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Moral attitudes and beliefs among couples pursuing PGD for sex selection

Published:September 28, 2010DOI:https://doi.org/10.1016/j.rbmo.2010.09.009

      Abstract

      This article reports the results from a study of couples participating in a research protocol in which IVF/preimplantation genetic diagnosis (PGD) was available for non-medical sex selection. The study sought to characterize the moral attitudes and beliefs of couples actively pursuing IVF/PGD solely for purposes related to sex selection. Eighteen couples participated in ethnographic interviews from November 2005 to April 2006. These interviews explored couples’ motivations for pursuing sex selection, moral beliefs and attitudes regarding sex selection and sources of moral ambivalence about the use of IVF/PGD for sex selection. Couples reported a combination of motivations for pursuing sex selection, including a desire to limit family size, concerns about parental age and financial concerns about multiple pregnancies. Many couples compared their decision to choices about abortion, maintaining that individuals have a right to make such decisions privately. Couples frequently expressed anxiety about telling their other children and family members about their plans to use IVF/PGD for sex selection. Few couples cited concerns about the physical or emotional burdens of IVF/PGD. The study’s findings suggest that couples pursuing IVF/PGD for sex selection view this as an ethically complex decision and express considerable uncertainty about the ethical acceptability of this practice.
      Our paper reports results from a study of couples participating in a research study in which IVF/preimplantation genetic diagnosis (PGD) was made available for non-medical sex selection. To our knowledge this is the first study to examine the moral attitudes and beliefs of couples actively seeking to use IVF/PGD solely for sex selection. The couples in our study provide a unique opportunity to examine the range of moral attitudes and beliefs held by couples actively seeking sex selection. The results we report provide much needed empirical data for clinicians who may be facing the difficult task of deciding whether, and in what manner, to offer patients the option of using IVF/PGD for sex selection.

