a trait, the Committee reaffirms its previous conclusion that initiating IVF and PGD solely for non-medical gender selection generally, e.g., for the first child, should be discouraged. It also concludes that initiating IVF and PGD solely to create gender variety in a family should at this time also be discouraged. It has not yet been clearly established that a couple’s desire for gender variety and offspring is sufficient to outweigh the need to show special respect to embryos. Nor has there been sufficient ethical and social debate as to whether there are circumstances in which embryos (even if none were destroyed) may be created and selected for transfer on non-medical grounds alone. These issues deserve close attention in the future.

Ethical considerations
The full Ethics Committee of the ASRM, in its May 2001 Committee Report (5), reached the principal conclusion that nonmedical gender selection was, under certain circumstances, an ethically appropriate medical procedure. This decision was reached despite several general ethical concerns, including the potential for inherent gender discrimination, inappropriate control over nonessential characteristics of children, unnecessary medical burdens and costs for parents, and inappropriate and potentially unfair use of limited medical resources. Concerns were also expressed over possible sex-ratio imbalances and psychological harm to sex-selected offspring, increased marital conflict over gender selection decisions, and reinforcement of gender biases as a whole (5).

Yet, exactly these same arguments, obviously found lacking by the Ethics Committee May 2001 opinion, are now voiced in opposition to the use of PGD for nonmedical gender selection purposes (3, 4). How they can be ignored in reference to preconception gender selection, but be applicable to the use of PGD, is unclear. Yet, this exactly appears to be the current position of the ASRM.

Misconceptions
In an editorial on September 30, 2001, the New York Times strongly suggested that the ASRM reconsider the opinion of its Ethics Committee, after its chairman had given the tentative go-ahead for the use of PGD (3). The editorial also voiced the widely heard argument that the use of PGD for the purpose of gender selection would significantly increase the prevalence of discarded embryos. This is an obvious misconception!

Preconception sperm sorting, of course, does not involve the creation of embryos for the purpose of gender selection and therefore does not, like PGD, create embryos for potential destruction. Yet, with gender selection by PGD, as in IVF cycles, performed for infertility, couples will have full discretion over what to do with their embryos. Some will, in fact, instruct the IVF laboratory to ethically destroy unused embryos. So do some patients in fertility-related IVF cycles. Others will donate excessive embryos to other couples (embryo adoption), and yet others will donate them to research. And, finally, like in routine IVF, some will have their embryos cryopreserved for future use.

It is also a misconception that couples going through a treatment cycle involving gender selection will always and forever only want children of the selected gender. In fact, it appears much more likely that once they have a child of the desired gender, the sex of further pregnancies will become less important. Cryopreserved excessive embryos may, therefore, be transferred at that point without further need for gender selection.

There also exists a misconception that nonmedical gender selection always involves a choice between female and male when, often, the choice is, in fact, between having yet another pregnancy or not. Families with a preponderance of one gender may simply not attempt another conception unless they are assured of a child of the desired sex.

Nonmedical gender selection in the Western world does not appear to favor one gender over the other. Abuses and a resultant impact on the balance of the sexes within the United States population is, therefore, extremely unlikely (7).

Opponents of gender selection by PGD also often raise the potential risks of IVF. Yet, no such argument is heard in association with egg donation, in which donors are allowed to take such risks without any benefits to themselves. Finally, the argument is frequently heard that sparse (IVF) resources should not be used for such elective causes, as if cosmetic surgeons were not using operating rooms all over the country!

Conclusions
Nonmedically indicated gender selection became an issue of contention in the United States only after the Ethics Committee of the ASRM legitimized the concept through a published opinion (5). Once elective gender selection is considered ethical, the principal rules of informed consent and the basic rights of families to determine how they wish to pursue their procreative choices should automatically mandate full disclosure of options and access to all treatments and procedures. Selected information and limited access to only one procedure option, especially if it is the qualitatively inferior one, appears, though currently the formal ASRM position, of questionable ethical validity.

Gender selection for nonmedical reasons either is or is not ethical. If the ASRM maintains its official opinion that it potentially is (in reference to preconception techniques), then one has to reach the same conclusion for all applicable techniques and leave it up to patients to decide which to choose. An alternative option, of course, would be to consider all gender selection procedures unethical and reverse the opinion of its Ethics Committee published in May 2001 (5).

It seems encouraging, however, that the Ethics Committee of the ASRM clearly appears to understand the temporary relevance of its most recent opinion by reaffirming that this issue deserves close attention in the future.

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References

1. Kolata G. Fertility ethics authority approves sex selection. : New York Times 2001September 28
2. Patel J. Making sure it’s a boy or girl. : Chicago Sun-Times 2001September 28

3. Choosing the sex of your baby [editorial]. : New York Times 2001September 30

4. Babies made to order [editorial]. : Chicago Tribune 2001October 7

5. Ethics Committee of the American Society for Reproductive Medicine . Preconception gender selection for nonmedical reasons. Fertil Steril. 2001;75:861-864 Full Text | PDF (48 KB) | MEDLINE | CrossRef

6. Fuggen EF, Black SH, Keyvanfar K, Schulman JD. Birth of normal daughters after microsort sperm separation and intrauterine insemination, in vitro fertilization or intracytoplasmic sperm injection. Hum Reprod. 1998;13:2367-2370 MEDLINE

7. Ethics Committee of the American Society of Reproductive Medicine . Preimplantation genetic diagnosis and sex selection. Fertil Steril. 1999;72:595-598 Full Text | PDF (55 KB) | MEDLINE | CrossRef

8. Gleicher N, Oleske DM, Tur-Kaspa I, Vidali A, Karande V. Reducing the risk of high-order multiple pregnancy after ovarian stimulation with gonadotropins. N Engl J Med. 2000;343:2-7 MEDLINE | CrossRef

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a The Center for Human Reproduction, New York, USA
b The Center for Human Reproduction, Chicago, USA
c The Foundation for Reproductive Medicine, Chicago Illinois, USA
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* Reprint requests: Norbert Gleicher, M.D., Center for Human Reproduction, 60 East Delaware Place, Suite 1400, Chicago, Illinois 60611 USA (FAX: 312-397-8396)
© 2002 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.