Infertility is estimated to affect around one fifth of couples in the UK. The two main procedures used to treat infertility are in-vitro fertilization (IVF), where fertilization of a woman’s egg is performed outside of her body and intracytoplasmic sperm injection (ICSI).

In IVF, a female receives hormones to stimulate her ovaries to produce eggs, which are then collected and mixed with sperm in a laboratory dish. A fertilized embryo is then placed back inside the womb. In the case of intracytoplasmic sperm injection, a single sperm is injected directly into an egg’s cytoplasm to allow more control over exactly which sperm fertilizes which egg. The procedure is also carried out in a laboratory and the fertilized egg is then placed inside the womb using the traditional IVF technique. This procedure is used when the quality or quantity of sperm is low.

Both of the above procedures can be used in cases of egg donation or surrogacy. Pre-implantation genetic analysis can also be performed with either procedure to check for genetic disorders.

There are many ethical concerns surrounding the subject of reproductive research and infertility treatment and the American Society for Reproductive Medicine has issued several statements about these issues. Some of these issues are described below.

Multiple pregnancy

In some cases of IVF, several fertilized eggs are transferred to the womb to increase the chance of conception. However, this also increases the chance of two or more fetuses developing, which increases the risk of premature birth, infant health problems and a low birth weight.

Embryos

When a woman undergoes assisted conception, the clinic she attends may offer to freeze any additional fertilized eggs that were not implanted, for any future attempts at conception. People need to consider what they would like done with the eggs in the event of death or divorce and be sure to give written instructions that reflect their wishes. People also need to consider what they would like to happen to the eggs if the clinic is ever unable to contact them.

Donor eggs/sperm or surrogacy

A couple may choose to use eggs or sperm from a donor or have a surrogate mother carry their child. In these cases, couples must discuss with the clinic or a lawyer about a contract being drawn up that defines the rights and responsibilities to the future child and family, of each party.

Ethical issues abroad

Ethical and legal issues vary between countries and with religious beliefs. Every person also has their own individual opinions, which further complicates matters. Even if a couple conceive using their own sperm and eggs, the creation of life outside of the body is a momentous act that sparks strong opinion and sentiment. If you add donor gametes or a surrogate mother to the equation, the situation can become even more complex.

In some countries, there is a legal framework to address these issues, whereas others rely on official guidelines. Examples of countries that have laws and statutes applying to fertility treatment legal issues include Canada, France, Germany, the UK and Finland. Examples of countries where legal issues are left to official guidelines include Mexico, Poland, Cyprus, India and the USA.

Some aspects of fertility treatment are regulated differently between countries, with something that is permitted in one country being completely banned in another. Before embarking on treatment, couples should check which countries permit the process they need and which have the most liberal legislation. This legislation applies to almost every step of the process, from whether a person is allowed to be treated in the first instance through to how long embryos can be stored. In countries such as Turkey and Canada for example, only married couples are allowed to have IVF and in Canada a stable nuclear family is a pre-requisite. In Spain, Sweden and the USA, on the other hand, a single person and homosexuals are allowed to undergo IVF.
Other legal and ethical issues that are subject to regulation are listed below:

• Using donor sperm or eggs – law guarantees anonymity of donors in Greece, for example, but this is no longer allowed in the UK.
• Embryo development period – In many countries, embryos are allowed to develop for a number of days to enable selection of the healthiest one for implantation, but in some countries, only early embryos can be implanted.
• Paying surrogates – Commercial surrogacy is not permitted in many countries, but is completely legal in India.
• Length of embryo storage time – In Spain and Canada, embryos can be stored for an unlimited period, whereas in Brazil, they can only be stored for three years.
• Embryo selection process and genetic screening – Genetic screening prior to implantation is completely banned in some countries but only subject to strict regulation in others.
• Maximum number of embryos implanted – In many countries there are strict single embryo transfer policies, whereas the number implanted is left to the physician’s discretion in others.
• The use of stored sperm or embryos after a partner’s death – In Iceland, frozen sperm are destroyed if a male partner dies, while in Belgium, sperm can be obtained for future treatment if written permission is given.
• Views regarding when life begins – The Catholic Church believes life begins at conception and only allows fertilization of eggs that will definitely be used, meaning all viable embryos have to be implanted. Other individuals believe life does not really start until a few weeks later and are content with selecting only the healthy embryos for implantation and discarding the rest.