      Keywords

      Introduction

      The use of assisted reproduction treatment for non-medical sex selection has been the subject of much ethical and professional debate. Non-medical sex selection consists of any non-medically indicated use of treatment to select gametes or embryos for sex. This includes family balancing, the practice of choosing spermatozoa or embryos on the basis of sex to balance out the ratio of girls to boys in a family. The ethical permissibility of using sperm separation techniques for preconception sex selection have been debated elsewhere (
      • Dahl E.
      The 10 most common objections to sex selection and why they are far from being conclusive: a Western perspective.
      ,
      • Robertson J.
      Sex selection: final word from the ASRM ethics committee on the use of PGD.
      ,
      • Simpson J.L.
      • Carson S.A.
      The reproductive option of sex selection.
      ). This paper is concerned with the combined use of IVF/preimplantation genetic diagnosis (PGD) to screen embryos for family balancing purposes by sex selection.
      Proponents of IVF/PGD for sex selection have appealed to reproductive autonomy, privacy in reproductive decision making and the moral superiority of preimplantation selection over sex selective abortion (
      • Dahl E.
      Preconception gender selection: a threat to the natural sex ratio?.
      ,
      • Malpani A.
      • Malpani A.
      • Modi D.
      Preimplantation sex selection for family balancing in India.
      ,
      • Merhi Z.O.
      • Pal L.
      Gender ‘‘tailored’’ conceptions: should the option of embryo gender selection be available to infertile couples undergoing assisted reproductive technology?.
      ,
      • Savulescu J.
      • Dahl E.
      Sex selection and preimplantation diagnosis: a response to the ethics committee of the American society for reproductive medicine.
      ,
      • Savulescu J.
      Sex selection: the case for.
      ). Opponents have argued that the use of assisted reproduction treatment to select embryos on the basis of sex reinforces existing sexism and expectations of conformity to stereotypical gender norms, presents undue physical burdens on women undergoing the procedures involved and is inconsistent with the ideal of parents having unconditional love for their children (
      • Blyth E.
      • Frith L.
      • Crawshaw M.
      Ethical objections to sex selection for non-medical reasons.
      ,
      • Herissone-Kelly P.
      Parental love and the ethics of sex selection.
      ,
      • Levy N.
      Against sex selection.
      ,
      • Seavilleklein V.
      • Sherwin S.
      The myth of the gendered chromosome: sex selection and the social interest.
      ). Several medical organizations have issued opinions stating that the creation and destruction of embryos to select for sex, or to enhance gender variety in the family, is an inappropriate way to allocate scarce medical resources and perpetuates gender bias (
      • American College of Obstetricians and Gynecologists’ Committee on Ethics
      Sex selection.
      ,
      • FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health
      Ethical guidelines on sex selection for non-medical purposes.
      ,
      • Human Fertilization and Embryology Authority
      Sex Selection: Choice and Responsibility in Reproduction.
      ,
      • Robertson J.A.
      Ethics and the future of preimplantation genetic diagnosis.
      ,
      • The Ethics Committee of the American Society for Reproductive Medicine
      Sex selection and preimplantation genetic diagnosis.
      ). Despite this professional opposition, the use of IVF/PGD to screen the sex of embryos for non-medical purposes appears to be increasing and in the USA in 2005 comprised up to 9% of IVF/PGD cycles (
      • Baruch S.
      • Kaufman D.
      • Hudson K.L.
      Genetic testing of embryos: practices and perspectives of US in vitro fertilization clinics.
      ).
      Although debates about the acceptability of using IVF/PGD for sex selection have appealed to a range of moral, political and religious values, these discussions have not included the perspectives of the users. This gap in current discussions about sex selection reflects the paucity of available empirical data on the motivations of individuals and couples who have used IVF/PGD to select embryos based on sex. Insight into how patients using IVF/PGD for sex selection conceptualize this practice can further elucidate ethical perspectives on sex selection, generate new normative claims about the acceptability of this use of IVF/PGD, and inform the development of ethical guidelines for clinical practice regarding sex selection.
      The need to examine patient perspectives is pressing, particularly given that a recent survey estimated that PGD is available at 75% of fertility clinics in the USA and is used in about 4–6% of IVF cases at those clinics, resulting in approximately 3000 IVF/PGD procedures conducted annually in the USA (
      • Baruch S.
      • Kaufman D.
      • Hudson K.L.
      Genetic testing of embryos: practices and perspectives of US in vitro fertilization clinics.
      ). A review of research studies on IVF/PGD archived in the PubMed database suggests that existing studies of users’ motivations have focused on individuals seeking IVF/PGD to screen embryos for heritable genetic conditions and aneuploidies (
      • Franklin S.
      • Roberts C.
      Born and Made: An Ethnography of Preimplantation Genetic Diagnosis.
      ,
      • Kalfoglou A.
      • Scott J.
      • Hudson K.
      PGD patients’ and providers’ attitudes to the uses and regulation of preimplantation genetic diagnosis.
      ,
      • Katz M.
      • Fitzgerald A.
      • Bankier A.
      • Savulescu J.
      • Cram D.S.
      Issues and concerns of couples presenting for preimplantation genetic diagnosis (PGD).
      ,
      • Lavery S.
      • Aurell R.
      • Turner C.
      • et al.
      Preimplantation genetic diagnosis: patients’ experiences and attitudes.
      ,
      • McGowan M.L.
      • Burant C.
      • Moran R.
      • Farrell R.M.
      Patient education and informed consent for preimplantation genetic diagnosis: health literacy for genetics and assisted reproductive technology.
      ). None of these studies have sought to describe individuals seeking IVF/PGD to screen embryos for non-medical reasons. Other researchers have prospectively assessed fertility patients’ preferences for various sex-selection techniques, although participants in these studies were not actively pursuing sex selection in the context of their fertility treatment (
      • Jain T.
      • Missmer S.A.
      • Gupta R.S.
      • Hornstein M.D.
      Preimplantation sex selection demand and preferences in an infertility population.
      ,
      • Missmer S.A.
      • Jain T.
      Preimplantation sex selection demand and preferences among infertility patients in Midwestern United States.
      ). Finally, while studies have examined patients’ use of assisted reproduction treatment for non-medical sex selection (
      • Colls P.
      • Silver L.
      • Olivera G.
      • et al.
      Preimplantation genetic diagnosis for gender selection in the USA.
      ,
      • Gleicher N.
      • Barad D.H.
      The choice of gender: is elective gender selection, indeed, sexist?.
      ,
      • Goossens V.
      • Harton G.
      • Moutou C.
      • et al.
      ESHRE PGD consortium data collection VIII: cycles from January to December 2005 with pregnancy follow-up to October 2006.
      ), these studies have sought to quantify the extent to which patients desire to have either a girl or a boy and have not sought to more fully examine couples’ motivations or concerns about the use of IVF/PGD for sex selection.
      This article reports the results from a study of couples participating in a research protocol in which IVF/PGD was available for sex selection. As far as is known, this is the first study to examine the moral attitudes and beliefs of couples actively pursuing IVF/PGD solely for purposes related to sex selection. The couples participating in this study were among the earliest potential adopters of IVF/PGD for sex selection and provided a unique opportunity to examine the range of moral attitudes and beliefs held by couples seeking IVF/PGD for sex selection. The aims of the study were to: (i) describe the motivations of couples interested in using IVF/PGD for sex selection; (ii) characterize moral beliefs and attitudes among couples interested in using IVF/PGD for sex selection; and (iii) examine the extent to which couples interested in sex selection report feelings of moral ambivalence about the use of IVF/PGD for sex selection. Results from this study provide much needed empirical data for clinicians facing the difficult task of deciding whether, and in what manner, to offer patients the option of using IVF/PGD for sex selection.

      Materials and methods

      Clinical setting

      Couples pursuing IVF/PGD for purposes related to sex selection were recruited through a research study at Baylor College of Medicine, a private medical school in Houston, Texas. The research study, entitled ‘Family balancing through preimplantation genetic diagnosis: patient interest and motive’, used conventional IVF techniques in combination with PGD to determine the sex of fertilized embryos prior to embryo transfer. Sex selection was offered to couples under a research protocol with narrow eligibility requirements. Eligibility was restricted to couples who had at least one biological child together (without prior use of any reproductive technologies), had at least one child who was not of the sex desired in their next pregnancy and had no other children together of the desired sex. Eligible women had to be between the ages of 18 and 42 and were required to meet standard medical criteria for IVF. Couples in the study were responsible for financial costs associated with all clinical examinations, consultations and IVF/PGD procedures, including those performed at their initial clinic visit.
      Couples interested in IVF/PGD for sex selection contacted a research coordinator, who scheduled a follow-up telephone call to explain the study and its eligibility requirements. The research coordinator also discussed scheduling constraints, IVF procedures and financial costs of participation. Couples interested in the study then scheduled an in-person clinic visit to discuss their participation in greater detail. This initial clinic visit consisted of three discrete appointments, each on a single day, and all couples in the study were required to participate in each of these appointments. First, the couple met with a genetic counsellor (SM) to assess whether the couple met eligibility requirements, take a family history, review study procedures (including IVF- and PGD-related procedures), provide an opportunity to answer any questions the couples had and obtain informed consent. Second, each couple participated in an interview with a medical ethicist (RS or LM) during which they discussed their interest in using IVF/PGD for sex selection. Finally, the couple met with a reproductive endocrinologist specializing in IVF (typically SC). In addition to discussing medical aspects of IVF, relevant clinical examinations were performed during this third appointment.

      Interviews

      The interviews with a medical ethicist were conducted in a private setting subsequent to obtaining informed consent. Couples were informed that the conversation would be confidential and that nothing said in the interview would be shared with their doctors or the research coordinator. Couples were also told that their access to IVF/PGD for sex selection would not be affected in any manner by the interview itself.
      A semi-structured interviewer guide was used to promote consistency of approach across interviewers and individual discussions. The interviewer guide was divided into seven primary areas of inquiry: (i) reasons for having another child; (ii) reasons for pursuing IVF/PGD for sex selection; (iii) understandings of relevant moral values; (iv) views on the scope of IVF/PGD use; (v) personal confidants consulted about the use of IVF/PGD for sex selection; (vi) plans regarding disclosure of IVF/PGD use; and (vii) current status of the couple’s decision to pursue IVF/PGD for sex selection. Interviewers posed open-ended questions to encourage participants to use their own words and moral frameworks to describe how they had reached a decision to pursue sex selection. For example, to begin a discussion of motivations for pursuing sex selection, interviewers asked: ‘Why is it important to you that your next child be a [girl/boy]?’ Similarly, to begin a discussion of with whom the couples had consulted about the acceptability of using IVF/PGD for sex selection, interviewers asked: ‘Prior to today, who have you talked to about your interest in the family balancing programme?’ Interviewers asked multiple follow-up questions to clarify respondent answers and provide additional insights into the reasoning that respondents used to support specific moral beliefs.
      Interviews were conducted from November 2005 to April 2006 and lasted between 20 and 75 min. Most interviews took 35–45 min to complete. All interviews were recorded and transcribed to allow for further analysis.

      Data analysis

      Interview transcripts were examined for thematic content using qualitative data analysis software (QSR NVivo 2.0). Data analysis followed a grounded-theory approach, with thematic coding limited to moral appeals, ethical beliefs, religious values and related sociocultural concepts. Interviewer notes were used to supplement and refine understandings of discursive themes.

      Human subjects

      This research study was approved by the Baylor College of Medicine Institutional Review Board. Informed consent was obtained from all research volunteers. Participants were not compensated for their participation in this study.

      Results

      Characteristics of couples pursuing IVF/PGD for sex selection

      The research coordinator received 492 inquiries about the study. These inquiries resulted in the scheduling of 50 in-person clinic appointments with couples interested in IVF/PGD for sex selection, which was the enrolment target for this study. Of the 50 couples scheduled to be seen in-person, 18 attended their scheduled appointments and were presented with the option of participating in the study. All 18 of these couples consented to participate and were interviewed. In one case, the male partner was not available for the interview.
      The mean age for women pursuing sex selection was 32 years (Table 1). Men were often a few years older than women, with a mean age of 35 years. Most couples were of Christian faith (81%) and had annual household incomes above US$60,000 (67%). The majority of couples had at least two children together. One-third of couples had three or more children of the opposite sex from that being sought through sex selection. Most couples indicated a preference for a boy (78%). It was not uncommon for couples to have travelled large distances to attend their clinic appointments and many mentioned the practical challenges they had encountered in scheduling their clinic visit. Participants first learned of the research study in a variety of ways, including the internet, television news stories, friends, family members and healthcare providers.
      Table 1Characteristics of 18 couples pursuing IVF/preimplantation genetic diagnosis (PGD) for sex selection at an academic medical centre in the USA.
      CharacteristicStudy population
      Mother’s age (years)31.7 ± 3.9
       <251 (6)
       25–294 (22)
       30–349 (50)
       35–394 (22)
       >390 (0)
      Father’s age (years)35.3 ± 6.1
       <251 (6)
       25–293 (17)
       30–345 (28)
       35–393 (17)
       >396 (33)
      Ethnicity (n = 36)
       Caucasian17 (47)
       Hispanic8 (22)
       Asian6 (17)
       African3 (8)
       Mixed ethnicity reported2 (6)
      Religious affiliation (n = 36)
       Christian29 (81)
       Jewish2 (6)
       Other3 (8)
       Not reported2 (6)
      Annual household income (US$)
       <40 K0 (0)
       41–60 K6 (33)
       61–80 K3 (17)
       81–100 K5 (28)
       >100 K4 (22)
      No. of children
       14 (22)
       28 (44)
       35 (28)
       41 (6)
      Gender preference for next child
       Boy14 (78)
       Girl4 (22)
      Method of hearing about research study
       Internet7 (39)
       Television6 (33)
       Family/friend2 (11)
       Healthcare provider2 (11)
       Other1 (6)
      Values are n (%) or mean ± SD.

      Motivations for pursuing sex selection

      A combination of motivations was typical of most couples pursuing IVF/PGD for sex selection (Table 2). Most couples expressed a desire to limit the overall size of their family and indicated that they would prefer to have a single additional pregnancy. Many couples mentioned the age of the mother or the father as a primary reason for wanting to limit their family size. Some couples also cited financial considerations, particularly the costs of having a large family, as a factor in wanting to limit family size. When asked whether they would consider having another child were it not for the availability of the IVF/PGD for sex selection, most couples said that they would try to have another child ‘naturally’ but qualified their responses by adding that they would only try one additional time.
      Table 2Common motivations expressed by 18 couples pursuing IVF/preimplantation genetic diagnosis (PGD) for sex selection.
      Motivations expressed by couplesn
      Age-related considerations (either female or male)14
      Desire for gender balance in the family14
      Desire to limit family size13
      References to gendered makeup of parents’ families12
      Interest in specific parenting experiences12
      Minimizing uncertainty relative to other methods of sex selection11
      Desire for a child of a particular sex (as distinct from a desire for gender

      balance in the family)
      11
      Desire to pass on a family name11
      Desire to enhance the experience of current children9
      An illustrative example of these perspectives on family size is captured in the following quote: ‘I think I’m interested in having another child anyways, but it would be nice to, I would like to have a boy. I’ve always actually imagined having a boy … With the first girl I thought, ok I don’t know what to do with a girl, but I did fine and now I have another girl. So it’d be nice to just balance that out with a boy. I don’t like to be pregnant per se so I guess if I had another girl, I think I’d end up getting pregnant, trying to have another baby after that and with advancing age and with my career and everything I’m just not sure if I want to have four children. If I have a boy, the third one, I’d like it to be … If I choose to have a fourth child it would be something I would decide at that point. I guess I would feel more pressured to have a fourth child if I had another girl’ (female, couple 8, seeking a boy).
      A large part of many couples’ interest in using IVF/PGD for sex selection was to increase the odds that what they regarded as a ‘last attempt’ to have a child of the preferred sex would be successful. Most couples were familiar with other techniques for increasing the likelihood of having a child of a particular sex, such as sperm sorting. Couples often said that they felt using IVF/PGD for sex selection was preferable to sperm sorting and intrauterine insemination because they believed the likelihood of their having a child of the preferred sex was greater if they used IVF/PGD. Since most of these couples were planning just a single additional pregnancy, the likelihood of the sex-selection technique achieving its goal was of particular concern among these couples. Many also said that prior to their most recent pregnancy they had used various non-medical techniques to increase the likelihood of having a child of a particular sex, such as tracking the timing of ovulation, changing diet or decreasing caffeine intake. Although many couples had tried these methods, most regarded these techniques as ‘old wives tales’ that were unlikely to be successful.
      Couples frequently cited an interest in ‘completing their family’ as another motivation for pursuing IVF/PGD for sex selection. These couples often described what they considered to be an overly feminine or masculine character in their families and discussed how they felt their current children would benefit from growing up with a sibling of the opposite sex. For instance, a male respondent seeking IVF/PGD to have a girl (couple 7) said: ‘part of the reason why, my interest in this is, we never had that female influence in my family. It was just the three boys and for my side of it, it would be to have that influence in our family. We just think that it would be good for our boys to have a sister more than even us.’ Frequently, one or both of the parents described their own childhood experiences growing up with siblings of the opposite sex to illustrate the benefits they associated with a gender-balanced family. In this context, it was also common for couples to reference an idealized family type in describing their interest in sex selection for family balancing. For example, later in the same interview, the female respondent in couple 7 commented: ‘Well, I do think that society has this neat little box of a boy and a girl and that’s your perfect family.’ Couples expressed varying levels of disappointment at not having had a child of the desired sex previously but rarely said that they were unhappy with their current family situations.
      Couples also characterized their interests in having a child of a particular sex by referencing personal interests in specific parenting experiences. The majority of these were fathers wanting the experience of raising a son or mothers wanting the experience of raising a daughter (same-gendered parenting experiences). In contrast to motivations related to family balancing, these personal interests were often described in relation to traditionally gendered social experiences shared by a parent and a child of a particular sex. For example, couple 5 explained their interest in having a daughter by saying ‘[male] Like the father will walk down his daughter and give [her] away when she gets married. You know those are all things that I am looking for … It’s important to me. I’d like to walk my daughter down the aisle when she’s getting married. I’d like to throw her a quinceañera … I stood in her [his wife’s] quinceañera. So it’d be nice to be able to say, ‘Hey, I stood in your mother’s fifteen. When she turned fifteen I was there. [female] And we still want that bond with the girl, like us being with me and my mom. I bond good with my boys but I don’t know. I want to have the feeling of bonding with a girl.’
      Although rarely cited as a primary motivation for pursuing sex selection, most couples seeking to increase their likelihood of having a son mentioned an interest in passing on a family name. For example, as the male respondent in couple 15 explained: ‘Well for me, it’s carrying the family name. My father had brothers, they’ve all had sons. I was his only son, I’d like to carry our name, you know. For me I find it very important to carry our name.’ Upon further investigation, this motivation – cited by both men and women – was found to be related to a broad set of interests in continuing family traditions and sharing wisdom from one generation to another. Several couples who expressed an interest in passing on a family name also mentioned grandparents and others in the family who viewed this as of particular importance.

      Moral beliefs about using IVF/PGD for sex selection

      Couples were confident that using IVF/PGD for sex selection was not unethical in their particular circumstances. All couples expressed strong commitments to reproductive autonomy, stressing the importance of having access to technologies such as IVF and PGD that might help them achieve their personal reproductive goals. Most couples viewed the use of IVF/PGD as generally safe. In the absence of major safety-related concerns about sex-selection techniques, most couples believed this was a choice that individual couples should be allowed to make for themselves. In fact, every couple felt that reproductive decisions were highly private matters that parents should be allowed to make independently. Couples often made statements like: ‘I think it’s a personal decision for us and it’s really nobody else’s business … This is the United States, and you know we get to do everything else we want to do’ (female, couple 12, seeking a girl).
      Several couples compared their decision about the use of IVF/PGD for sex selection to individual choices about abortion, maintaining that individuals have a right to make such decisions privately. As a male respondent seeking to have a boy (couple 2) stated this point: ‘I guess on that, I believe that … it’s not if you think people should be allowed to do it or not allowed to do it. I think that the fact is that you have the decision to make. It belongs to you not to any other entity. The issue, and specifically whether it’s abortion or gender selection, doesn’t matter. The issue is, the decision is the parents’ to make not anybody else’s.’
      The highly private way in which these couples conceptualized the decision to pursue sex selection was reflected in their comments about the people they had consulted, or were planning to consult, in deciding about the use of IVF/PGD for sex selection. Most couples said they had not discussed their interest in sex selection with anyone else, and although they wanted to learn more about the medical procedures involved before making a final decision, most did not have any questions about relevant ethical or religious considerations that may be at stake. Similarly, very few couples reported that they had sought advice from a religious authority, close friend, family member or other personal advisor on moral issues.
      Frequently there was strong agreement between the male and female partner regarding their interest in pursuing IVF/PGD for sex selection. Couples occasionally expressed differences concerning their respective levels of interest in trying conventional reproductive approaches for one additional pregnancy but this was not common. It was typical, however, for one of the two partners to express considerably more enthusiasm for sex selection than the other. Couples often had discussed their respective levels of interest and potential reservations at length prior to the clinic visit and could clearly articulate points of disagreement between themselves.

      Moral ambivalence about using IVF/PGD for sex selection

      The disposition of unused embryos produced through IVF was a common source of moral uncertainty for couples (Table 3). Most couples said they did not want to destroy unused embryos solely on the basis of sex. Many of these couples were familiar with other options for the disposition of unused embryos, including donation to infertile couples or medical researchers. Several couples indicated that concerns about the disposition of any unused embryos might ultimately prevent them from using IVF/PGD for sex selection and that they were not yet sure how to resolve this moral tension. As a female respondent seeking a boy (couple 9) described this tension: ‘Yeah, I mean we’re both Catholic but we’re not devout Catholic and we’re not really even sure what our religion says about this and we’re not even sure we should be doing this but you know it’s a personal decision for us … There are definitely some religious and ethical issues for me about what to do with the embryos, the embryos that aren’t used and that’s an issue for me I think that I haven’t really resolved. I mean it’s a personal decision. We’re for abortion; it’s like abortion. I mean, we feel that it’s a right that everybody should have, but for us personally we don’t believe in that. I think that’s how this goes.’
      Table 3Sources of moral ambivalence among 18 couples pursuing IVF/preimplantation genetic diagnosis (PGD) for sex selection.
      Concerns expressed by couplesn
      Creation and destruction of fertilized human embryos12
      Psychological impact on current children12
      Negative response by family members11
      Financial costs of IVF/PGD10
      Personal religious concerns9
      Possibility of multiples and reduction6
      Medical burden of IVF/PGD on the mother6
      Psychological impact on the child produced via IVF/PGD2
      As in the previous quote, couples also cited personal and familial religious traditions as a source of moral uncertainty. Many couples indicated that others in their immediate family would likely object to their use of IVF/PGD on religious grounds. Most of the couples did not share those religious concerns, although it was not uncommon for one of the two partners to express some level of religion-based discomfort. For these couples, there were frequent comparisons drawn between new reproductive technologies and birth control, both of which were viewed by most couples as personally acceptable despite objections expressed by some religious authorities. Concerns about personal conflicts with familial religious traditions tended to focus on either the destruction of human embryos (as illustrated in the quote above) or the possibility of going against God’s will. For example, several families said that God may have intended for them to have a family that consisted only of girls and that their pursuit of IVF/PGD may be opposing God’s will. In contrast, other couples reasoned that if God has made IVF/PGD available to man then it is acceptable for couples to use the technology. In general, however, religious traditions did not factor heavily in these couples’ reasoning about the acceptability or personal use of IVF/PGD for sex selection.
      Another source of moral ambivalence for these couples was the decision about whether to disclose their use of IVF/PGD to others, particularly parents and grandparents. All couples viewed the use of reproductive technologies as an extremely private matter and most had not told others in their family about their plans to use IVF/PGD for sex selection. Most couples expressed concerns that other family members might not be familiar with new reproductive technologies and may view IVF/PGD as ‘unnatural’ or inappropriate to use for sex selection. Couples often identified at least one person in their family that they expected to react negatively to their decision. Approximately half of the couples planned to avoid potential conflicts with their families by not disclosing their use of IVF/PGD for sex selection (to anyone), saying that this decision was theirs alone to make and that it did not matter what others thought of that decision.
      Most couples felt that it would be awkward to disclose their use of IVF/PGD to the child who was conceived in this manner. These couples thought that there was at least some potential for the child to be harmed psychologically by this knowledge. Many of the couples who expressed this concern said they would disclose their use of IVF/PGD to their (future) child only when he or she was old enough to understand the factors that contributed to their decision, which might not be until that child was an adult.
      Several couples also expressed anxiety about the prospect of telling their other children about their plans to use IVF/PGD for sex selection. A few couples said they would not tell their other children about their decision because of concerns that older siblings might feel less wanted. As a mother of three girls seeking a boy (couple 17) put it: ‘I would never want my daughters to feel insignificant, that they weren’t enough, because they are. So I would never want them to feel like we were just searching for that boy because that’s not the case.’ However, the majority of couples said they planned to share this information with their other children and felt that they could manage any harmful effects by stressing to those children that they were loved equally. Couples expressed worries that telling other family members about their interest in IVF/PGD for sex selection might result in their current children learning about that interest in a manner that was insensitive to the potential impact of the information.
      Few couples cited concerns about physical risks or emotional burdens as a result of IVF- or PGD-related procedures as a source of personal concern. Although several couples mentioned that they wanted to learn more about the risks associated with hormone treatments and the pain of egg retrieval before making a final decision, those concerns were not common. The relative absence of those perspectives may have been a function of the timing of the interview itself, however, which was prior to the appointment with a reproductive endocrinologist. Even when concerns about the physical burdens of IVF were mentioned they tended to be vaguely articulated. For example, as a female respondent interested in a boy (couple 7) explained, ‘I know there is medication and shots and things like that.’
      Although most couples were convinced that it was morally acceptable to use IVF/PGD for sex selection and that this would be a good option for their personal family situation, a significant source of decisional ambivalence was the potential cost of IVF/PGD. Couples often reported that their decision to pursue sex selection would be based in large part on the extent to which their health insurance provider would cover some of the costs of the procedures involved. Thus, while clearly evident in the interviews, the moral tensions above were just one among several considerations shaping couples’ decisions about the use of IVF/PGD for sex selection. Ultimately, a combination of financial costs, practical burdens, and moral concerns may have limited these couples’ interest in pursuing sex selection since only two of the 18 couples proceeded with IVF/PGD as part of the research study.

      Discussion

      Although there is a large professional literature on moral dimensions of sex selection, as far as is known there are no studies that have sought to characterize moral attitudes and beliefs among couples pursuing IVF/PGD for this purpose. Empirical data on this topic are critical for understanding how couples who are interested in sex selection view moral dimensions of this practice and can inform decisions about whether, and in what form, to offer IVF/PGD for sex selection. Couples’ attitudes about ethical aspects of sex selection will directly influence the adoption of sex-selection techniques, particularly patients’ perceptions of the potential benefits and risks of using IVF/PGD for this purpose. As such, several findings from the current study are relevant to ongoing ethical analyses of the use of assisted reproduction treatment for sex selection.
      First, the current findings suggest that couples pursuing IVF/PGD for sex selection have a wide range of motivations. These couples tended to frame their interests in sex selection with respect to both individual desires for specific parenting experiences (self-interests) and desires to enhance family dynamics (family-centred interests). Although many couples cited advancing age and concerns about family size as key factors in their decision to pursue IVF/PGD for sex selection, the sources of these concerns were highly variable. Additionally, while all the couples in this study were very interested in having a child of a particular sex, none indicated that they were so vested in that outcome that they would be emotionally devastated if that was not possible.
      These couples had also considered the possible effects, both positive and negative, that their use of IVF/PGD for sex selection could have on their other children and on their personal relationships with other family members. Many couples articulated multiple reasons why sex selection might be viewed as morally problematic and expressed some degree of self-doubt about the use of IVF/PGD for sex selection. These findings suggest that clinicians who are approached by couples who are interested in sex selection should not make assumptions about the sources of their interest, nor should clinicians conclude that patients’ interests in sex selection will diminish subsequent to a more in-depth discussion of relevant ethical considerations.
      Second, the findings both validate and call into question several common assumptions about the moral reasoning of couples who are interested in sex selection. For example, consistent with a priori assumptions about couples who may be pursuing sex selection, it was found that couples interested in using IVF/PGD for this purpose had strong beliefs about reproductive liberty and parental privacy. Couples repeatedly stressed the importance of these moral values and cited them as primary reasons why they felt the use IVF/PGD for sex selection was morally acceptable in their personal situation. This finding is consistent with the emphasis that prior normative analyses have placed on respect for reproductive-liberty interests (
      • Dahl E.
      Preconception gender selection: a threat to the natural sex ratio?.
      ,
      • Malpani A.
      • Malpani A.
      • Modi D.
      Preimplantation sex selection for family balancing in India.
      ,
      • Merhi Z.O.
      • Pal L.
      Gender ‘‘tailored’’ conceptions: should the option of embryo gender selection be available to infertile couples undergoing assisted reproductive technology?.
      ,
      • Savulescu J.
      • Dahl E.
      Sex selection and preimplantation diagnosis: a response to the ethics committee of the American society for reproductive medicine.
      ,
      • Savulescu J.
      Sex selection: the case for.
      ).
      In other ways, however, the moral reasoning of couples pursuing IVF/PGD for sex selection departed from familiar perspectives in the bioethics literature, such as concerns voiced by critics that the practice is inherently sexist and perpetuates gender discrimination (
      • Blyth E.
      • Frith L.
      • Crawshaw M.
      Ethical objections to sex selection for non-medical reasons.
      ,
      • Levy N.
      Against sex selection.
      ,
      • Seavilleklein V.
      • Sherwin S.
      The myth of the gendered chromosome: sex selection and the social interest.
      ). Couples who participated in this study voiced a less commonly articulated perspective in the bioethics literature, specifically that an individual’s desire for gender balance in their family is ethically complex and may not be inherently sexist, immoral or socially consequential (
      • Steinbock B.
      Sex selection: not obviously wrong.
      ). For example, it was uncommon for couples to identify concerns that sex selection perpetuates gender-based discrimination as a source of moral ambivalence regarding their personal use of IVF/PGD for sex selection.
      Similarly, based on the existing empirical literature and medical consensus statements about sex selection one might also expect that couples interested in IVF/PGD for this purpose would hold strong views about the inherent value of one sex over the other (
      • American College of Obstetricians and Gynecologists’ Committee on Ethics
      Sex selection.
      ,
      • Gleicher N.
      • Barad D.H.
      The choice of gender: is elective gender selection, indeed, sexist?.
      ). The majority of participants in this study were seeking sex selection to have a boy (78%), which is consistent with previous research on users of IVF/PGD in the USA and Europe (
      • Gleicher N.
      • Barad D.H.
      The choice of gender: is elective gender selection, indeed, sexist?.
      ,
      • Goossens V.
      • Harton G.
      • Moutou C.
      • et al.
      ESHRE PGD consortium data collection VIII: cycles from January to December 2005 with pregnancy follow-up to October 2006.
      ). However, it was much more common for these couples to express a desire for an idealized nuclear family of a mother, a father and children of both sexes (in contrast to a simple preference for a boy).
      • Jain T.
      • Missmer S.A.
      • Gupta R.S.
      • Hornstein M.D.
      Preimplantation sex selection demand and preferences in an infertility population.
      and
      • Missmer S.A.
      • Jain T.
      Preimplantation sex selection demand and preferences among infertility patients in Midwestern United States.
      reported a similar desire to use sex selection to achieve a gender-balanced family in infertility patients who already had at least one child. Couples in the current study rarely drew moral distinctions between using IVF/PGD for purposes related to ‘family balancing’ in contrast to the pursuit of (individual) sex selection, a distinction that features prominently in some ethical and empirical analyses (
      • Colls P.
      • Silver L.
      • Olivera G.
      • et al.
      Preimplantation genetic diagnosis for gender selection in the USA.
      ,
      • Puri S.
      • Nachtigall R.D.
      The ethics of sex selection: a comparison of the attitudes and experiences of primary care physicians and physician providers of clinical sex selection services.
      ,
      • Robertson J.A.
      Preconception gender selection.
      ). This suggests that the moral significance of this distinction may not be especially salient in decisions of couples actively pursuing sex selection.
      Couples tended to view the use of IVF/PGD for sex selection as a highly personal matter, not as a societal concern. From this perspective, much of their moral deliberation involved weighing potential benefits and burdens to themselves, their immediate families and their future child. Larger societal implications of allowing IVF/PGD to be used for sex selection were not evident in their personal decision making about the acceptability of sex selection. In this sense, the moral reasoning of couples actively pursuing IVF/PGD for sex selection did not parallel the framing of major ethical issues described by ethicists and medical professionals. Similar to Steinbock’s assessment of the ethics of sex selection (
      • Steinbock B.
      Sex selection: not obviously wrong.
      ), the current findings suggest that bioethical debates about the use of IVF/PGD for sex selection would benefit from an additional analysis of moral considerations that factor into a couple’s decision to pursue assisted reproduction treatment for sex selection.
      Lastly, the findings suggest that even the most motivated of couples pursuing IVF/PGD for sex selection tend to express moral reservations about this approach. Although couples in this study typically had weighed the potential benefits and burdens of using IVF/PGD for sex selection and concluded, at least tentatively, that on balance the benefits outweighed any potential harms, most continued to express uncertainty about various moral issues raised by the use of IVF/PGD for sex selection. For example, many couples had already experienced the birth of a child that they had hoped would be of the opposite sex and did not feel that child was any less loved as a result of their initial disappointment. At the same time, these couples were frequently ambivalent about whether they would tell their future child or others in their families about their use of IVF/PGD for sex selection. Similarly, the disposition of unused embryos created via IVF was a common source of moral uncertainty for many couples.
      Patient education and informed-consent practices in IVF clinics typically address medical aspects of IVF and offer genetic counselling about the information that PGD can provide (
      • McGowan M.L.
      Producing users of preimplantation genetic diagnosis: dominant and marginalized discourses in the US context.
      ). The current findings suggest that it also may be appropriate for IVF clinics to recommend pre-decisional counselling for couples who are interested in using IVF/PGD for sex selection. When considering how best to structure or implement such a practice, programme directors might consider looking to similar models such as those found in a typical genetic counselling session done prior to initiating IVF/PGD for medical reasons, in which a counsellor explores a patient’s motivations for pursuing assisted reproduction treatment. Analogous counselling should be a standard procedure for couples seeking IVF/PGD for non-medical reasons. If conducted by appropriately trained clinical staff, this counselling could provide an opportunity to explore sources of moral ambivalence.
      Pre-decisional counselling may also provide a clinical setting in which to revisit couples’ understandings of relevant medical procedures and their risks, including familiarity with the potential psychosocial implications of using IVF/PGD for sex selection. To the extent that many couples in this study stated that they had not discussed their plans to pursue sex selection with others due to worries about their disapproval, pre-decisional counselling may be welcomed by couples who view this as an opportunity to discuss personal reservations about the use IVF/PGD for sex selection in an open and non-judgmental setting. Pre-decisional counselling also might reveal differences between individual partners or identify mistaken beliefs about IVF or PGD (which were common among the couples interviewed). The findings also suggest that efforts to provide some type of moral counselling may need to precede initial clinic visits since many couples seemed to have struggled with these decisional matters prior to their first clinic visit.

      Limitations of this study

      This study was limited to a small number of participants who responded to several non-standardized announcements of the availability of sex selection in a research study at a single academic medical centre in the USA and may not be representative of patient experiences at other fertility clinics. It is noteworthy, however, that every couple who visited the clinic to consider participation in the research study was interviewed. In addition, since IVF/PGD was offered at a well-known academic medical centre, the institutional reputation of the institution may have provided some level of moral legitimacy to the use of IVF/PGD for sex selection. These findings may not be typical of couples who either do not fit the eligibility requirements of this study or who seek sex selection in other clinical settings. Future research should seek to characterize moral attitudes and beliefs among couples seeking IVF/PGD for sex selection in other settings.
      There also is the possible limitation that participants may have responded to questions posed by the interviewers in a manner that would present them and their motivations in the best possible light to ensure that they would not compromise their eligibility to continue on with IVF/PGD for sex selection. Despite reassurances by the research coordinator and interviewers, it is possible that participants may have perceived the interview as part of the selection process for the study. Although it is difficult to assess to what extent participants may have tailored their self-presentations to suit the situation at hand, the results of this study will be useful for future studies of IVF/PGD users and lay the groundwork for larger studies of patients’ views about sex selection.
      Lastly, since only two of the 18 couples ultimately chose to pursue IVF/PGD for sex selection, there is inconsistency between the level of interest that couples expressed in their interviews and the uptake of IVF/PGD for sex selection. This study was not able to conduct follow-up interviews with couples and thus could not describe their reasons for not proceeding with IVF/PGD for sex selection. Future research is needed to assess couples’ reasons for continuing with or withdrawing from a sex-selection programme and to what extent various medical, financial and moral issues factor into their personal decisions.
      In conclusion, to date, the full range of ethical issues raised by the use of IVF/PGD for sex selection has not been examined adequately, in part because these debates have focused largely on the question of whether sex selection is morally justifiable, rather than on the manner in which various reproductive technologies might be used for this purpose. One of the main contributions of this study is to push ongoing bioethical debates forward by framing a broader set of moral considerations that individuals pursuing IVF/PGD for sex selection will bring to future clinical encounters. These perspectives can inform a more practically oriented discussion of ethical considerations in the use of assisted reproduction treatment for sex selection.
      As with the emergence of other medical technologies, clinical practices should be guided by the best available data, including data on the moral attitudes and beliefs of individuals seeking new reproductive options. The current data, combined with the low frequency with which couples elected to pursue sex selection, call into question a common view that the introduction of a new assisted reproduction treatment will result in a technological imperative wherein the mere availability of this new reproductive option will result in its widespread use. Concerns about a technological imperative to pursue sex selection assume that couples will not approach their personal decision making in a morally serious fashion. The current findings suggest that it would be both naïve and disrespectful to view couples interested in using IVF/PGD for sex selection as such one-dimensional individuals blinded to anything but the opportunity of having a child of a particular sex. Couples interested in sex selection engage that decision in a morally reflective manner and bring to the decision making process substantial diversity of moral values and cultural perspectives that defy a priori classification. A comparable level of moral seriousness should be reflected in an informed-consent process that reflects the richness of moral attitudes and beliefs among couples considering sex selection.

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